Health Sector Development Program IV (2010/11 – 2014/15)

Health Sector Development Program Four(HSDP-IV) H SD P IV I Table of Contents Acronyms ...........................................................................................................................................III Preamble............................................................................................................................................ IV Foreword ............................................................................................................................................ V Executive summary ..................................................................................................................... VIII Chapter 1. Country profile ............................................................................................................ 2 1.1 Country context ................................................................................................................................................... 2 1.2 National health profile ...................................................................................................................................... 4 1.2.1 Health status ............................................................................................................................................................................................... 4 1.2.2 National health system ........................................................................................................................................................................... 5 1.2.3 Health system organisation ................................................................................................................................................................. 5 Chapter 2. Overview of HSDP I, II and III .................................................................................. 8 2.1 Summaries of past HSDP performance ........................................................................................................ 8 2.2 Detailed account of HSDP III performance ................................................................................................. 8 2.2.1 Health service delivery & quality of care in HSDP III ................................................................................................................ 8 2.2.2 Health sector reform ............................................................................................................................................................................. 21 2.2.3 Health facility construction and expansion ................................................................................................................................. 22 2.2.4 Human resource development .......................................................................................................................................................... 23 2.2.5 Pharmaceutical services ...................................................................................................................................................................... 25 2.2.6 Health and health related services and product regulation ................................................................................................ 26 2.2.7 Harmonisation and alignment .......................................................................................................................................................... 26 2.2.8 Health care financing............................................................................................................................................................................ 28 2.2.9 Pastoralist health service .................................................................................................................................................................... 31 2.2.10 Operational research .......................................................................................................................................................................... 32 2.2.11 Cross cutting issues ............................................................................................................................................................................. 32 Chapter 3. Health Sector Development Programme IV ..................................................... 34 3.1 HSDP-IV planning process, methodology & principles ....................................................................... 34 3.2 The policy framework ..................................................................................................................................... 34 3.2.1 National policies and strategies ....................................................................................................................................................... 35 3.2.2 International policies and goals ....................................................................................................................................................... 35 3.3 Health sector strategic assessment ............................................................................................................ 36 3.3.1 Roles of federal & local governments ……………………………………………………………………………………………………. 36 3.3.2 Mission, vision and core values of the Ethiopian health sector ........................................................................................... 38 3.3.3 SWOT analysis for the health sector ............................................................................................................................................... 39 3.3.4 Stakeholder analysis .............................................................................................................................................................................. 40 3.4 Strategy of the HSDP-IV .................................................................................................................................. 40 3.4.1 Customer value proposition of HSDP-IV ....................................................................................................................................... 41 3.4.2 Strategic themes and strategic results .......................................................................................................................................... 41 3.4.3 Strategic perspectives ........................................................................................................................................................................... 44 3.5 Strategic objectives & map for Ethiopian health sector ..................................................................... 45 3.5.1 The ten strategic objectives (SOs) ................................................................................................................................................... 45 3.5.2 Health sector strategy map ................................................................................................................................................................ 51 3.6 Performance indicators, targets & strategic initiatives ..................................................................... 51 3.6.1 Sector core performance indicators & targets ........................................................................................................................... 51 3.6.2 Directions of HSDP-IV ........................................................................................................................................................................... 52 3.6.3 Performance indicators, targets & initiative by strategic objective ................................................................................. 56 Chapter 4. Costing and financing HSDP-IV ............................................................................ 66 4.1 Costing methodology ....................................................................................................................................... 66 4.2 Costing scenarios and assumptions for HSDP-IV .................................................................................. 66 4.3 Cost and impact of scaling-up ....................................................................................................................... 68 4.4 Financing gap ..................................................................................................................................................... 72 4.5 Financing channels and arrangements for HSDP-IV ............................................................................ 75 4.6 Preferred channels of financing HSDP-IV ................................................................................................ 76 4.7 Application of “one-budget” to channels and mechanisms ............................................................... 76 H SD P IV II Chapter 5. Management arrangement of HSDP-IV ............................................................. 80 5.1 Governance structure ...................................................................................................................................... 80 5.2 Inter-sectoral collaboration & public private partnership ............................................................... 81 5.3 Health service delivery arrangement........................................................................................................ 82 5.4 Health planning ................................................................................................................................................. 83 5.5 Financial management and auditing ......................................................................................................... 84 5.6 Procurement and logistics management ................................................................................................. 85 5.7 Monitoring and evaluation ............................................................................................................................ 87 5.8 Key indicators for results framework at national level ..................................................................... 88 5.9 Risk mitigation ................................................................................................................................................... 90 Annex section ................................................................................................................................... 92 Annex 1: How to Build a Balanced Scorecard – Nine Steps to Success .................................................. 92 Annex 2: Challenges & gaps of HSDP III & linkages to HSDP-IV ............................................................... 95 Annex 3: Summary of bottleneck analysis conducted for HSDP-IV ........................................................ 98 Annex 4: Projection of human resources requirement ........................................................................... 101 Annex 5: Planning and budgeting calendar ................................................................................................. 102 Annex 6: Budget analysis* .................................................................................................................................. 103 Annex 7: High impact interventions & indicators ...................................................................................... 106 Annex 8: Detailed indicators for monitoring HSDP-IV quality indication ........................................ 109 Endnotes .................................................................................................................................................................... 120 Tables: Table 1. Trends of health facility construction ....................................................................................................................... 23 Table 2. Total number of available human resources during successive HSDP phases ....................................... 24 Table 3. Total number of available human resources for health by region, 2009 .................................................. 25 Table 4. SWOT analysis of the health sector ............................................................................................................................ 39 Table 5. Stakeholders analysis ....................................................................................................................................................... 40 Table 6. The health sector customer value proposition ...................................................................................................... 41 Table 7. Perspectives of HSDP-IV .................................................................................................................................................. 44 Table 8. Summarised priorities and targets of HSDP-IV ..................................................................................................... 52 Table 9. Additional cost and mortality reduction estimates 2010/11 – 2014/15 .................................................. 68 Table 10. Budget estimate by scenario, service delivery, investment & recurrent costs (US$ mill) .............. 70 Table 11. Base-case scenario: estimated budget by HSDP-IV programme areas (US$mill) ............................... 71 Table 12. Best-case scenario: estimated budget by HSDP-IV programme areas (US$mill) ................................ 72 Table 13. Total budget, projected commitment & funding gap by programme areas ........................................... 75 Figures: Figure 1. Delivery by skilled birth attendants in regions, 2008/09 ................................................................................. 9 Figure 2. Trend in immunisation coverage, 2004/05-2008/09 ...................................................................................... 10 Figure 3. Immunisation coverage across regions, 2008/09 ............................................................................................. 11 Figure 4. Facilities providing HCT/VCT, PMTCT, and ART services, 2009/10 ......................................................... 12 Figure 5. Trend in actual numbers of PLHIV accessed care, 2004/05-2009/10 ..................................................... 13 Figure 6. PLHIV Currently on ART across regions, 2009/10 ............................................................................................ 14 Figure 7. Trend in TB Detection, Treatment & Cure Rate, 2004/05-2008/09 ......................................................... 15 Figure 8. TB Case detection, treatment success and cure rates, 2008/09 .................................................................. 18 Figure 9. Trends in the training of HEWs, 2004/05-2009/10 ......................................................................................... 19 Figure 10. Trends of construction of Health Posts, 2004/05-2009/10 ....................................................................... 20 Figure 11. Trends of health expenditure in USD/capita ..................................................................................................... 31 Figure 12. The Health Sector Strategic Management System “House” ......................................................................... 44 Figure 13. Health Sector Strategy Map ....................................................................................................................................... 51 Figure 14. Progress towards MDGs and additional cost per capita ............................................................................... 68 Figure 15. Allocation of total budget estimates by level of service delivery ............................................................. 70 Figure 16. Breakdown of health expenditures – indicative plans by financing sources ...................................... 73 Figure 17. HSPD-IV Financing Gap, 2010/11 to 2014/15 ................................................................................................. 73 Figure 18. Funding gap over the coming five years period in Million US$ ................................................................. 74 Figure 19. Ethiopian Health Tier System ................................................................................................................................... 83 Acronyms AFB ........ Acid-fast bacilli (TB) AIDS ....... Acquired Immunodeficiency Syndrome ANC ........ Antenatal Care ARM ........ Annual Review Meeting ART ......... Anti-Retroviral Therapy ARV ........ Anti-retroviral Drug AWD ...... Acute watery diarrhoea BEmONC . Basic Emergency Obstetric & Newborn Care BoFED .... Bureau of Finance & Economic Development BPR ....... Business Process Re-engineering BSC ....... Balanced Scorecard CBHI ...... Community-based health insurance CEmONC .. Comprehensive Emergency Obstetric & Newborn Care CJSC ...... Central Joint Steering Committee CMP ........ Constant Market Price CPR ....... Contraceptive prevalence rate CSO ....... Civil Society Organisation CSRP ...... Civil Service Reform Program DDT ........ dichlorodiphenyltrichloroethane (pesticide) DOTS ...... Directly Observed Treatment Short Course DP .......... Development Partner DPT ......... Vaccine for Diphtheria, pertussis & tetanus EDHS ...... Ethiopian Demographic & Health Survey EFY ......... Ethiopian Fiscal Year EmONC .. Emergency Obstetric & Newborn Care EMR ........ Electronic Medical Records EOS ....... Enhanced Outreach Strategy EPI .......... Expanded Programme of Immunisation MoH ........ Ministry of Health FP ........... Family Planning GAVI ....... Global Alliance for Vaccines & Immunisation GoE ......... Government of Ethiopia HAPCO ... HIV/AIDS Prevention & Control Office HC .......... Health Centre HCT ........ HIV Counselling & Testing HEP ......... Health Extension Package HEW ........ Health Extension Workers HF ........... Health Facility HHs ........ Households HITs ........ Health information technicians HIV .......... Human Immunodeficiency Virus HMIS ....... Health Management Information System HPN ........ Health, Population & Nutrition HPs ......... Health Posts HRD ........ Human Resources Development HRH ....... Human resources for health HRIS ...... Human resources information system HSDP ...... Health Sector Development Programme ICT ......... Information Communication Technology IESO ...... Integrated Emergency Obstetric & Surgery IHP+ ....... International Health Partnership IMNCI ..... Integrated management of neonatal & childhood illnesses IMR ........ Infant mortality rate IPFSMIS. Integrated Pharmaceuticals Fund & Supply Management Information System IRS ......... Indoor residual spraying IT ............ Information technology ITN ........... Insecticide Treated Nets JCCC ....... Joint Core Coordinating Committee JCF ......... Joint Consultative Forum JFA ......... Joint Financing Arrangement LLITN ...... Long-lasting insecticide treated nets LMIS ........ Logistics Management Information System M&E ......... Monitoring & Evaluation MDG-PF .. MDG performance fund MDGs ...... Millennium Development Goals MDR ........ Multiple Drug Resistance MMR ........ Maternal Mortality Ratio MNCH ..... Maternal, neonatal & child health MOE ......... Ministry of Education MoFED .... Ministry of Finance & Economic Development NAC ......... National Advisory Committee NCDs ....... Non-communicable diseases NGO ........ Non-governmental organisation NHA ......... National Health Accounts NTDs ....... Neglected tropical diseases OI ............ Opportunistic infections ORS ........ Oral rehydration salts/solution ORT ........ Oral Rehydration Treatment OVC ........ Orphans & vulnerable children PASDEP . . Plan for Accelerated & Sustained Development to End Poverty Penta ....... vaccine for five diseases: diphtheria, tetanus, pertussis (whooping cough), hepatitis B & poliomyelitis (polio) PFSA ...... Pharmaceutical Fund & Supply Agency PHC ........ Primary health care PHCU ....... Primary Health Care Unit PLHIV ...... Persons living with HIV PMQI ........ Performance Monitoring & Quality Improvement PMTCT .... Prevention of Mother to Child Transmission PPD ........ Planning & Programming Department RDT ........ Rapid Diagnostic Test RH ............ Reproductive Health RHB ......... Regional Health Bureau RJSC ....... Regional Joint Steering Committee SNNPR .... Southern Nations Nationalities & Peoples Region SO ........... Strategic Objective STIs ......... Sexually Transmitted Infections SWOT ..... Strengths, weaknesses, opportunities & threats analysis TA ........... Technical assistance TB ............ Tuberculosis U-5 .......... Under 5 years old UNICEF ... United Nations Children’s Fund USD ........ United States dollars VCT .......... Voluntary Counselling & Testing WASH ..... Water & Sanitation for Health WHO ........ World Health Organisation WJSC ..... Woreda Joint Steering Committee WoFED ... Woreda Office of Finance & Economic Development WoHO ...... Woreda Health Office ZHD ......... Zonal Health Department H SD P IV IV Preamble Ethiopia has been implementing Health Sector Development Programme (HSDP) since 1997/8. The first, second and third phases of HSDP were completed in June 2002, June 2005 and June 2010 respectively. This led to the development of the fourth phase of HSDP, which covers a period of five year, i.e., July 2010 to June 2015. Preparation of HSDP-IV has been guided by a concept note and a TOR developed jointly and agreed collectively by the Government and Health Development Partners. The Executive Committee of the MoH and the Joint MoH and RHB Steering Committee led the process at the highest levels. These Committees have selected the strategic themes and objectives to be used as a framework for development of the HSDP-IV. Subsequently, multidisciplinary teams were established to prepare the draft document based on the guiding framework. The first draft produced by the multidisciplinary team was discussed by the Executive Committee of MoH and the Joint MoH and RHB Steering Committee, after which it was shared with all stakeholders for their feedback. Finally, it was subjected to two rounds of Joint Assessment for National Strategies (JANS) including an international consultative workshop. At the onset, Government made a decision to develop the HSPD IV strategic plan by using the Balanced Scorecard (BSC) approach, and arranged appropriate BSC training for leadership and team members. The basic steps MoH used to develop the HSDP-IV using BSC include: a) Conducting an organisational assessment, b) Setting strategic elements, c) Setting strategic objectives, d) Preparing a strategic map of the objectives, e) Indicating performance measures & targets of the strategic plan, and f) Preparing strategic initiatives expected to achieve the overall strategic plan. The other main methodology used has been the Marginal Budgeting for Bottleneck (MBB) approach. The MBB helped to systematically look into the health system bottlenecks, high impact interventions, different scenarios and associated costs of achieving results that have been planned under the HSDP-IV. HSDP IV is health chapter of the National Growth and Transformation Plan which was approved by the highest body of the government. The feedbacks obtained from the two rounds of the JANS were carefully recorded and used to amend the document. The final document was edited by a professional editor and the edition was backed up by a team of technical experts who were part of the HSDP IV preparation process. H SD P IV V Foreword Real ownership begins with decisive leadership and meaningful engagement in the planning process. And in this respect, I believe that the painstaking work and extensive consultations involved in preparing for this fourth phase of our Health Sector Development Programme (HSDP-IV) have effectively consolidated the strong collective ownership needed to ensure its successful implementation. Initiated by the Government of Ethiopia in 1997, the HSDP has evolved into a robust and comprehensive national planning instrument. It is essentially a twenty-year strategic roadmap for our health sector, which we have been regularly appraising, improving and implementing as a series of five-year investment plans, focusing on the country’s most pressing public health problems. Each five-year plan aims to build on the key achievements, best- practices and lessons learned of the preceding one. The previous five-year plan – HSDP-III (2005/6 - 2009/10) was both ambitious and successful. Directly aligned with the health-related Millennium Development Goals (MDGs), HSDP-III focused on high-impact health system strengthening interventions needed to accelerate scale-up and coverage of key health services for HIV, TB, malaria, as well as maternal and child health. With the steadfast and increasingly flexible support and collaboration of our diverse partners its implementation over the last five years has enabled us to register substantial progress towards improving the health status of Ethiopians. The majority of HSDP-III’s ambitious targets have been successfully attained. Under-five mortality has dropped significantly, thanks to the rapid expansion in immunization coverage. In 2008/09, 82% of Ethiopian children had received the Penta/DPT-3 vaccine (a combination vaccine against Diphtheria, Pertussis, and Tetanus), compared to only 51.5% in 1995. A combination of interventions has also enabled a steady decline in the maternal mortality ratio from 1068 per 100,000 live births in 1990 to 590 by 2008. Malaria and HIV-related deaths and cases have also plummeted. A recent malaria assessment indicated a 54% and 55% reduction in malaria admission and deaths respectively. And by 2008/09, about 152,472 HIV patients were accessing anti-retroviral treatment and receiving care from 511 sites throughout the country. Our Government’s firm commitment to a community-centered effort aimed at ensuring universal access to primary health care has been central to this progress. This approach is being driven by our community- based Health Extension Program (HEP) which has rapidly trained and deployed over 34,000 government salaried health extension workers throughout the country — two for each 15,000 rural kebeles and a select number of city administrations. In parallel, we have also been investing heavily in the expansion of our health infrastructure - an accelerated effort which aims to put in place and fully equip 15,000 health posts and 3,200 health centers around the country along with other vital inputs, including the necessary staff, pharmaceuticals and other supplies -- all backed by an effective information system. Under HSDP-III, 14,500 health posts and 2,800 health centres were completed and equipped. H SD P IV VI We have also made considerable gains in addressing critical shortages of health professionals. The roll-out of HEP alone almost doubled our country’s health workforce in less than three years. Further, significant progress was made through accelerated training programs, particularly for lower and mid-level cadres. Since 2007, more than 3,700 health officers have been trained and deployed to rural health centres. There has also been an important expansion in the enrolment capacity of midwifery schools. In addition, HSDP-III saw the launch of an innovative graduate level health officer training program in emergency obstetrics and surgery. While the firm commitment of our Government has been key, we also recognize that this encouraging progress would not have been possible without the steadfast support of our diverse partners. Harmonising and enhancing the collective impact of our partners’ support has been foremost among our objectives during HSDP-III. The signing of our groundbreaking ‘‘Code of Conduct to Promote Harmonization in the Health Sector’’ in 2005 paved the way for the endorsement of the HSDP Harmonisation Manual (HHM) in 2007. Our subsequent decision to sign up to the International Health Partnership (IHP+) was thus, straightforward. In August 2008, Ethiopia became the first country to conclude an IHP+ Country Compact. And we In line with the ‘one plan, one budget, one report’ principles of our IHP+ Compact, a comprehensive woreda or district-based planning instrument was installed and the 'Millennium Development Goal Performance Fund or ‘MDG Fund’ was established. The MDG Fund, an innovative pooled funding mechanism designed to allow both for greater predictability in the flow of resources and optimal flexibility in their allocation, has since been endorsed by nine of our major development partners. With the scale-up of our successfully piloted new health management information system (HMIS) throughout the country, the establishment of a unified monitoring and evaluation system is also well underway. *** Clearly, sustaining and building on these significant gains will be a tremendous challenge. Yet, we have courageously and deliberately set even more ambitious targets for HSDP-IV. While the firm focus on primary health care expansion, health system strengthening interventions and the health MDGs will be maintained, we aim to achieve even more over the coming five years. We can expect great results for at least three compelling reasons: First, is that recognizing the sheer untapped potential of HEP we have already put in place a national mechanism to help us broaden and deepen the engagement of local communities and particularly women in the management of their own health. We are working to build a ‘women-centered’ health system, by linking leaders at the national, regional and district levels with women’s groups in every village across the country. These development teams are being empowered to monitor the health and well-being. Through the aggressive social mobilization of this massive army of HEWs and local development teams, we are determined to bring about the fundamental grassroots change needed to achieve our MDG targets. Second, is that we are consolidating the positive changes made through the radical sector-wide reforms which we embarked upon in 2009. Having H SD P IV VII successfully redesigned our core business processes and established institutional frameworks for key functions, we are now focusing on the aggressive implementation of key capacity building and performance management measures throughout the sector. In particular, we expect that the full implementation of the Balanced Score Card system will greatly enhance the overall performance of our sector by further strengthening ownership and accountability at all levels. Third, is the steadfast support and renewed commitment of our diverse partners. Tackling the challenges ahead will no doubt require the continued concerted efforts of our Government, the private sector, non-governmental organisations, multilateral and bilateral development partners, and above all the public at large. And the strong partnerships we have built up over the last phase inspire great optimism. More of our partners are committing to make contributions to the MDG Pooled Fund and to support us in more flexible ways. Last year, Ethiopia also became among the first group of countries to apply the Joint Assessment of National Strategy (JANS) – a tool developed under the IHP+ to help countries move towards “one plan” -- in appraising our HSDP-IV. This exercise has helped to further bolster and maintain the positive momentum and progress we have made over the past few years and renewed our collective commitment to further advance harmonization among all partners. HSDP-IV is a particularly significant phase not only because it is the last five- year plan that will get us through our final ‘sprint’ to the MDGs, but also because it constitutes a key component of our Government’s recently launched five- year Growth and Transformation Plan (2011-2015). This means that we can also expect that the concomitant investments and gains envisaged by the GTP in the infrastructure, water, trade and industry sectors will have an added catalytic effect on all our efforts in the health sector. And so, at this critical juncture as we embark steadily on this final lap towards the 2015 MDGs, I want to assure all our partners, and my colleagues throughout the sector, that our Government’s resolve has never been stronger. We are committed to continue playing the lead role in working hard to achieve the targets set out in this document. I would like to express my profound appreciation to all those who have been involved in the development of this landmark document. Its successful completion and publication would not have been possible without the committed efforts and vital contributions of a wide range of stakeholders. Above all, I want to thank all our partners for endorsing this document as our common guiding reference for our operations for the coming five years. We should all be proud of the strong partnership and important progress we have made together, and derive from these achievements, renewed optimism about the continued gains we stand to make over the coming years. Tedros Adhanom Ghebreyesus (PhD) Minister of Health, Federal Democratic Republic of Ethiopia H SD P IV VIII Executive summary Country context and health profile The 2007 population and housing census estimated a total population in 2010 of 79.8 million. About 5/6ths of the population live in rural areas (83.6% rural vs. only 16.4% urban) and the population age pyramid has remained quite young: 44% are under 15 years, over half (52%) are between 15 to 65 years, and only 3% of all persons are over the age of 65 years. Average lifetime fertility has declined from 6.4 births per woman (1990) down to 5.4 births (DHS 2005), but rural women still average of three more births per woman compared to urban women. Even with declining fertility, the annual population growth rate is 2.6%. Health status Despite major health improvements in the last fifteen years, the population still faces high morbidity and mortality rates and health status remains relatively poor. The DHS of 2005 showed a life expectancy of 54 years (53.4 years for male and 55.4 for female), and an IMR of 77/1000. Under-five mortality rate has been reduced to 101/1000 in 2010. The main health problems are preventable communicable diseases and nutritional disorders. More than 90% of child deaths are due to pneumonia, diarrhoea, malaria, neonatal problems, malnutrition and HIV/AIDS, or combinations of these conditions. Although the MMR has declined to 590/100,000, it is still among the world’s highest. The major causes of maternal death are obstructed/prolonged labour (13%), ruptured uterus (12%), severe pre-eclampsia/eclampsia (11%) and malaria (9%), and complications from abortion (6%). The major supply side constraints are shortages of skilled midwives, weak referral system at health centres, inadequate availability of BEmONC and CEmONC equipment, and under- financing. On the demand side, cultural and societal norms, distances to functioning health centres and financial barriers were the major constraints. Government health system During the past fifteen years, the Ministry of Health (MoH) has developed a first national health policy, followed by four consecutive Health Sector Development Plans (HSDPs). The recently implemented Business Process Reengineering (BPR) of the health sector has introduced a three-tier health care delivery system: Primary level one covering about 60,000-100,000 people; level two is a General Hospital covering 1-1.5 million people; and level three is a Comprehensive Specialised Hospital for about 3.5-5 million people. Summary of achievements for HSDP III Health service delivery and quality of care - By 2008/09, antenatal care and FP coverage both rose significantly, and deliveries assisted by skilled health personnel reached 18.4%. Malaria admissions and deaths have been reduced by more than 50% compared to the baseline period of 2001-2004. In 2009, the national point prevalence for HIV was 2.3% and the adult HIV incidence was 0.28. However, PMTCT prophylaxis is only reaching 8.2% of close to 80,000 HIV-positive pregnant mothers within a year. National TB cure and treatment success rates are on track toward targets, but case detection rates remain low. H SD P IV IX By the end of HSDP III, the Health Extension Programme (HEP) had trained and deployed a total of 33,819 HEWs, surpassing the target number. Even so, HEP only reached 89% of communities, versus the planned target of 100%. Health systems - Health sector reforms have intensified through the application of Business Process Reengineering (BPR), leading to a set of new approaches including benchmarking best practices, designing new processes, revising organisational structures and a selection of key processes. The BPR has been progressively implemented at all levels followed by changes in staff deployment, specific job assignments and the recruitment of new staff. Aiming for harmonisation and alignment, major objective of the health sector is to have the One-Plan, One-Budget and One-Report approach at all levels of the health system. Ethiopia is a signatory of the Global IHP+ Compact and the first to develop and sign a Country-based IHP+ Compact. Governance of the health sector is improved, with key coordinating and steering committees performing well, including the MoH-RHBs Joint Steering Committee, MoH-HPN Joint Consultative Forum and the Joint Core Coordinating Committee. The introduction of health financing reforms has included: retention and utilisation of revenue, administration of the fee waiver system and establishment of functioning facility governance bodies. Work is on-going to develop and implement both Social Health Insurance and community-based health insurance (CBHI). The combination of CBHI and SHI will cover about 50% of the population by the end of the HSDP-IV period. Ethiopia’s fourth National Health Accounts study (NHA, 2010) showed that per capita health expenditure has increased from USD 7.14 (in 2004/05) to USD 16.09 (in 2007/08). HSDP­IV planning process, methodology & principles Preparation of HSDP-IV was guided by a concept note and a TOR developed jointly and agreed collectively by the Government and Health Development Partners. The Executive Committee of the MoH and the Joint MoH and RHB Steering Committee led the process at the highest levels. These Committees selected the strategic themes and objectives to be used as a framework for development of the HSDP-IV. Subsequently, multidisciplinary teams prepared the draft document based on the guiding framework. At the onset, Government made a decision to develop the HSPD IV strategic plan by using the Balanced Scorecard (BSC) approach. The basic steps used in preparing the HSDP-IV using the BSC included: a) Conducting an organisational assessment, b) Setting strategic elements, c) Setting strategic objectives, d) Preparing a strategic map of the objectives, e) Indicating performance measures & targets of the strategic plan, and f) Preparing strategic initiatives expected to achieve the overall strategic plan. The other main methodology used has been the Marginal Budgeting for Bottleneck (MBB) approach, in which planners systematically looked into the health system bottlenecks, high impact interventions, target setting in different scenarios and associated costs of achieving results that have been planned under the HSDP-IV. HSDP-IV is a policy level strategic document that will guide the development of sub-national plans and set the rules of engagement in the health sector for the H SD P IV X next five years. In order to realise this, the following principles have been applied in the development of HSDP-IV: • Government leadership; • Comprehensive coverage of priority health sector issues; & • Enhanced responsiveness to community health needs; • Linkage between HSDP-IV with sub- national HSDPs & strategies/programmes on health priorities & targets. • Extensive consultation & consensus with stakeholders; Policy environment While the National Health Policy has been the umbrella for the development of HSDP-IV, other health and health related policies and strategies have also been considered. The influential international commitment giving direction to the HSDP IV is global declaration of MDGs. See details in the full strategy document Mission, Vision and Core values of the health sector Mission of the health sector To reduce morbidity, mortality and disability and improve the health status of the Ethiopian people through providing and regulating a comprehensive package of promotive, preventive, curative and rehabilitative health services via a decentralised and democratised health system. Vision of the health sector To see healthy, productive, and prosperous Ethiopians Core values of the health sector Community first • We are here for nothing but to serve, empower and satisfy our community. • We involve, engage and empower the community to produce its own Health • We have three priorities: Community, Community, and Community. Collaboration • We work together in a spirit of mutual support and understanding to achieve our collective goals. Commitments • No matter what challenges we face and discomforts we feel, we stand firm, be patient and exert our utmost and sustained effort to achieve our goals. Change • We innovate new ways of doing things and are open minded to reforms. Trust • We ensure maximum vulnerability and integrity to each other. H SD P IV XI Organisational assessment One of the crucial steps in the planning process was a SWOT analysis of health sector strengths, weaknesses, opportunities and threats. The organisational assessment also included a stakeholder analysis that looked at six categories: community; Parliaments, Prime Minister’s Office, Council of Ministers, Regional Governments; Line Ministries; Development Partners; CSOs, NGOs, Diaspora, Professional Associations; Private for profit; and Civil Servants. Within each stakeholder category, the analysis looked into: behaviours we desire; their needs; resistance issues; their influence; and institutional response. Strategy of the HSDP­IV HSDP-IV is situated within and supports the government’s overall vision for Ethiopia to become a middle-income country soon after the MDG target date of 2015. To do so, the health sector of Ethiopia will have to stretch to attain its objectives of reaching every section of the population with effective health interventions. Some important processes will include defining customer value proposition, strategic themes, strategic results, and perspectives. Customer value proposition of HSDP-IV - In the context of HSDP-IV, the customer value proposition is the set of attributes that define services the health sector should provide, the principles underpinning its relationship with the community and how the health sector wishes to be perceived. This is a critical factor in developing, deepening and retaining the sector’s relationship with the community towards the achievement of the mission. Strategic themes and strategic results Strategic themes are the main focus areas of the sector strategy, and form the key areas in which the Health Sector must excel to achieve its mission, vision and strategy. Strategic Themes Explanation Strategic results 1. Excellence in health service delivery Provision & management of curative, preventive, rehabilitative & emergency health services, & promotion of good health practices at individual, family & societal level. Includes provision of maternal, neonatal, child, youth & adolescent health services & public health emergency services. A community that practices & produces good health, protected from emergency health hazards & has access to quality health care at all levels & at all times. 2. Excellence in leadership & governance Evidence-based planning, monitoring, evaluation, policy formulation & implementation. Includes development & implementation of a regulatory framework. Incorporates equitable & effective resource allocation & leadership development within sector & community. It also includes development and implementation of Health Development Army Communities served by accountable & transparent institutions & their safety ensured. Decision making in sector is evidence-based & promotes equitable & effective allocation and/or application of health resources 3. Excellence in health infrastructure & resources Development, rehabilitation & maintenance of health facilities & medical equipment that meet standards & are accessible to communities being served by qualified & motivated health professionals Communities have access to health facilities that are well equipped, supplied, maintained & ICT networked as per the standards & are well staffed with qualified & motivated employees. H SD P IV XII Strategic objectives for the health sector This strategy document uses strategic objectives to break strategic themes into more actionable activities that lead to strategic results. They are selected in terms of their potential to bring significant impact in the sector’s strategy. The ten strategic objectives (SOs) SO - C1: Improve access to health services SO – C2: Improve community ownership SO - F1: Maximise resource mobilisation and utilisation SO - P1: Improve quality of health services SO – P2: Improve public health emergency preparedness & response SO – P3: Improve pharmaceutical supply and services SO – P4: Improve regulatory system SO – P5: Improve evidence-based decision making by harmonisation and alignment SO – CB 1: Improve health infrastructure SO – CB 2: Improve human capital and leadership The full strategy document includes a strategic map that illustrates the cause and effect relationship of strategic objectives listed above for the health sector. The map provides an insight how the health sector plans to contribute added value to the community and how the intended outcome and customer value proposition will be achieved. Performance indicators, targets & strategic initiatives Sector core performance indicators and targets are listed in the table below. Summarised priorities and targets of HSDP-IV Priority Areas Impact Outcome Vehicles Blood lines Maternal & Newborn Health MMR 267/100,000 CPR= 66% Deliveries attended by skilled birth attendants= 62% Health Post 1: 3000-5000 population Health Centre 1:15,000-25,000 population (rural) 1:40,000 population (urban) Primary Hospital 1: 60,000-100,000 population General Hospital 1: 1,000,000-1,500,000 population Comprehensive Specialised Hospital 1: 3.500,000- 5,000,000 population • Health Extension Program • Health Development Army • Supply chain management • Regulatory system • Harmonisation & Alignment • Health Care Financing • Human Resource Development • Health Information System • Continuous quality improvement program • Referral system Child Health U5MR 68/1000 IMR 31/1000 Fully Immunised= 90% Pneumonia treatment = 81% HIV/AIDS HIV incidence 0.14 ART =484,966 PMTCT= 77% TB Mortality from all forms of TB = 20/100,000 TB case detection (All forms) 75% Malaria Lab confirmed Malaria incidence <5 per 1000 Pregnant women who slept under LLIN the previous night = 86% Increase proportion of U5 children who slept under LLITN the previous night = 86%. Nutrition Wasting prevalence 3% H SD P IV XIII Strategic initiatives of HSDP­IV Many of the listed initiatives and programmatic interventions were under implementation before HSDP-IV. The majority of these activities will continue to be implemented as per the agreed strategic directions. Two areas where there will be significant additional attention are ‘critical programmes’ and ‘emerging regions’. Critical programmes - Despite high expectations, HSDP III achievements were weak in having skilled attendants at delivery, PMTCT and TB case detection rate. HSDP-IV will therefore increase attention to these programmes, with the intention of achieving greater political commitment, better allocation of resources and closer follow up. Regions needing special support - i.e. Afar, Somali, Beneshangul-Gumuz and Gambella, present unique challenges for health service delivery and health system development. They have poor infrastructure, hardship environmental conditions, and pastoral or semi-pastoral populations. HSDP-IV will further strengthen special support to these regions through various mechanisms already in place. The remarkable achievements in rural HEP coverage will be scaled up expanding deeper into families and communities through the implementation of health development army. Targets (including outputs and outcomes) have been defined for all the strategic objectives and linked to specific initiatives to be undertaken toward meeting these targets. Costing and financing HSDP­IV Ethiopia and its development partners have made considerable progress toward the MDGs. The health sector is vigorously implementing evidence-based high- impact intervention packages at all levels, including HEP packages at the family and community level, expansion of outreach services and medium to high level clinical care. However, there are still major bottlenecks to be tackled during the next five years of HSDP-IV implementation, especially lack of resources and weak implementation capacity. There are also low utilisation levels for some proven interventions, which imply the need for more work to increase community demand and timely use at each level of the health care system. It is anticipated that reaching the MDGs in the coming five years will need increases in health expenditure; and the HSDP-IV costing is taking this into consideration. Costing for the HSDP-IV has been conducted with the Marginal Budgeting for Bottlenecks (MBB) tool based on evidence about the impact of existing interventions on health. The MBB focuses on the marginal costs and impacts in mortality reduction, which helps in estimating the extra efforts and resources needed to reach the MDGs. Costing scenarios for HSDP­IV The costing estimate is based on two scenarios; each scenario calls for a certain level of reinforcement of the cornerstones of the health system or the coverage determinants. Additional cost and mortality reduction estimates 2010/11 – 2014/15 Base-case Scenario Best-case Scenario Under five mortality reduction 33.8% Under five mortality reduction 46% Maternal mortality reduction 54.8% Maternal mortality reduction 56.6% Cost per capita per year in US$ 11.96 Cost per capita per year in US$ 13.96 The base-case scenario stipulates the need to mobilise an additional US$ 11.96 per capita per year on average over the five years. The investment is estimated to reduce under-five mortality by 33.8% and maternal mortality by 54.8%. Ethiopia would be able to achieve the health MDGs with the implementation of the base-case Scenario. The best-case scenario calls for a higher supplemental investment of US$ 13.96 per capita per year, but it would result in much higher reductions in mortality – bringing down under-five mortality by 46% and maternal mortality by 56.6%. In terms of resource mobilisation, however, the best-case scenario calls for almost doubling the current Total Health Expenditure by the end of HSDP-IV. The additional cost estimate has been translated into total budget estimates for the coming five years. Total budget for the coming five years is estimated at US$ 8.83 billion under the base-case scenario and US$ 10.828 billion for the best-case scenario. This represents an average annual increase of public health spending by 9% over the next five years in the base-case scenario, and 13.5% increase under the best-case scenario. Level of service delivery: A substantial proportion of the total budget estimate is allocated to make existing health facilities fully functional and improve quality of care at all levels of service delivery points. In both the base-case and best-case scenarios about 43% of the total budget is allocated to strengthen services at clinical level, including health centres, primary/district and general hospitals. Over 45% of the total investment is aimed at sustaining and strengthening the Health Extension Programme including the outreach services from health centres for immunisation and family planning. About 15% of the total investment envisaged is to further strengthen the health management and administrative capacity from Woreda Health Office, Regional Health Bureaus, to MoH. Financing gap Taking into consideration the current poverty levels and the pace of the country’s economic growth, it is projected that there will be a significant financing gap that will need additional resource mobilisation, with the consequence that a substantial proportion of the required resources may have to come from development partners. While progress has been made on pooled funding with the introduction of the MDG Performance Fund, there is still no firm commitment for health financing beyond 2011/12, leaving big uncertainties in planning for health services. In contrast to the Paris declaration, the trend in the past several years has been an increasing donor preference for earmarked project funding, rather than harmonised pool-funding. Moreover, a H SD P IV XV disaggregated analysis of the financing gap by programme areas shows inequities in the health sector. The major financing gap remains high in health systems followed by maternal-newborn health and child health. To assess the funding gap for the implementation of HSDP-IV, the estimated total budget is compared to the projected resource commitment from Government treasury and development partners. The contribution of Government to HSDP-IV is expected to rise from US$ 249 million in 2009/10 to US$ 307 million in 2014/15. As depicted in Figure 17 (below), both the base- case and best case scenarios encounter a substantial funding gap. In addition, the gap widens over time, as most development partners are not able to accurately predict for the later years of HSDP-IV. Figure 17. HSPD-IV Financing Gap, 2010/11 to 2014/15 Application of “one­budget” to funding channels and mechanisms The main purposes of implementing a “one budget” approach at all levels of the health system are to: 1) Ensure that various channels and funding mechanisms finance “one plan”; and 2) Reduce the transaction costs for the government that arise when dealing with multiple channels and financing mechanisms. The HSDP Harmonisation Manual has proposed processes to speed up harmonisation; under this arrangement, “one-plan financing” could be realised by applying the following procedures: • Making sure that all project support is aligned with priorities in the sector; • Providing information regarding project activities and funds allocated to local Government in the locations where the project is implemented to ensure that project activities are incorporated in the “one-plan” at that particular level of the health system; • Ensuring regular negotiation and discussion between local Government and project managers to allow flexibility, and to avoid gaps and overlaps; H SD P IV XVI • Promoting accountability and coherence through joint monitoring and evaluation (with local Government and other stakeholders) of project implementation. Management arrangement of HSDP­IV Governance structures The governance system has been revised in order to strengthen and rationalize the structures. The Joint Consultative Forum (JCF) is the highest governing body and will serve as a joint forum for dialogue on sector policy and reform issues between GoE, DPs and other stakeholders. The Joint Core Coordinating Committee (JCCC) will continue to be the technical arm of the JCF and also the Policy, Plan and Finance General Directorate. In-addition to these governance structures, the Global Fund coordinating mechanism (CCM) and the coordination mechanism for the EPI activities (ICC), will remain as is and may be strengthened or merged with other functional bodies as appropriate in the future. Inter­sectoral collaboration & public private partnership The HSDP-IV plan is that inter-sectoral collaboration will take place at different levels of the health system through formal government institutions (such as regional and Woreda councils) and health sector governance structures (such as CJSC, RJSC and WJSC). The major hallmark for intersectoral collaboration is the operationalisation of joint planning, implementation, monitoring and evaluation at all levels of the health system, as described in key MoH documents (such as the HSDP Harmonisation Manual). A complete set of manuals and tools will be developed to also guide public/private partnerships in health. Health planning The Ethiopian health planning is composed of two planning cycles. The first and most significant reference planning cycle is the five year strategic planning called the HSDP. It serves as a guiding blueprint on which all other plans are developed, e.g., Regional Health Plans, etc. The second is the annual planning cycle that translates the five year HSDP into the annual Plan of Work with details of achievable targets, strategies and interventions under the different levels of the health care system. Financial management The financial management of HSDP-IV will be aligned with existing government procedures. The GOE has set uncompromising standards of financial management for the funds that are part of the block grant/direct budget support. In Ethiopia, the accounting system is sufficiently developed to track different sources of funding all the way to final uses. The challenge remains on how to routinely monitor and report funding by HSDP component. It is envisaged that this will be facilitated through the harmonisation of budget coding outlined in the Financing Plan. The integrated financial management system, which contracted out, is also expected to bring remarkable improvement to the financial management, quality and speed of reporting. Monitoring and evaluation The monitoring plan for HSDP-IV will draw significant lessons from the previous experiences, which suffered from insufficient and poor quality of information for H SD P IV XVII planning, monitoring and evaluation purposes. In order to improve M&E, the monitoring and evaluation system is designed as part of the Policy, Planning and M&E core Process and is being implemented at all levels of the health system. A single results-based framework with a small number of indicators to make the monitoring and evaluation process effective and efficient will be agreed for the national level M&E system. H SD P IV XVIII 1 Chapter Country profile H SD P IV 2 Chapter 1. Country profile This chapter is an overview of Ethiopian geography and climate, demographic situation, education, administrative structure, socioeconomic situation, health status and health system organisation. 1.1 Country context Geography and climate Ethiopia is Africa’s oldest independent country. It is the tenth largest country in Africa, covering 1,104,300 square kilometres (with 1 million sq km land area and 104,300 sq km water) and is the major constituent of the landmass known as the Horn of Africa. It is bordered on the north-northeast by Eritrea, on the east by Djibouti and Somalia, on the south by Kenya, and on the west-southwest by Sudan. Its geographical coordinates are between 8 00 N and 38 00 E. Ethiopia is a country with great geographical diversity ranging from peaks up to 4,550m above sea level down to a depression of 110m below sea level. More than half of the country lies above 1,500 meters. The predominant climate type is tropical monsoon, with three broad climatic variations: the “Kolla”, or hot lowlands, below approximately 1,500 meters, the “Wayna Degas” at 1,500- 2,400 meters and the “Dega” or cool temperate highlands above 2,400 meters. Demographic situation Projections from the 2007 population and housing census estimate a total population in 2010 of 79.8 million. Ethiopia is a mosaic of nationalities and peoples, varying in size from more than 18 million to less than 1000 and having more than 80 different spoken languages. According to the 2007 census, it is one of the least urbanised countries in the world with about 5/6ths of the population living in rural areas (83.6% rural vs. only 16.4% urban). The largest city in the country is the capital, Addis Ababa, with 2.7 million people (about 4% of the total population). Nationally, the average household size is 4.7 persons. The population age pyramid has remained predominately young: 44% are under 15 years, over half (52%) are between 15 to 65 years, and only 3% of all persons are over the age of 65 years. The sex ratio between male and female is almost equal, and women in the reproductive ages constitute 24% of the population. While the average lifetime fertility has declined in the past 15 years from a 1990 level of 6.4 births per woman down to 5.4 births (DHS 2005)1, rural women still have an average of three more births per woman compared to women in urban areas. Overall, even with the fertility decline, the population is still growing at an annual rate of 2.6%. The lowest rate of population growth is in the Amhara region, which, at 1.7%, is lower than population replacement. Government and administration Under the 1994 constitution, Ethiopia is a Federal Democratic Republic with three branches of governance and administration. The executive branch includes the Prime Minister, Council of Ministers and Council of State. The legislative branch has a bicameral Parliament consisting of the House of H SD P IV 3 Federation or upper chamber and the House of People's Representatives or lower chamber. The representatives in the lower chamber are elected by popular vote from single-member districts to serve five-year terms. The judicial branch is comprised of federal and regional courts. The Federal Democratic Republic of Ethiopia has nine Regional States: Tigray, Afar, Amhara, Oromia, Somali, Southern Nation Nationalities and Peoples Region (SNNPR), Benishangul-Gumuz, Gambella, Harari; and the City Administration Councils of two cities: Dire Dawa and Addis Ababa. The regional states and city administrations are subdivided into 817 administrative Woredas (districts). A Woreda/District is the basic decentralised administrative unit and has an administrative council composed of elected members. The 817 Woredas are further divided into about 16,253 Kebeles, the smallest administrative unit. There are also two zones and seven Woredas designated as "special". These are medium sized towns or traditional sites of various nations. Socio­economic situation The Government of Ethiopia follows a market–based and agriculture led industrialisation policy for the development and management of the economy. There have been a number of policy initiatives and measures taken in these directions, including privatisation of state enterprises and the rationalisation of government regulations, a process which is still on-going. Ethiopia's economy depends heavily on the agricultural sector; agriculture accounts for 83.4% of the labour force, about 43.2% of the Gross Domestic Product (GDP) and 80% of exports2. Regular droughts combined with poor cultivation practices, make Ethiopia's economy vulnerable to climatic changes. Despite such obvious challenges, Ethiopia has shown an impressive economic growth over the last seven years. The Poverty Head Count Index has declined from the 1996 level of 45.5% to 32.7% in 2007/083. The reduction in poverty has been more pronounced in rural than urban areas. Even with this growth, the annual per capita earnings of 377 USD at CMP remain below the Sub- Saharan average. The overall economic dependency ratio for the country is estimated at 93 dependents per 100 persons in the working age group of 15-64 years. During the Sustainable Development & Poverty Reduction Programme (SDPRP I) period (2002/03 - 2004/05), real Gross Domestic Product (GDP) grew on average by about 5% per annum. However, during the first three years of PASDEP, Ethiopia averaged a double digit economic growth of 11.8% per annum with steady and strong positive performance in real GDP4. This steady growth marks a significant progress, not only compared to the 7% annual growth target required to meet the MDGs, but also to realise Ethiopia’s objective to become a middle-income country in the next two decades. Another important feature of the Ethiopia’s economic reform is greater equalisation of opportunities for women to participate in the economic development. The Ethiopian Constitution recognizes the principle of equality of access to economic opportunities, employment and property ownership for women. Following this principle, the government has formulated a national gender policy, which formally recognizes equality between the sexes and sets up mechanisms for the improvement of women’s conditions, such as the H SD P IV 4 establishment of the Ministry of Women’s Affairs. The main strategies employed to implement the national policy include gender mainstreaming in sector and development programmes, advocacy and capacity-building initiatives. Educational status The intimate linkage between health and education has been firmly established in a number of studies, which taken collectively, offer some ideas about how education and health could potentially reinforce each other towards the rapid socio-economic development of the country. Epidemiological and health service research in Ethiopia has shown that illiteracy is usually associated with high health risks and low health seeking behaviour. In addition to a wide range of diseases and child mortality associated with illiteracy or under-education, HIV/AIDS infection is also disproportionately high in out of school youth. Despite major progress in education, national literacy levels are still low. The total adult literacy rate (persons above 15 years who can read and write) is 36% (50% for male and 23% for female). According to the MoE 2010 Progress Report, the Gross Enrolment Ratio (GER) has increased from 2.2% in 2004/05 to 4.2% in 2008/09. The gross enrolment ratio in primary school rose from 32% in 1990/91 to over 94.2% in 2009/10, with a male-to-female proportion of 98.7% and 93%, respectively. 1.2 National health profile 1.2.1 Health status The major health problems of the country are largely preventable communicable diseases and nutritional disorders. More than 90% of child deaths are due to pneumonia, diarrhoea, malaria, neonatal problems, malnutrition and HIV/AIDS, and often as a combination of these conditions. Despite major strides to improve the health of the population in the last one and half decades, Ethiopia’s population still face a high rate of morbidity and mortality and the health status remains relatively poor. Vital health indicators from the DHS 2005 show a life expectancy of 54 years (53.4 years for male and 55.4 for female), and an IMR of 77/1000. Under-five mortality rate has been reduced to 101/1000 in 20105. Although the rates have declined in the past 15 years, these are still very high levels. In terms of women health, the MMR has declined to 590/100,000, but this is still among the world’s highest6. The major causes of maternal death are obstructed/prolonged labour (13%), ruptured uterus (12%), severe pre- eclampsia/eclampsia (11%) and malaria (9%)7. Significantly, 4% of all maternal deaths were attributable to complications from abortion. The major supply side constraints affecting maternal health are shortages of skilled midwives, weak referral system at health centre levels, lack of inadequate availability of BEmONC and CEmONC equipment, and under-financing of the service. On the demand side, cultural and societal norms, distances to functioning health centres and financial barriers were the major constraints. H SD P IV 5 1.2.2 National health system Following the change of government in 1991, the new Government of Ethiopia put in place many political and socio-economic transformation measures. Among these, it developed a first national health policy, which was followed by the formulation of consecutive phases of comprehensive Health Sector Development Plans (HSDPs), starting from 1997/98. The policy and the first HSDP were based on critical reviews of prevailing national health problems and a broader awareness of newly emerging health problems in the country. At the core of the health policy are democratisation and decentralisation of the health care system; developing preventive, promotive and curative components of health care; assurance of accessibility of health care for all parts of the population; and encouraging private and NGO participation in the health sector. During the past fifteen years, the Ministry of Health has built an impressive framework for improving the health for all, including maternal and neonatal health. This has included a wide range of strategies such as Making Pregnancy Safer (2000), Reproductive Health Strategy (2006), Adolescent and Youth Reproductive Health Strategy (2006) and the Revised Abortion Law (2005). There are also strategies on free service for key maternal and child health services (Health Care Financing Strategy), the training and deployment of new workforce of female Health Extension Workers (HEWs) for institutionalising community health care with clean and safe delivery at Health Post (HP) level, and deployment of Health Officers (HOs) with Master’s degree training (MSc) in Integrated Emergency Obstetric and Surgery (IESO) skills. The Ministry has also established the MDG Performance Package Fund and given priority to maternal health, which is expected to facilitate mobilising additional funding opportunities. 1.2.3 Health system organisation Recently, the health sector has introduced a three-tier health care delivery system: level one is a Woreda/District health system comprised of a primary hospital (to cover 60,000-100,000 people), health centres (1/15,000-25,000 population) and their satellite Health Posts (1/3,000-5,000 population) connected to each other by a referral system. The primary hospital, health centre and health posts form a Primary Health Care Unit (PHCU). Level two is a General Hospital covering a population of 1-1.5 million people; and level three is a Specialised Hospital covering a population of 3.5-5 million people. Rapid expansion of the private for profit and NGO sectors is augmenting the public | private | NGO partnership for health and boosting health service coverage and utilisation. The devolution of power to regional governments has resulted in largely shifting the decision making for public service delivery from the centre to being under the authority of the regions and down to the district level. Offices at different levels from the Ministry of Health to Regional Health Bureaus (RHBs) and Woreda Health Offices share in decision making processes, powers, duties and responsibilities. The Ministry and the RHBs focus more on policy matters and technical support while Woreda Health Offices manage and coordinate the operation of the district health system under their jurisdiction. H SD P IV 6 Chapter Overview of HSDP I, II and III2 H SD P IV 8 Chapter 2. Overview of HSDP I, II and III The three consecutive HSDPs that have been implemented since 1997/98 are reviewed here with respect to achievements, implementation challenges and lesson learned and doable recommendations for further health sector planning. 2.1 Summaries of past HSDP performance Records from the implementation of HSDP I and II show that encouraging improvements occurred in health service coverage as well as in the utilisation of services at all levels of the Ethiopian health care system. In terms of physical health facilities, 3,135 new Health Posts were constructed8, far exceeding the insubstantial amount of 76 HPs in 1996/97. Health Centres were increased from the number in 1996/97 of 243 to 519 in 2003/04; hospitals were also increased from 87 in 1996/97 to 126 including private hospitals in 2003/04. There have been also significant increases in the availability of health workers of all professional categories, particularly among of Nurses and Health Officers [see Tables 2 & 3 below in this chapter]. A new Health Extension Package (HEP) was created and tested toward the end of HSDP II aimed at achieving universal PHC coverage and institutionalisation of the community health services at health post level. By the conclusion of HSDP II in 2004/5, there were 2,800 trained and deployed female HEWs with another 7,138 already enrolled for training9. Priority health programmes including prevention and control of infectious communicable diseases such as HIV/AIDS, Malaria and TB, have achieved notable improvements during these periods, especially in family planning. Contraceptive coverage grew dramatically from the low proportion (only 4%) in 1996/97 up to 25% in 2004/0510. 2.2 Detailed account of HSDP III performance The following sections provide detailed account of performance of HSDP III in priority programmes and health system issues. 2.2.1 Health service delivery & quality of care in HSDP III 2.2.1.1 Family Health Service The major targets for family health services under HSDP III were: • To increase family planning service coverage (CPR) from 25% to 60%; • To increase institutional deliveries attended by skilled health workers from 12% to 32%; • To ensure provision of BEmONC in 100% of HCs, CEmONC in 87% of the hospitals and 20% of the HCs; • To increase DPT3/Penta3 coverage from 70% to 85%, • To increase the proportion of fully immunised children from 45% to 80%, H SD P IV 9 • To expand IMNCI implementation from 36% to 90% of Health Facilities, and Community IMNCI (CIMNCI) implementation from 12% to 80% of the districts in the country. In order to achieve these targets, MoH made substantial investments in procuring equipment for clean delivery and B/CEmONC services. Accelerated training of health officers was initiated and around 5,000 were enrolled, of which about 70% were graduated and deployed. A masters level programme in Emergency Surgery and Obstetrics for health officers was introduced; the first cohort has already graduated and been deployed. Inadequacies in the pre- service training of HEWs in MNCH were recognised, and a one month in-service training on clean and safe delivery was designed and implemented for HEWs in all regions. Key pilot initiatives such as Making Pregnancy Safer have been evaluated. Figure 1. Delivery by skilled birth attendants in regions, 2008/09 By 2008/09, antenatal care coverage had reached 68%, postnatal care 34% and family planning coverage was 56.2%, as measured by CPR11. Clean and safe delivery by HEWs increased to 10.8%. The percentage of deliveries assisted by skilled health personnel rose to 18.4% from the baseline of 12%, although there was a wide variation among regions. Regional disaggregation showed levels of delivery with a skilled worker ranging from 5.6% in Benishangul-Gumuz region to 62.5% in Addis Ababa; five regions (Tigray, SNNPR, Harari, Addis Ababa, and Dire Dawa) performed above the national average12. An EmONC assessment was conducted in 2007 on a total of 111 hospitals; of these, 51% provided comprehensive EmONC, 14% had basic emergency obstetric services, and 34% of hospitals had a partially functioning EmONC13. In H SD P IV 10 the same assessment, a total of 684 health centres provided obstetric and neonatal services, but only one health centre provided comprehensive EmONC, nine had Basic EmONC, and 674 provided just partial EmONC services, which is far behind the targets set in HSDP III. The EmONC Assessment Report documented some critical gaps; almost half of the facilities did not provide newborn resuscitation and only 80% provided parenteral antibiotics. Lack of essential equipment, such as “Ambu-bags” and masks, and shortages of skilled workers were the major constraints causing such low performance. According to the MoH 2008/09 administrative report, IMNCI provision was also short of the planned targets. Only 930 health centres (68.2%) and 81 hospitals (72.9%) were providing IMNCI, and just 215 Woredas in ten regions were providing Community IMNCI interventions. Meanwhile, encouraging progress was made in developing strategies, guidelines, and standards for adolescent and youth reproductive health. Minimum service delivery packages for youth friendly reproductive health service were prepared and health care providers were trained on areas of youth friendly services. One year before the termination of HSDP III, Pentavalent immunisation coverage had reached 82%, measles immunisation coverage was 76.6%, and the percentage of fully immunised children was 65.5%14. These results indicate that the HSDP III target was met for measles immunisation coverage and nearly so for the percentage of fully immunised children. Figure 2. Trend in immunization coverage, 2008/09 Five regions (Addis Ababa, Harari, Amhara, Tigray, and SNNP) have persistently attained immunisation levels above the national average for the last three consecutive years, while levels in Gambella, Afar and Somali regions are the farthest below the targets. H SD P IV 11 Figure 3. Immunization coverage across regions, 2008/09 2.2.1.2 Prevention and control of communicable diseases Malaria and other vector born diseases prevention and control Malaria prevention and control has enjoyed the utmost government commitment and considerable attention from the health policy makers since the beginning of HSDP I. Strategies to reduce the overall burden of morbidity and case fatality rates have substantially remained the same: comprehensive approach to vector control; early diagnosis and prompt treatment; and surveillance, prevention and rapid management of malaria epidemics when and where they occur. The major targets for HSDP III in malaria prevention and control were: • to distribute 20 million ITNs to households in malarious areas; • to increase the proportion of ITN usage, especially for under 5 children from 2% to 63%, and for pregnant women from 2% to 49%; • to reduce malaria morbidity from 22% to 10%; and • to reduce the malaria case fatality rate in age groups of 5 years and above from 4.5% to 2% and in the under 5 children from 5% to 2%. The distribution of ITNs successfully reached around 22.2 million in 2008/09, making Ethiopia the third highest bed net coverage achiever in Sub-Saharan Africa after Togo and Sierra Leone15. The majority of the ITNs are long lasting insecticide treated nets (LLITN). They have been distributed to communities, including those in hard-to-reach areas, through health facilities, enhanced outreaches, and special community campaigns. The most effective anti-malarial drug, artemether-lumefantrine (Coartem), was introduced nationwide as the first line treatment for Plasmodium falciparum malaria. Access to parasitological diagnosis of malaria has been extended to the peripheral health facilities, including HPs, through the introduction of rapid diagnostic tests (RDTs). Indoor residual spraying (IRS) has been continued as a vector control measure for prevention of malaria epidemics. Much of the scaling-up in malaria prevention and control has been community-based, including basic diagnosis and treatment being carried out by HEWs at health posts or during house-to-house visits. H SD P IV 12 A recent national malaria assessment has shown a 54% and 55% reduction in malaria admission and death, respectively, as compared to baseline period of 2001-200416. The in-patient case fatality rate of malaria in age group >5 years is 3.3%, while the case fatality rate of malaria in age group <5 is 4.5%17. The prevalence of household ownership of at least one ITN in areas below 2,000m was 65.6% and at least one LLITN was 65.3%18. In malarious areas, ITN use by children under five years and pregnant women has remarkably leapt from 2.8% and 1.6% to 41.2% and 42.5%, respectively19. HIV/AIDS prevention and control program HIV/AIDS prevention and control was recognised as a top priority health intervention from the start of HSDP I. The national HIV/AIDS policy was issued in 1998, and in subsequent years, it was followed by the establishment of a National AIDS Council, National AIDS Secretariat, and other relevant bodies. Notwithstanding these efforts, Ethiopia has continued to face a mixed HIV/AIDS epidemic amongst the sub-populations and geographic areas. The plan under HSDP III was to achieve provision of VCT/HCT services in 100% of hospitals and HCs, PMTCT services in 100% of hospitals and 70% of HCs and increase the number of PLHIV on ART from 13,000 to 263,000. These targets were set to achieve a reduction in the adult incidence of HIV from 0.68% to 0.65% and also maintain the prevalence of HIV at the existing state. Recent reports and assessments showed there have been marked increases in the number of health facilities and sites providing HCT, PMTCT, and ART services during the HSDP III period. According to MoH 2008/09 Administrative report, there has been an increase in health facilities providing HIV services rising from 801 to 1823 for (VCT) HCT, from 93 to 1023 for PMTCT and from 168 to 511 for ART. The number of clients using (VCT) HCT services has gone up to a record of 8,295,483 persons as compared to the 564, 321 in 1998. Meanwhile, only 6,466 HIV-positive mothers received PMTCT prophylaxis at the end of the fourth year of HSDP III, a performance that just reached 8.2% of an estimated 79,184 HIV- positive pregnant mothers and 14,148 HIV-infected births within a year. Figure 4. Facilities providing HCT/VCT, PMTCT, and ART services, 2009/10 H SD P IV 13 By 2009, the estimated HIV prevalence rates for male and female were 1.8% and 2.8%, respectively. There were also a total 855,720 AIDS orphans in the country. Overall, the national point prevalence for 2009 was 2.3%20. During the same year, adult HIV incidence was 0.28 resulting in total AIDS related deaths of 44,75121. Urban HIV prevalence was 7.7% in 2008 with an estimated 62% of total PLHIV in the country residing in urban areas. Rural HIV prevalence was 0.9%, and accounted for 38% of total PLHIV. In urban settings, the epidemic varies from 2.4% in the Somali region to 9.9% in Tigray, 10.7% in Amhara and 10.8% in Afar. The rural HIV epidemic also varies among regions, ranging from 0.4% prevalence in Somali region to 1.5% in Amhara region22. It is still a challenge to describe the true national trend in HIV incidence and prevalence due to the varying methodologies in different surveys. In 2009, the HIV/AIDS Prevention and Control Office (HAPCO) estimated that there were around 1,116,216 people living with HIV and of these 336,160 needed ART. Recent Service delivery reports from HAPCO (Feb. 2010) indicate that the number of PLHIV ever enrolled in an ART programme has increased to 443,964, while those ever started on ART increased to 246,347 and the number of PLHIV on ART reached to 179,183. Thus ART coverage reached 53% (percentage of PLHIV currently on ART out of the total eligible), which showed significant progress compared to the baseline of 13,000 in 2005/06. Figure 5. Trend in actual numbers of PLHIV accessed care, 2004/05-2009/1023 Among regions, the highest proportion of PLHIV enrolled in HIV care is seen in Amhara, Oromia and Addis Ababa. Harari region manages to enrol far more than the target (122%), but Somali region only reaches 13% of the eligible target. The Beneshangul-Gumuz, Dire Dawa, Addis Ababa, and Tigray regions also performed well, enrolling 66%, 66%, 68% and 73% of the targeted eligible persons respectively. H SD P IV 14 Figure 6. PLHIV Currently on ART across regions, 2009/10 TB and leprosy control programme (TLCP) Tuberculosis has remained a major global public health problem. Ethiopia ranks seventh among the world’s 22 high-burden tuberculosis (TB) countries24. Prevention and control of TB has created additional challenge to health care systems in many of developing countries including Ethiopia due its linkage with HIV/AIDS. WHO recommends a focus on the Three 'I's, isoniazid preventive treatment, intensified case finding for active TB, and TB infection control, to be the key public health strategies to decrease the impact of TB on people living with HIV. Ethiopia has run an integrated TB and leprosy control programme (TLCP) health care intervention since the beginning of HSDP I. The general objective of the TLCP is to reduce the incidence and prevalence of TB and Leprosy as well as the occurrence of disability and psychological suffering related to both diseases; and to reduce mortality resulting from TB to such an extent that both diseases are no longer public health problems. HSDP III mainly focused on enhancing the detection rate and completion of regularly provided treatment as the main strategy for the prevention and control of TB. The target set in HSDP III for the prevention and control of TB was to achieve 85% treatment success rate and a detection rate of 70% of new sputum-positive TB cases. H SD P IV 15 Figure 7. Trend in TB Detection, Treatment & Cure Rate, 2008/0925 The national cure and treatment success rates are 67% and 84%, which is on track towards the HSDP III target, while the case detection rate remains at 34%, far less than what was planned for HSDP III. Regional disaggregation showed highest Case Detection Rate in urban administrations (Harari 95%, Dire Dawa 81% and Addis Ababa 63%). The Somali, Amhara and Tigray regions performed lowest at 19%, 23%, and 26% respectively. With reference to Treatment Success Rate, all but three regions (Tigray 79%, Addis Ababa 72%, and Harari 64%) were above the national average; the highest performances were in Afar (92%) and Gambella (89%). Figure 8. TB Case detection, treatment success and cure rates, 2008/09 In 2009/10, 3,465 (35.4%) health facilities out of the 14,329 health facilities (hospitals, health centres, clinics, nucleus health centres and health posts) were providing TB-DOTS service and 879 (7%) health facilities were implementing TB/HIV collaborative activities26. According to WHO estimates in 2009, the incidence ratio of all forms of TB in Ethiopia was 379 per 100,000; in the same H SD P IV 16 year, the prevalence of TB Infections was 579/100,000 and the mortality rate due to TB was 92/100,000. In terms of leprosy control, WHO figures show that the prevalence of leprosy in Ethiopia is estimated at 6 per 100,000 in 2005/2006 with an estimated 4,000- 5,000 cases detected every year. Like Tuberculosis control, leprosy control is based on enhancing the detection rate and completion of regularly provided treatment. There have been improvements in the detection rate and treatment of leprosy. The treatment completion rate for Leprosy cases has reached 89% from the baseline of 82% in 2004/0527. More effort is required, however, to reduce the prevalence of grade 2 disability from 12% to less than 10% as targeted in HSDP III. There were 3,878 new cases detected in 2008/2009. Reports have also shown that there has been a decline in proportion of grade 2 disabilities among new leprosy cases from 9% in 2007/2008 to 7% in 2008/2009. These figures are still far behind the target of 2% in HSDP III. Blindness prevention and control programme The prevalence of blindness in Ethiopia is 1.6%; there are 1.2 million people with blindness of all causes and 2.8 million people with low vision. Cataract, trachoma, glaucoma and childhood blindness are the major causes of blindness in Ethiopia. Cataract and trachoma account for more than 60% of all blindness28. Prior to HSDP III, the MoH launched the Global Initiative on blindness prevention and control, VISION 2020; established a National Eye Bank and developed a standardised cataract surgeons' training curriculum. Under HSDP III, the plan was to reduce active trachoma in 80 targeted Woredas by 80% and increase the Cataract Surgical Rate (CSR) from 350 to 600 per million population per year. The main strategy in place for trachoma control is “SAFE”, i.e., Surgery, Antibiotics, Facial cleanliness and Environmental Sanitation, including preventive measures. The HSDP III performance report showed that the number of Woredas implementing SAFE Strategy for trachoma reached 124 and about 37,000 cataract surgeries were performed in 2008/2009, making a cataract surgical rate of 460 /million/year for an achievement rate of close to 60% of the HSDP III target. Ophthalmic human resources and service delivery has improved over the years. From 2004 to 2008/09, the number of ophthalmologists increased from 63 to 76 and primary eye care units from 46 to 54; and the number of cataract surgeries increased from around 20,000 in 2002 to 25,000 in 2004 and 37,000 in 2008/09. Onchocerciasis control and dracunculiasis eradication Concerning onchocerciasis control, the plan was to expand the programme to all highly affected districts by 2005 and eliminate the disease by 2020. The evaluation of the past performance indicated that the programme has been successfully expanded to all the affected districts during HSDP II period. The target under HSDP III has been to achieve a 65% onchocerciasis control in all Community-Directed Treatment with Ivermectin (CDTI) areas and ensure the progress and sustainability of the programme. The HSDP III performance H SD P IV 17 reports shows that therapeutic coverage for 2008 and 2009 has reached 75% and 77%, respectively. Ethiopia is one of 12 dracunculiasis endemic countries that agreed to take concerted actions to interrupt local transmission of the disease by 2009. Nonetheless, 23 indigenous cases were reported in 2009 from Gambella Regional state making it difficult to make progress towards a Dracunculiasis free country. 2.2.1.3 Prevention and control of non­communicable diseases The largest proportion of serious injuries in Ethiopia comes from road traffic accidents; they have become one of the major national health burdens. The health sector recognizes that injuries have multiple causes that necessitate a multi-sectoral approach towards effective prevention and rapid responses when they occur, including efforts to strengthen the quality and availability of emergency medical services. The target under HSDP III was to improve the proportion of people seeking formal health care in the case of serious illness or injury from 41% to 55%. An assessment report by the MoH in 2008 has shown that non-communicable diseases such as cardiovascular diseases, diabetes mellitus and cancers along with injuries are amongst the major contributors to the high level of mortality and morbidity in Ethiopia. In 2007, researchers looking at the pattern of injuries in Addis Ababa found that injuries accounted for 27% of all emergency visits, 5% of all hospitalisations, and 3% of deaths. The findings from a community- based survey in Jimma Zone in 2007 showed that prevalence rate of injury was 8.9% per year; out of the 304 individuals studied, 83.5% had received health care at different levels of health facilities and 5.2% were admitted for inpatient care29. 2.2.1.4 Integrated Disease Surveillance & Public Health Emergency Management HSDP-II planned to establish and strengthen Integrated Disease Surveillance (IDSR) in health facilities and at the community level in order to bring a significant reduction in the incidence of epidemics and outbreaks. This surveillance observed a remarkable frequency and geographic coverage of acute watery diarrhoea (AWD) in the last five years. In addition to their impact on human health, the outbreaks also put significant pressure on other programmes by diverting attention and resources. Under the BPR, these observations led to identifying Public Health Emergency Management (PHEM) preparedness and response as a core process to be introduced. In order to establish PHEM teams at MoH and RHBs, 13 epidemic intelligence service officers are being trained at Master’s Degree level in Addis Ababa University. Twenty diseases have been selected for surveillance and detection and a new forecasting, early warning, response and record system has been designed. 2.2.1.5 Hygiene & environmental health The objective of this section is to increase the coverage and access to hygiene and environmental health services for the rural and urban populations of the country. During HSDP I and II, the MoH developed a National Sanitation H SD P IV 18 Strategy and instituted measures for strengthening water quality monitoring by the public sector. Access to sanitation facilities improved from 12.5% to 17% in 2002/2003; and access to toilet facilities increased from 10% to 29% in 2003/2004. During these periods, it also became possible to open two additional International Vaccination Centres at St. Paul and St. Peter TB Specialised Hospitals. However, the services for hygiene and environmental health have not sufficiently reached the majority of rural population and have been limited largely to urban areas, particularly in some regions of the country. The country is also prone to climatic changes resulting in recurrent drought in different parts with potential impact on health of the population and health services infrastructure. HSDP III had specific targets for hygiene and environmental health. Some of these are increasing the latrine coverage from 20% to 80% and to reach 100% in the medical and other waste management system in public and private health institutions. During HSDP III, the Ministry developed a National Hygiene and Sanitation Strategy and a National Protocol for Hygiene. In this period the MoH commenced implementation of Community Led Total Sanitation (CLTS). They also started a National Millennium Hygiene and Sanitation Movement with the development of a mass mobilisation and communication strategy. Four regional towns have been selected for the Healthy Cities Programme. The work also included the development of Urban Health Service Package with five manuals for the delivery of urban health services. While significant progress has been made, it seems the achievements in hygiene and environmental health are still well below target levels. Latrine coverage has reached 60%, which falls short of meeting the target30. Waste management has reached 60%, again very far from the HSDP III target. Other important activities included the establishment of a committee for infection prevention in public hospitals. 2.2.1.6 Health Extension Programme (HEP) Under HSDP II, the Health Extension Programme was introduced in 2002/03 with a fundamental philosophy that if the right health knowledge and skill is transferred, households can take responsibility for producing and maintaining their own health. Substantial investments in human resources, health infrastructure, pharmaceutical supplies and operational costs have been made for the successful implementation of the program. H SD P IV 19 Figure 9. Trends in the training of HEWs, 2004/05-2009/10 Under HSDP III it was planned to cover all rural Kebeles with the HEP, aiming to achieve universal PHC coverage by 2008 through vigorous and incremental implementation of the programme nationwide. From the very start HEP was supported with the development of 16 different health intervention packages to be delivered by HEWs at community level. These packages along with implementation guidelines were made available to implementers as well as to technical and vocational training institutions. In pastoral areas, the packages have been subjected to modification commensurate to the life style of the pastoralist population. The training of all female HEWs has been progressing well, leading to community acceptance and encouraging signs of demand for HEP services. By the end of HSDP III, a total of 33,819 HEWs were trained and deployed, surpassing the HSDP III target of 33,033 HEWs31. Meanwhile, the model households that had been trained and graduated only reached a cumulative total of 4,061,532 from an eligible total of 15,850,457 households. Thus, coverage only reached 25.6%, leaving a huge gap of more than 11 million households to be trained and graduated. This will require progressive and sustained efforts at all regions and levels of the health care system. H SD P IV 20 Figure 10. Trends of construction of Health Posts, 2004/05-2009/10 There has been tremendous progress in the construction of health posts (HPs) for the delivery of HEP at community level. The total number of HPs has increased from the baseline of 6,191 in 2004/05 to 14,416 in 2009/10, more than doubling in a space of only four years. Even so, this number only reached 89% of communities, versus the planned target of 100% under HSDP III32. Equipping HPs with medical kits remain a major challenge during HSDP III; only 83.1% or 13,510 HPs out the planned target of 16,253 HPs were fully equipped. As part of the implementation, 2,566 HEP supervisors were trained and deployed, thus achieving 80.2% coverage against the plan of 3,200. The MoH prepared technical guidelines for HEP supportive supervision together with other technical reference books for rural HEP and manuals for school health program; these have been as part of the BPR. In addition, the implementation manual for pastoralist and semi-pastoralist areas was finalised and distributed to respective regions. Other major activities in support of HEP included establishing HEP departments at regional levels and respective structures at zonal and Woreda levels to strengthen the management support to HEP. In order to expand urban HEP in seven regions of the country, 15 HEP packages along with a manual were developed and distributed for implementation. Training and deployment of urban HEWs is already in progress in Tigray, Amhara, Oromia; SNNP, Harari, Dire Dawa; and Addis Ababa. Accordingly, these regions have trained and deployed a total of 2,319 Urban Health Extension workers achieving 42% of the targeted number. 2.2.1.7 Medical services In addition to constructing and expanding health facilities, during HSDP III, the MoH focused on strengthening management of health facilities to enable delivery of effective, efficient and quality medical services. The MoH launched the Ethiopian Hospital Reform Implementation Guidelines to provide guidance for hospital managers about how to improve nursing care, facilities and equipment management, human resource management, infection prevention and quality management. Similar guidelines are also being developed for Health Centres. H SD P IV 21 An assessment done in 47 selected hospitals on their performance for the year 2009 showed 50.8% bed occupancy rate (BOR), 27.8% patients per bed per year as bed turn-over rate (BTR), and 6.7 days of average length of stay (ALOS). The same revealed that average cost per patient–day equivalent (PDE) of 196 ETB33. With respect to per capita attendance rate though there is difficulty to measure progress due to erratic implementation of the new HMIS in regions the performance in 2009/10 is 0.3. Yet an increasing number of indigenous and international NGOs are currently involved in various aspects of service delivery; in 2008/09, there were 277 private-not-for-profit clinics and 1,788 private-for- profit clinics in the country. The total number of hospital beds is 13,922, which mean that there is about 1.9 beds per 10,000 population, which compares to 9 beds per 10,000 population average for Sub-Saharan Africa and 27 beds per 10,000 population globally34. 2.2.1.8 Nutrition Nutritional disorders are among the main causes of morbidity and mortality. The major problems are protein-energy malnutrition and micronutrient deficiencies such as vitamin A, iron, and iodine. In addition to the efforts by Agricultural and Rural Development Sector, which is responsible for making adequate nutrition available to the population, during HSDP I & II the Health Sector supported good nutritional practice in homes. Specifically, the MoH provided health education, treatment of severely malnourished children and prevented nutritional problems through provision of micronutrients to vulnerable populations (mothers and children). Nutrition was also made part of the HEP packages. During HSDP III, the MoH developed and implemented the National Nutrition Strategy and programme. This plan included a target of creating access for 90% of children 6-59 months to nutritional screening. To this end, nutritional screening was done every three months at HP level, aiming to screen more than 95% of the 6-59 month old children. The plan also targeted increasing the proportion of infants 0-5 months exclusively breast fed from 38% to 63%. Based on the DHS 2005 the national coverage of exclusively breast fed infants is 49%. However, a recent study in four regions (Amhara, Oromia, SNNPR and Tigray) showed that the prevalence had reached 76% by 2008/0935. The proportion of children aged 6-59 months getting vitamin A supplementation per year reached 95% in 2008/09. Transition from the Enhanced Outreach Strategy (EOS) into the Health Extension Package (HEP) started in 39 districts in conjunction with the Community-Based Nutrition (CBN) roll-out. The core package of CBN interventions was implemented in 849 sub-districts of Amhara, Oromia, SNNPR and Tigray Regions (surpassing the target of 60% coverage). 2.2.2 Health sector reform Health sector reform in Ethiopia is part of the on-going socio-economic reforms that started with Civil Service Reform and is now covering the entire public sector of the country. The health reforms have been intensified through the application of a new concept known as Business Process Reengineering (BPR), which is a tool for comprehensive analysis, redesign and revamping of the H SD P IV 22 sector. The BPR is a country led, multi-sectoral undertaking implemented within the government’s civil service reform. The BPR process informs a fundamental rethinking and requires a purposeful and radical redesign of health business processes to achieve dramatic improvements in critical, contemporary measures of performance such as cost, quality, service and speed. The purpose of the BPR in the health sector is to establish customer focused institutions, rapid scaling up of health services and enhancing the quality of care, thereby improving the health status of the Ethiopian people as desired in the mission of the health sector. Following a deep and systematic analysis of the “AS-IS” situation at all levels of the health system, including health facilities, the sector has introduced a number of innovative approaches. These new approaches include benchmarking best practices, designing new processes, revising organisational structures and a selection of key processes (8 core and 5 support processes). The new core processes are: • Health & Health-Related Services & Product Regulation; • Health Care Delivery; • Health Infrastructure Expansion & Rehabilitation; • Pharmaceutical Supply; • Policy, Planning, Monitoring & Evaluation; • Public Health Emergency Management; • Research & Technology Transfer, • Resource Mobilisation & Health Insurance. The support processes are: • Human Resources Development /Management • Legal Services; • Procurement, Finance and General Service; • Program-Based Audit; • Public Relations. The BPR has been progressively implemented through a series of training sessions for managers and technicians at all levels followed by changes in staff deployment, specific job assignments and the recruitment of new staff. All of these reforms are being done under the close oversight of the top health leadership. 2.2.3 Health facility construction and expansion Since HSDP I, health facility construction, expansion, rehabilitation, furnishing and equipping has mainly focused on PHC facilities: HPs and HCs and to a certain extent hospitals. By the end of HSDP II, the number of public HCs had increased by 70% from 412 in 1996/97 to 519 in 2003/04. In the same period, the number of HPs increased from 76 in 1996/97 to 2,899. The number of hospitals (both public and private) also increased from 87 in 1996/97 to 126 in 2003/04. There was also a considerable health facility rehabilitation programme and furnishing during HSDP I and HSDP II, including improvements in support facilities. As a result, the potential health service coverage increased from 45% in 1996/97 to 64.02% by 2003/04. The HSDP III plan was to further expand these and other services by the end of 2008 with the aims of achieving universal health service coverage and improving the delivery of primary health care services to the most neglected rural populations. This was an extension of the Accelerated Expansion of Primary H SD P IV 23 Health Service Coverage that was launched at the midterm of HSDP II. The HSDP III target in this component has been to attain a 100% general potential health service coverage by reaching the level of 3200 functioning HCs. This was to be done through construction, equipping and furnishing of 253 new HCs; upgrading 1,457 HPs to HC level; and upgrading 30% of HCs to enable them to perform EmONC services. Table 1. Trends of health facility construction Facility HSDP I (1996/7) HSDP II (2003/2004) HSDP III (2010) HPs 76 2,899 14,416 HCs 412 519 2822 Hospitals1 87 126 195 Health sector progress in facility construction, upgrading and equipping under HSDP III has been remarkable. The number of HPs has now reached 14,416, achieving 88.7% of the target by 2009/10. There are now 2,822 HCs, which is 85.5% of the 3,200 HCs targeted by the end of HSDP-III. An additional 378 HCs need to be constructed to reach the 100% target. Of the health posts, 13,510 HPs have been equipped, representing 83.1% of the target, which was to equip 16,253 health posts. At the beginning of HSDP III, there were 82 hospitals of all types (37 District, 39 Zonal and 6 Specialised Hospitals). The planned target under HSDP III was just a small increase in the number of hospitals for a total of 89 (42 district, 41 zonal, and 6 specialised). However, the 2008/09 report showed that the target has been surpassed to reach a current total of 116 Public Hospitals (nearly a 25% increase)36. Construction of support facilities is also moving ahead; 21 blood banks are in progress in six regions with 95% of the construction completed in 2009. A National Laboratory Master Plan has also been completed. 2.2.4 Human resource development Human Resource Development (HRD) has been a key component in the successive HSDPs. In HSDP III, the main HRD objective was improving the staffing level at various levels as well as establishing implementation of transparent and accountable Human Resource Management (HRM) at all levels. It was envisaged that this would be made possible through increasing the With 1 It shows both Public and private hospitals as of 2009/10 H SD P IV 24 number and capacity of training institutions; using health institutions as training centres; establishing a platform for the effective implementation of CSRP; and introducing incentive packages. the aim of improving services, the government initiated the BPR process that thoroughly analysed the HRH situation in the country. Based on this a comprehensive HRH strategic plan was developed through the involvement of relevant stakeholders, development partners and international consultants. The resulting plan details the HRH planning, management, education, training and skill development, legal framework and financing mechanism. Considering the HRH staffing numbers and composition required to achieve universal Primary Health Care (PHC) coverage by the end of HSDP III, the MoH focussed on scaling up training of community and Mid-Level Health Professionals (MLHPs). To meet the needs for the community level HEP, a total of 31,831 HEWs were trained and deployed. For MLHPs, an Accelerated Health Officer Training Programme (AHOTP) was launched in 2005 to address the clinical service and public health sector management needs at district level. So far, more than 5,000 health officer trainees (generic and upgrade) have been enrolled with 3,573 Health officers graduated and deployed. To address the HRH need for Comprehensive Emergency Obstetric Care (CEmONC) and other emergency surgical services at PHC level, a masters’ level curriculum on Emergency Surgery was developed and training started in five universities. To address critical shortages and the maldistribution of doctors, a new medical school was opened in St. Paul’s Hospital, the Millennium Medical School. This school has an innovative curriculum that integrates clinical skills and social accountability. Overall, comparing the available professionals at the end of HSDP III with the targets for the period shows targets have been met for the community level and most of the Mid-Level Health Professionals (MLHPs). However, there are still major gaps for medical doctors, midwives and anaesthesia professionals (See Table below), especially when considering the long lead time and limited involvement of the private sector in training these professionals. Table 2. Total number of available human resources during successive HSDP phases HR Category End HSDP I - 1994 HSDP II - End 1997 HSDP III (data from 2009) Total No Ratio to population Total No Ratio to population Total No Ratio to Population Target All physicians 1,888 1:35,603 1,996 1:35,604 2152 1: 36,158 1:14,662 Specialist 652 1:103,098 775 1:91,698 1151 1:67,604 General practitioners 1,236 1: 54,385 1221 1:58,203 1001 1:77,735 Public health officers 484 1:138,884 683 1:104,050 1,606 1: 48,451 1:63,785 Nurses BSc degree, & Diploma (except midwives) 11,976 1:5,613 14,270 1: 4,980 20,109 1: 3,870 1:4725 Midwives (Senior) 862 1:77,981 1,274 1: 55,782 1,379 1: 13,204 1:6,759 Pharmacists 118 1:569,661 172 1:413,174 661 1: 117,397 Pharmacy Tech. 793 1: 84,767 1171 1: 60,688 3,013 1: 25,755 Environmental HW 971 1: 69,228 1169 1: 60,792 1,819 1: 42,660 Laboratory technicians & technologists 1,695 1:39,657 2,403 1: 29,574 2,989 1: 25,961 Health Extension Workers - - 2,737 1: 23,775 33,819 1:2,301 1:2,500 Table 3. Total number of available human resources for health by region, 2009 Region Physician (GP, specialist) Physician : Population Ratio Health Officer (HO) HO : Population Ratio All Nurses Nurse : Population Ratio Mid- wives Midwife: Population Ratio HEW* HEW : Population Ratio Tigray 101 1:44,880 188 1:24,111 2,332 1:1,944 185 1:24,502 1,433 1:3,163 Afar 15 1:98,258 29 1:50,823 185 1:7,967 − − 572 1:2,577 Amhara 304 1:58,567 434 1:41,024 3,790 1:4,698 212 1:83,983 7,471 1:2,383 Oromia 378 1:76,075 448 1:64,189 5,040 1:5,706 287 1:100,197 13856 1:2,075 Somalia 71 1:65,817 12 1:389,415 314 1:14,882 45 1:103,844 1,427 1:3,275 Ben-Gumuz 12 1:59,309 42 1:16,945 452 1:1,575 37 1:19,235 499 1:1,426 SNNPR 242 1:65,817 220 1:72,398 3,980 1:4,002 316 1:50,404 7,915 1:2,012 Gambella 13 1:25,585 13 1:25,585 91 1:3,655 4 1:83,150 457 1:728 Harari 29 1:6,655 31 1:6,226 276 1:699 29 1:6,655 47 1:4,106 Addis Ababa 934 1:3,056 170 1:16,791 3,377 1:845 244 1:11,699 NA - Dire Dawa 53 1:6,796 19 1:18,957 272 1:1,324 20 1:18,009 142 1:2,537 National 2,152 1:36,158 1,606 1:48,451 20,109 1:3,870 1,379 1:56,427 33,819 1:2,301 The above table shows the health professional to population ratio in selected key categories of health professionals across regions. As of 2009, the numbers of health professionals in different parts of the country were still lower than the targets that had been set. The inequity is particularly evident in rural agrarian and pastoralist regions. 2.2.5 Pharmaceutical services Since HSDP I, the government has been committed to ensuring community access to essential medicines that are safe, effective and of assured quality as well as supporting rational drug prescription and use. In the on-going health sector reform, ensuring a regular and adequate supply of pharmaceuticals has been considered as one of the core processes in the BPR and the following have been implemented so far. In order to improve efficiency in the supply chain of pharmaceuticals and medical supplies, PHARMID has been transformed into the Pharmaceutical Fund and Supply Agency (PFSA) with several measures taken to strengthen the capacity of the new agency. These measures include: • Deployment of more regular staff and mobilisation of TAs. • Design of the LMIS • Selecting 18 sites for warehouses and hubs, and beginning construction. • Overhauling and strengthening transport capacity of the Agency through procurement of 92 trucks. • Improvement in Revolving Drug Fund (RDF) volume by making available additional funding. • Building cold rooms that increased national capacity five-fold. PFSA has developed a national list for procurement of Essential Pharmaceuticals. It has been able to develop a pharmaceutical forecasting plan in consultation with health facilities about what would be required for need-based procurement. The Agency has undertaken capacity building activities in the areas of drug H SD P IV 26 supply management and also engaged in the establishment and strengthening of Drug and Therapeutic Committees (DTC) in health facilities to improve the supply and rational use of pharmaceuticals. The new Agency has already started handling bulk procurement, storage and distribution of pharmaceuticals. 2.2.6 Health and health related services and product regulation A key principle underpinning the health sector BPR was improving the quality of health services through institutionalising accountability and transparency. One mechanism of achieving this was to seriously consider the separation of purchaser, provider and regulator in the health system. As part of this important endeavour, the former Drug Administration and Control Agency (DACA) has undergone an institutional transformation into a new group called the Food, Medicine and Health Service Administration and Control Agency (FMHACA). The mandate of the new agency is to undertake inspection and quality control of health and health related products; premises, professionals and health delivery processes in an integrated manner. The Agency is being strengthened through the construction of a new building at the federal level. New branch offices at regional levels have helped the Agency to expand the drug administration and control system throughout the country. The agency now has five branch offices enabling delegation on drug administration and control to RHBs. The agency is working closely with RHBs on drug quality and rational use through the process of reviewing drug documents, physical and laboratory quality assurance checks. The Agency works collaboratively with other relevant government offices on prevention and control for the use of narcotic drugs, including tobacco. The agency has also recently procured and installed modern equipment for the safe disposal of expired drugs. 2.2.7 Harmonisation and alignment Under harmonisation and alignment, the major objective is to have the One- Plan, One-Budget and One-Report approach at all levels of the health system. In this approach, all actors in the sector should work together to harmonise and align their actions and procedures with the country’s systems. A Code of Conduct between the MoH and its major Health Development Partners was signed in 2005 to guide everyone’s actions in support of HSDP. Afterwards, an operational manual entitled “HSDP Harmonisation Manual” was prepared in 2007 and subsequently endorsed by stakeholders. Ethiopia has been one of the signatories of the Global IHP+ Compact and one of the countries in the first wave to develop and sign a Country-based IHP+ Compact. One Plan The Government has been implementing a comprehensive national socio- economic development plan called, “the Plan for Accelerated and Sustained Development to End Poverty-PASDEP”. This is a single national plan that guides all other sectoral plans, including health, for the years covering 2005/06- 2009/10. The health sector wide strategic plan (HSDP) is the product of substantial consultations between the Ministry of Health and the Health Development Partners. In 2005, the MoH and its partners developed the HSDP III as a single programme framework, i.e., ‘one plan’, for coordinating health interventions aligned with the PASDEP. The goals, targets and costing of HSDP- III were also aligned with the health MDGs. H SD P IV 27 One of the most important achievements in HSDP III was the inclusion of “Woreda-Based Health Sector Planning”, which was a breakthrough in the health planning system that helped ensure vertical and horizontal alignments in the health intervention priorities of the sector. In the four consecutive years from 2006, Woreda-based health sector plans have been prepared in line with the principle of “one plan, one budget, and one report” of the HSDP Harmonisation Manual (HHM) based on agreed priorities and targets. This planning system created a platform for joint planning by all stakeholders at all levels of the health system including health development partners. This exercise also improved the capacities of Woreda health offices in conducting evidence-based planning, which has returned remarkable results. One Budget In HSDP terms, the principle of “One budget” means that all available funding for health activities (government and donor sources) are effectively pooled and should flow through government channels. Another important issue is that all funds for health activities should be reflected in just one plan and one documented budget, although actual funding disbursements may flow through separate channels. Subsequent to signing the IHP+ Compact in 2008, the MoH and health development partners jointly commissioned an independent health system assessment to examine its financial administration, procurement, equity and social inclusion with the intention of filling the prevailing resource gaps. The assessment identified critical capacity limitations at Planning, Program & Finance - General Directorate (PPF-GD), Finance and Audit section of the MoH, and PFSA that were impeding efforts to enhance performance in accord with the reform design. Another finding was the slow pace in the scaling up of HMIS and M&E. The assessment report made relevant recommendations for mitigating these challenges, which were documented as part of POA of MoH. This assessment led to establishment of the MDG Performance Fund as an important step toward agreement on a one-budget framework in the health sector of Ethiopia. MoH and Development Partners developed a Joint Financing Arrangement (JFA) for the MDG Performance Fund that has been signed by seven Development Partners, thereby enabling the MoH to access and make use of pooled funds. The health sector now has a sector-wide Medium Term Expenditure Framework (MTEF) for aligning the allocation of available domestic and external resources for HSDP-IV priorities. It is seen as a useful instrument for negotiation and advocacy in mobilising additional internal and external resources. Some milestone activities have been completed, including resource mapping and gap analysis at the federal level. Many development partners, though not yet all of them, have disclosed their three-year resource commitments to the health sector. Similar activities are in progress at Woreda level where resources from local governments, NGOs and other organisations are expected to be captured in the one plan framework. One Report/One M&E One of the major targets of HSDP II was to establish the HMIS throughout the health delivery system, with functioning HMIS units at all levels. The aim was to ensure information availability for evidence-based health planning and decision- H SD P IV 28 making. The multi-stakeholder HMIS National Advisory Committee (NAC) was established during HSDP II and facilitated the design and pilot testing of the new HMIS during HSDP III. Scaling up the new HMIS to all regions began with a regional readiness assessment, after which the RHBs developed detailed implementation plans. The MoH then printed and distributed HMIS tools to regions. HMIS Resident Mentors have been deployed to implementing regions. More recently, a system of Electronic Medical Records (EMR) has been pilot tested in a hospital setting and is now ready for scaling up at the national level. As part of the BPR, integrated supportive supervision, operational research, performance reviews and quality assurance and inspections are now complementing M&E to inform strategic planning of the health sector. The MoH has finalised implementation manuals, tools and system requirements for the implementation of these approaches. Joint Performance reviews such as the ARM and Joint Review Mission (JRM) are being undertaken according to the plan; the Annual Review Meeting (ARM) has been conducted every year. The level of Completeness in the annual HSDP report has also shown significant improvement over the HSDP III period. Governance of HSDP Key coordinating and steering committees are performing well, including the MoH-RHBs Joint Steering Committee, MoH-HPN Joint Consultative Forum and the Joint Core Coordinating Committee. The MoH-RHBs Joint Steering Committee is chaired by the Minister and meets every two months. It promotes and monitors implementation of HSDP Harmonisation Manual and Civil Service Reform agendas (BPR), as well as the other strategic objectives of the HSDP. The Joint Consultative Forum and JCCC meetings have also been regularly functional, with the JCCC focusing on technical and operational issues. Meanwhile, the Central Joint Steering Committee (CJSC), which is the top policy decision-making and governance body of the sector, meets far less often. 2.2.8 Health care financing As clearly indicated in the 4th National Health Accounts (2010), health services in Ethiopia are primarily financed from four sources: a) the federal and regional governments; b) grants and loans from bilateral and multilateral donors; c) non- governmental organisations; and d) private contributions. Although health financing has improved significantly over the years, it remains a major challenge for the health system of Ethiopia. Since HSDP III, a health care financing strategy was adopted by MoH, mainly focusing on improving the efficiency of allocation and utilisation of public sector health resources. It has also dealt with mobilising additional resources from international donors and health development partners, retention and utilisation of user fee revenues at health facility level, introducing private wings in the public hospitals and, perhaps most importantly, the initiation and development of risk sharing mechanisms such as public and community-based health insurance schemes. The objectives of the health care financing component of HSDP are aimed at achieving a sustainable health care financing system. More specifically, the objectives call for mobilisation of increased resources to the health sector, promoting efficient allocation, effective expenditure management for allocative equity, and better utilisation of available health resources. H SD P IV 29 Over the course of the HSDPs, various background studies on health care financing issues have contributed to the design and introduction of health financing reforms. Since the first HSDP, there have been four National Health Accounts (NHA) studies conducted. A Proclamation on Health Service Delivery, Administration and Management, including regulations on all the five components of the reform was drafted and endorsed. RHBs of Tigray, Amhara, Oromia, Benishangul-Gumuz, SNNPR, and Addis Ababa translated most of the reforms into action. The reform components include: retention and utilisation of revenue, administration of the fee waiver system and establishment of functioning facility governance bodies. Other parts of the reforms have included outsourcing of non-clinical services, establishing private wings in health facilities and the exemption of certain services. Retention and utilisation of revenue Ratification of the Health Care Financing Reform proclamation and regulation by the regional governments and City Councils will be the initial steps to commence user fee revenue retention and use at health facility level. The MoH has prepared a number of generic operational manuals to be used, if needed with modifications, for the implementation of the reforms adapted to local conditions. The manuals describe in detail the processes of user fee revenue collection, financial administration, accounting, auditing and procurement of goods and services. The processes are expected to be steered by a functional health facility governance board with key representatives from health, finance, community and other relevant sectors. The facility board will meet on a regular basis and decide on the use of the retained revenue for the eligible expenditure areas, as broadly described in the operational manual. The performance report for health care financing up to the end of fiscal year 2008/2009 showed that 73 hospitals and 823 health centres have started retaining revenue. Encouragingly, 95% of these units collecting user fees had used the revenue at their level. Regarding the target of retention and use of 100% of revenue generated at hospitals and HCs, the same report showed that out of 116 potential hospitals, 73 of 116 hospitals (62.9%) and 823 of 2,142 health centres (38.4%) were able to collect user fee revenue in 2008/09. Of these, 66 (90.4%) and 782 (95%), respectively, utilised their collected revenue. Health insurance Looking at the health care financing mechanism in Ethiopia, one can easily observe the significant contribution of out of pocket payment by households. As per the fourth National Health Account study conducted in 2009/10, which was based on 2007/08 data, household out of pocket payments constituted about 37% of the total health expenditure. Such financing is regressive & impedes access to health services. In order to address this problem & create equitable financing mechanism, the government of Ethiopia is currently undertaking a number of activities to introduce health insurance with the overall objective of achieving universal access. The process of establishing and institutionalisation of an insurance system in Ethiopia was started by various studies and experience sharing visits to several African, Latin American and Asian countries. The MoH built on this work to develop a national health insurance strategy. According to the strategy, two H SD P IV 30 types of health insurance, i.e., social health insurance and community-based health insurance will be implemented to cover the population. Social health insurance will cover employees in the formal sector, which is mainly payroll- based while community-based health insurance will cover the rural population and the informal sector in urban areas. The preliminary work on health insurance led to a background document on Social Health Insurance (SHI) that proposed key policy and technical recommendations, e.g., detailing eligibility for membership, premium levels, benefits packages and an institutional structure for the Federal Social Health Insurance Agency (FSHIA). To date, a draft law and regulation have been revised and presented for policy and technical discussions. A series of consultative discussions have been conducted in Addis Ababa and the regions. The legal framework has been improved based on the inputs from the various stakeholders and then submitted a second time to the Council of Ministers for endorsement and the subsequent ratification by the Federal Parliament. The Social Health Insurance (SHI) Proclamation has finally been approved by the Council of Ministers and then approved by Parliament in July 2010. Other activities are now underway to start its implementation in December 2011. The regulation which contains the detailed features of the health insurance scheme including membership, benefit package, institutional arrangement, etc. has been prepared and is ready for public consultation. Once this consultation has been carried out and feedback incorporated, it will be submitted again to the Council of Ministers for approval. Parallel to the work on social health insurance, various activities have been undertaken to develop and pilot community-based health insurance (CBHI). The CBHI, which aims to cover more than 83.6% of the population, is planned to be implemented in two stages. After piloting, it will be scaled up throughout the country drawing on lessons from the pilot phase. Thirteen Woredas (covering 1.45 million people) in four pilot regions (Tigray, Amhara, Oromia and SNNPR) have been selected to pilot the CBHI. To ensure the acceptability and sustainability of the CBHI, feasibility studies have been made in the four pilot regions and the reports of the studies have served as inputs to the design of the scheme. Preparations for the Woreda level piloting, including detailed implementation plans, have been finalised and the schemes are expected to provide services to their members by early 2011. A Regional Steering Committee has already been established in three of the four pilot regions, and one is being developed in Amhara Region. Trend of expenditure in the health sector Ethiopia’s fourth National Health Accounts study (NHA, 2010) showed that national health expenditures have grown significantly from the 2004/05 level of 4.5 Billion Birr (USD 522 million) up to Birr 11.1 billion (USD 1.2 billion) in 2007/08. In the same time period, the per capita health expenditure has increased from USD 7.14 (in 2004/05) to USD 16.09 (in 2007/08). [see figure 11, next page] The NHA report also identified proportions of health expenditure by source of financing. In rank order, these were 40% by development partners, 37% by household out-of-pocket expenditure, 21% by Government (central and H SD P IV 31 regional) and the rest by a combination of employer insurance schemes and other private sources. Figure 11. Trends of health expenditure in USD/capita Official government reports monitoring health expenditure over the PASDEP period show that the health budget share of the total government budget has been increasing. In 2008/09, for example, the health budget allocation was 10.1% of the received regional public block grant from the federal government. Meanwhile, Ethiopia’s health system is challenged by the need to mobilise sufficient health funding for the continuous improvements necessary to reach its stated mission and vision. This gap drives an on-going inward and outward search for additional health resources, such as community and social insurance schemes, enhancing user fee revenues and increased mobilisation of funding from external sources, such as global and health development partners. 2.2.9 Pastoralist health service Pastoralist peoples in Ethiopia constitute about 10% of the national population. As part of government’s broader effort to integrate technical assistance and other support to the Newly Emerging Regions, an inter-ministerial board with members from six ministries was established under the Ministry of Federal Affairs. Nomadic and pastoral communities have many special health needs that are not completely met by the largely static facility-based health system that has been established for the rest of the country. This gap prompted MoH to establish two core objectives under HSDP-II regarding Pastoralist health services and systems. These were: a) to establish an appropriate health service delivery for the pastoralist population and; b) to increase coverage and utilisation of health services in pastoralist population. Working toward these aims, the MoH developed a concept paper, "Health Service Delivery to Pastoralists". The 16 HEP packages were adapted to pastoralists’ needs and translated into local languages. Following the redesign and implementation of CSRP and the BPR in HSDP III, one of the major organisational transformations in the MoH was creating the Pastoralist Health Promotion and Disease Prevention Directorate to focus attention on health of the pastoralist populations. H SD P IV 32 2.2.10 Operational research Operational research in health is essential to identify critical operational and systems problems and to produce evidence for planning and decision making to improve services. Although it is a crucial part of M&E, operational research has not been conducted in a coordinated manner during the HSDP I and II periods. In HSDP III, the BPR resulted in redesigning Research and Technology Transfer as a core process of the MoH. There was a surge in the number of operational studies during HSDP III that covered a wide range of areas. These have included: a) Child health - coverage of child and tetanus (TT) immunisation, coverage and impact of the expanded programme of immunisation, EPI coverage survey; nutritional surveillance, national nutrition baseline survey; b) Communicable diseases - HIV/AIDS, TB; malaria, effectiveness of Coartem, effectiveness of residual DDT spray; c) Public health - surveillance of major public health problems; d) Reproductive health - causes of maternal mortality (Maternal death audit); prevalence of cervical cancer; effect of Misoprostol; choice of family planning; and e) Services - traditional medicine; EOS coverage validation survey; health commodity tracking; cost of health services. 2.2.11 Cross cutting issues Gender Gender has remained a crucial cross cutting concern that has prompted the MoH to set clear objectives for gender mainstreaming at all levels of the health system. Toward this end, government has developed an analytic framework on gender and health, including compilation and analysis of data on female workers to be used for advocacy purposes. The final version of this document is yet to be published and distributed to stakeholders. There has been also a rapid assessment aimed at the prevention of physical abuse to women and ensuring the provision of adequate health services for the victims of abuse. Based on the results of the assessment and the identified gaps, the MoH has prepared a draft training manual for use by health workers. This training manual has been further refined through a consultative workshop attended by all concerned stakeholders. Chapter Health Sector Development Programme IV3 H SD P IV 34 Chapter 3. Health Sector Development Programme IV 3.1 HSDP­IV planning process, methodology & principles Preparation of HSDP-IV has been guided by a concept note and a TOR developed jointly and agreed collectively by the Government and Health Development Partners. The Executive Committee of the MoH and the Joint MoH and RHB Steering Committee led the process at the highest levels. These Committees have selected the Strategic Themes and Objectives to be used as a framework for development of the HSDP-IV. Subsequently, multidisciplinary teams were established to prepare the draft document based on the guiding framework. The first draft produced by the multidisciplinary team was discussed by the Executive Committee of MoH and the Joint MoH and RHB Steering Committee, after which it was shared with all stakeholders for their feedback. Finally, it was subjected to two rounds of Joint Assessment for National Strategies (JANS). At the onset, Government made a decision to develop the HSPD IV strategic plan by using the Balanced Scorecard (BSC) approach, and arranged appropriate BSC training for leadership and team members [see Annex 1 for summary of the BSC process]. The basic steps MoH used to prepare the HSDP-IV with BSC include: a) Conducting an organisational assessment, b) Setting strategic elements, c) Setting strategic objectives, d) Preparing a strategic map of the objectives, e) Indicating performance measures & targets of the strategic plan, and f) Preparing strategic initiatives expected to achieve the overall strategic plan. The other main methodology used has been the Marginal Budgeting for Bottleneck (MBB) approach. The MBB helped to systematically look into the health system bottlenecks, high impact interventions, setting targets in different scenarios and associated costs of achieving results that have been planned under the HSDP-IV. HSDP IV is health chapter of the National Growth and Transformation Plan which was approved by the highest body of the government. HSDP-IV is a policy level strategic document that will guide the development of sub-national plans and set the rules of engagement in the health sector for the next five years. In order to realise this, the following principles have been applied in the development of HSDP-IV: • Government leadership; • Enhanced responsiveness to community health needs; • Extensive consultation & consensus with stakeholders; • Comprehensive coverage of priority health sector issues; & • Linkage between HSDP-IV with sub- national HSDPs & strategies/programmes on health priorities & targets. 3.2 The policy framework Health care is one of the crucial components of basic social services that has direct links to national growth and development and to social welfare. H SD P IV 36 3.3 Health sector strategic assessment 3.3.1 Roles of Federal and local governments Mandates of the Ministry of Health Proclamation No. 475/1995 of the Federal Democratic Republic of Ethiopia defines the Powers and Duties of the Executive Organs. This proclamation, in part 3 No. 10, states the common Powers and Duties as follows: • Initiate policies & laws, prepare plans & budget, & upon approval, implement same; • Ensure the enforcement of laws, regulations & directives of the Federal Government; • Undertake studies & researches; • Enter into contracts & international agreements in accordance with the law; • Give assistance & advice as necessary to Regional executive organs. Specific duties and responsibilities bestowed upon the Ministry of Health include: • Cause the expansion of health services; • Establish & administer referral hospitals as well as study & research centres; • Determine standards to be maintained by health services, except where such power is expressly given by law to another organ; • Issue licenses & supervise hospitals & services established by foreign organisations & investors; • Cause the study of traditional medicines, organise research & experimental centres for same; • Determine required qualifications of professionals engaged in public health services at various levels, & provide certificates of competence for same; • Devise strategies, means & ways for implementing prevention, control & eradication of communicable diseases; • Undertake necessary quarantine control to protect public health; & • Undertake studies with a view to determining the nutritional value of food. There are also four authorised Agencies under the MoH with specific mandates. These mandates focus mainly on a) ensuring safety and quality of products and health services through registration, Licensing and inspection of health professionals, pharmaceuticals, food establishments and Health institutions; b) improving the knowledge, attitude, behaviour and practice of the population on prevention and control of HIV/AIDS and healthy life style; c) conducting public health and nutrition researches and other studies that will contribute to the improvement of the health of the population; d) ensuring the regular adequate supply of effective, safe and affordable essential drugs, medical supplies and equipment in the public and private sector and ensuring their rational use. The autonomous health institutions report both to MoH and to MoFED. Mandates of the Regional Health Bureaus Regional Health Bureaus have the powers and duties to: • Prepare, based on national health policy, health care plan & programme for people of the region, & to implement same when approved; • Ensure adherence to health laws, regulations & directives related to public health in the region; • Organise & administer hospitals, health centres, Health Posts, research & training institutions that are established by the regional government; • Issue license to health centres, clinics, laboratories & pharmacies to be established by NGOs, other government agencies ( OGAs) & private investors; supervise same to ensure that they maintain the national standards; • Participate in quarantine control for public health; H SD P IV 37 • Ensure that professionals engaged in public health services in the region operate within the prescribed standards & supervise same; • Ensure adequate & regular supply of effective, safe & affordable essential drugs, medical supplies & equipment in the region; • Cause the application, together with modern medicine, of traditional medicines & treatment methods whose efficiency is ascertained; • Cause the provision of vaccinations, & take other measures, to prevent & eradicate communicable diseases; and • Ascertain the nutritional value of foods. Mandates of Woreda Health Offices Woreda Health Offices are mandated to manage and coordinate the operation of primary health care services at Woreda levels. They are responsible for planning, financing, monitoring and evaluating of all health programmes and service deliveries in the Woreda. The division of duties and responsibilities between federal, regional and Woreda levels in the management of and control of health providers includes: • MoH is responsible for referral hospitals & the national level study & research centres; • RHBs are responsible for all types of hospitals, health centres & health clinics in the region; also for health professional training institutions as established by the regional government; • WHO are responsible for primary health care services: Health Centres, Health Posts. The role of Administrative Councils In addition to MoH, and the line institutions at sub-national level, the Administrative Councils at regional, zonal and district levels will play crucial roles in the implementation of HSDP-IV. Some of these include: • Provide political leadership for health; • Ensure community demand for health care is properly addressed; • Plan, mobilise & allocate resources; monitor & evaluate programmes & service delivery; • Facilitating inter-sectoral collaboration; & • Provide guidance to enhance the partnerships for health with NGOs, CSOs, private sector, etc. H SD P IV 38 3.3.2 Mission, vision and core values of the Ethiopian health sector Mission of the health sector To reduce morbidity, mortality and disability and improve the health status of the Ethiopian people through providing and regulating a comprehensive package of promotive, preventive, curative and rehabilitative health services via a decentralised and democratised health system. Vision of the health sector To see healthy, productive, and prosperous Ethiopians Core values of the health sector Community first • We are here for nothing but to serve, empower and satisfy our community. • We involve, engage and empower the community to produce its own Health • We have three priorities: Community, Community, and Community. Collaboration • We work together in a spirit of mutual support and understanding to achieve our collective goals. Commitments • No matter what challenges we face and discomforts we feel, we stand firm, be patient and exert our utmost and sustained effort to achieve our goals. Change • We innovate new ways of doing things and are open minded to reforms. Trust • We ensure maximum vulnerability and integrity to each other. 3. 3. 3 S W O T a n al ys is fo r th e he al th s ec to r T h e su m m ar y o f en a b le rs ( st re n g th s & o p p o rt u n it ie s) a n d p ai n s (w ea kn es se s & t h re at s) a re p re se n te d i n t h e ta b le b el o w . T a b le 4 . S W O T a n a ly si s o f th e h e a lt h s e ct o r En ab ler s Pa in s St re ng th s W ea kn es se s • Hi gh co ve ra ge of H ea lth E xte ns ion Pr og ra mm e • Ad op tio n o f c os t e ffe cti ve st ra teg ies (R BM , Ma kin g p re gn an cy sa fer - MP S, IM NC I, DO TS , e tc. ) • Su cc es se s i n m ala ria pr ev en tio n & co ntr ol • Inc re as ed co ve ra ge of A RT • Su sta ine d h igh co ve ra ge of E PI • Ac ce ler ate d t ra ini ng of he alt h p ro fes sio na ls • Ra pid ex pa ns ion of he alt h c en tre s & he alt h po sts • Fin ali sa tio n o f B PR in th e s ec tor • Co mm en cin g u se of IT fo r t ele me dic ine , tel e- ed uc ati on , e lec tro nic m ed ica l re co rd s etc . • Inc re as ed su pp ly of me dic al eq uip me nt • Inc re as ed al loc ati on & ex pe nd itu re on he alt h • Im pr ov em en t in ha rm on isa tio n & al ign me nt • On e pla n s tre am lin ed in th e s ec tor • MD G Fu nd es tab lis he d t o e nfo rce on e bu dg et • Pr og re ss in sc ali ng up na tio na l H MI S as pa rt of on e M &E fr am ew or k • W ell de fin ed H SD P Go ve rn an ce (C JS C, RJ SC , e tc. ) • Ina de qu ate ca pa cit y t o i mp lem en t d ec en tra lis ed he alt h s ys tem • Ina de qu ate fo llo w- up on im ple me nta tio n o f po lic ies , g uid eli ne s, sta nd ar ds & pr oto co ls • Lo w uti lis ati on of he alt h s er vic es • W ea k r efe rra l s ys tem ; • Sl ow & er ra tic im ple me nta tio n o f B PR • Ou t-d ate d h ea lth fa cil ity st an da rd s & lo w he alt h se rvi ce qu ali ty • Lo w co ve ra ge of sk ille d d eli ve ry & Ne wb or n c ar e, TB ca se de tec tio n, PM TC T • Ina de qu ate at ten tio n t o N CD s & N TD s • Ina de qu ate m an ag em en t & su pp or t to P MT CT se rvi ce s, TB -L ep ro sy co ntr ol at su b- na tio na l lev els . • Ina de qu ate w ate r s up ply & W AS H to He alt h fac ilit ies , s ch oo ls, & co mm un itie s • Ina de qu ate ca pa cit y o f p re pa re dn es s t o e ffic ien tly re sp on d t o t hr ea ts of ep ide mi cs su ch as M ala ria . • La ck of H ea lth in fra str uc tur e m ain ten an ce ca pa cit y ( Bu ild ing , M ed ica l e qu ipm en t, I T) • Sh or tag e o f d ru gs , m ed ica l s up pli es , e qu ipm en t, & co mm od itie s • Sl ow im ple me nta tio n o f H ea lth C om mo dit ies Su pp ly Sy ste m (H CS S) • W ea k r eg ula tor y s ys tem fo r d ru gs & su pp lie s • Ina de qu ate co or din ati on m ec ha nis m for pu bli c pr iva te pa rtn er sh ip in he alt h • W ea k i mp lem en tat ion of H SD P go ve rn an ce (s uc h a s the C JS C) • Lo w qu ali ty of tra ini ng s & Lo w pe rfo rm an ce in tra ini ng & de plo ym en t o f m od el fam ilie s; • La ck of H R mo tiv ati on & re ten tio n s tra teg y; ab se nc e of sta nd ar dis ed co nti nu ou s p ro fes sio na l de ve lop me nt (C PD ) p ro gr am me s • Sh or tag e & at trit ion of hi gh ly sk ille d p ro fes sio na ls • La ck of ca re er de ve lop me nt for H EW s; Po or co or din ati on of H EW in -se rvi ce tr ain ing s b y v ar iou s pa rtn er s. • W ea k M &E & us e o f in fo for ev ide nc e- ba se d de cis ion m ak ing at lo we r le ve ls • Pe rsi ste ntl y i na de qu ate & in eq uit ab le dis trib uti on of re so ur ce s c om pa re d t o n ee ds & pr ior itie s ( E. g., He alt h s ys tem , M NC H, & H ea lth In fra str uc tur e Ex pa ns ion ) • W ea k f ina nc ial m an ag em en t; i na de qu ate ca pa cit y for fu nd liq uid ati on , r ep or tin g & au dit ing (P ro mi ne nt on H IV /A ID S fun din g) . • Po or pr og re ss to ad op t c om mo n b ud ge tar y fra me wo rk & re po rtin g f or ma t b y D Ps • Ma ny D Ps sl ow to jo in IH P Co mp ac t & JF A • Po or pr ed ict ab ilit y & di sb ur se me nt of co mm itte d fun ds (5 5.4 % in 20 09 ) b y D Ps Op po rtu ni tie s • Av ail ab ilit y o f c oh er en t & pr o- po or de ve lop me nt po lic y i nc lud ing he alt h • De mo cra tis ing & de ce ntr ali sin g h ea lth sy ste m • Av ail ab ilit y o f s ou nd he alt h p oli cy • Inc re as ing co mm un ity pa rtic ipa tio n • Inc re as ing na tio na l in co me ; • Inc re as ing hu ma n r es ou rce ou tpu t v ia ca pa cit y b uil din g p ro gr am me • He alt h i s a cc or de d p rio rity by G ov er nm en t • Do me sti c m an ufa ctu rin g c ap ac ity of dr ug s; • Inc re as ing ed uc ati on of gi rls • Em er gin g g lob al he alt h i nit iat ive s • Ex pa ns ion of th e p riv ate se cto r • Inc re as ing e xte rn al re so ur ce s & T A • Ex pa ns ion of in fra str uc tur e ( ro ad , IC T, ele ctr ici ty Th re at s • Po ve rty & hi gh le ve l o f p op ula tio n g ro wt h • Ins tab ilit y o f n eig hb ou rin g c ou ntr ies - • Ne wl y e me rg ing pa nd em ics • Ma nm ad e & na tur al dis as ter s • Ad ult ill ite ra cy • Gl ob al fin an cia l c ris is (ri sin g c os t o f p ha rm ac eu tic als , su pp lie s e tc. ) • Po or ai d e ffe cti ve ne ss • Br ain dr ain , h igh tu rn ov er of he alt h s taf f, e sp ec ial ly me dic al do cto rs H SD P IV 40 3.3.4 Stakeholder analysis The attainment of missions and objectives of HSDP- IV is largely dependent on the collective efforts and roles played by different stakeholders. It will help to clarify contributions expected from each actor; and to describe possible areas of collaboration that would create synergy toward HSDP-IV’s strategic objectives. Table 5. Stakeholders analysis Stakeholders Behaviours we desire Their needs Resistance issues Their influence Institutional response Community Ownership Healthy life style Empowerment, Information Access to quality of health care Stewardship Dissatisfaction Opting for unsafe alternatives Underutilisation High Community mobilisation, ensure participation Strengthen Health committee Quality, equitable service Parliaments, Prime Minister’s Office, Council of Ministers, Regional Governments Ratification of proclamations, policies, etc. Resources allocation Implementation of proclamations, policy, etc. Equity & quality Plans & Reports Organisational restructuring High Put in place strong M&E system & comprehensive capacity building mechanisms Line Ministries (Education, Water, Finance, Labour, Women’s Affairs, Agriculture, etc.) Intersectoral collaboration Evidence-based plans; Reports Effective & efficient use of resources & coordination Technical support Fragmentation Dissatisfaction Considering health as low priority Medium Collaboration Transparency Advocacy Development Partners Harmonised & aligned Participation More financing Technical support Financial system accountable & transparent Involved in planning, implementation & M&E Fragmentation High transaction cost Inefficiency & ineffective Medium Government leadership Transparency Efficient resource use Build financial mgmt capacity CSOs, NGOs, Diaspora, Professional Associations Harmonisation & alignment Participation, resource & TA Involvement in planning, implementation & M&E Dissatisfaction Fragmentation Medium Transparency, Advocacy Capacity building Private for profit Quality Partnership, Rules & regulations Low quality Medium Transparency, collaboration Advocacy, Civil servants Commitment, Participation Conducive environment Transparency Dissatisfaction Unproductive Attrition Medium Motivation, Involvement 3.4 Strategy of the HSDP­IV HSDP-IV is situated within and supports the government’s overall vision for Ethiopia to become a middle-income country. Some important processes will include defining customer value proposition, strategic themes, strategic results, and perspectives. H SD P IV 41 3.4.1 Customer value proposition of HSDP­IV In the context of HSDP-IV, the customer value proposition shows attributes that define services the health sector should provide, principles underpinning its relations with the community and how the health sector wishes to be perceived. Table 6. The health sector customer value proposition Product or service attributes Image Relationship Products & services the Health Sector provides have these characteristics: • Accessibility–information, physical, financial, etc. • Timeliness of services • Quality of health care services & information, • Safety & healthy environment • Empowering community & employees • Conducive environment The image that the Health Sector wants to portray has the following characteristics: • Transparent • Supportive • Trustworthy • Professional • Customer-Friendly/Oriented • Committed The relationship the Health Sector wants with its community could be described as: • Complementary • Cooperative (participatory) • Respectful & ethical • Harmonious (Mutual Understanding) • Transparent relationship • Dependable (Stewardship) • Responsive • Equitable 3.4.2 Strategic themes and strategic results The strategic themes of the HSDP-IV are the focus areas where the health sector should excel to achieve its objectives and targets. Strategic themes of the health sector: • Excellence in health service delivery and quality of care • Excellence in leadership and governance • Excellence in health infrastructure and resources Strategic Theme 1: Excellence in health service delivery and quality of care This theme refers to the provision and management of curative, preventive, rehabilitative and emergency health services and the promotion of good health practices (personal hygiene, nutrition, environmental health) at individual, family and societal level. It includes provision of maternal, neonatal, child, youth and adolescent health services and public health emergency services. Strategic Result 1: A community that practices and produces good health, protected from emergency health hazards and has access to quality health care at all levels and at all times. Key concepts: • Health promotion; • Emergency Medical (system) service; • Disease prevention; • Health service delivery at household, community & facility level. • Curative & rehabilitative service; • Public Health Emergency Management; These concepts are mainly to improve maternal, neonatal, child, adolescent and youth health, nutrition, hygiene and environmental health (WASH) and to reduce/combat HIV/AIDS, TB and Malaria and other communicable and non- communicable diseases. How will successes be measured? H SD P IV 42 • Increased Knowledge, Attitude & Practice of the community • Reduction of maternal, neonatal & child morbidity & mortality • Reduction of malnutrition, wasting & stunting • Reduction in incidence & prevalence of communicable &non- communicable diseases • Controlling & reduction of medical & epidemic emergency How will these help to move to the higher level of success? • Ensuring effective, timely delivery of quality health care • Ensure service quality & provision per standard • Accessibility of services (physical, financial, information & cultural) • Enhancing behavioural change communication Strategic Theme 2: Excellence in leadership and governance; This theme refers to planning, monitoring, evaluation, policy formulation and implementation that is evidence-based. It also includes the development and implementation of a regulatory framework. It incorporates the equitable and effective resource allocation and leadership development within the sector and the community. It also includes development and implementation of Health Development Army (HDA). Strategic Result 2: Communities are served by accountable and transparent institutions and their safety is ensured. Decision making in the sector is evidence-based and promotes equitable and effective allocation and/or application of health resources. Key concepts: • Evidence-based policy making & implementing; • Planning, monitoring & evaluation; • Ensuring equitable & effective resource allocation (finance, staffing & infrastructure); • Leadership & community development; • Regulatory framework; • Accountability & transparency; • Harmonisation & alignment. • Community participation How will successes be measured? • Use of research & health info outcomes for evidence-based decision making (planning, developing policy & regulatory frameworks) • Improved partnerships • Timely decision • Equitable resource allocation (finance, human capital & infrastructure) on evidence-based need • Empowerment of employees at every level • Enhancement in the public safety How will these help to move to the higher level of success? • Policy will define priorities • Public-Private partnership will be enhanced • Efficient use of resources • Enhanced community participation (planning, M&E, regulation enforcement, policy formulation) & ownership, satisfaction • Implementation of Health Development Army Strategic Theme 3: Excellence in health infrastructure and resources; This theme refers to the development, rehabilitation and maintenance of health facilities and medical equipment that meet standards and are accessible to communities being served by qualified and motivated health professionals. H SD P IV 43 Strategic Result 3: Ensuring communities have access to health facilities that are well equipped, supplied, maintained and ICT networked as per the standards and are well staffed with qualified and motivated employees. Key Concepts: • Expansion of new health facilities & other health infrastructure, • Expansion, rehabilitation & maintenance of existing infrastructure. • Health care financing - resource mobilisation & risk pooling • Health workforce – training, deployment, career development & improved HRH management • Pharmaceutical supply - planning, quantifying, selection, procurement storage & distribution • Technology transfer – adoption of new technology & practices for the production & utilisation of health care products. • Effective medical equipment management • Enhanced Information Communication Technology for health How will successes be measured? • The extent that communities are accessing standardised health facilities • No stock-outs of essential drugs at all facilities • Improved functionality of medical equipment • Enhanced retention for qualified work force • Ensuring community’s enrolment in health insurance schemes. • Development of critical work force skills • Improved access & quality of health services via use of ICT How will these help to move to the higher level of success? • Ensuring community access to standardised health facilities, with services delivered by qualified & motivated health professionals. • Health facilities will have better communication & data exchange to improve the quality of reporting & service provision 3.4.3 Strategic perspectives Figure 12. The Health Sector Strategic Management System “House” Table 7. Perspectives of HSDP-IV Perspective Key Concepts Key Questions Community ‘engagement’ ‘Empowerment’, ‘Ownership’ How can we enable the community to produce & own its health? Finance ‘Efficiency’ How do we mobilise & utilise more resources effectively & efficiently? Integration & responsiveness (Internal process) ‘Quality’ How can we enhance our integration & responsiveness in order to improve quality, timeliness, & functionality? Capacity building (Learning & growth) ‘Capacity’ To excel in our processes, what capacities must the health sector & the community has & should improve? H SD P IV 45 3.5 Strategic objectives & map for Ethiopian health sector Ten strategic objectives were selected in terms of their potential to bring significant impact in the sector’s strategy. 3.5.1 The ten strategic objectives (SOs) SO ­ C1: Improve access to health services This strategic objective is meant to improve accessibility of health services of all kinds, including emergency and referral services, and thereby ensure service utilisation. It is expected that better accessibility will then lead to improvements in the health of mothers, neonates, children, adolescent and youth. It is seen as an important strategy to improve nutrition status; improve hygiene and environmental health; and reduce the incidence and prevalence of HIV/AIDS, TB, malaria and other communicable and non-communicable diseases. The expected outcome will be increased citizen confidence in the health system and proactive seeking of prevention and treatment services from health facilities. They have to believe and develop confidence that they will be able to receive the best medical care when they are in need; that they can reduce their risk of contracting diseases; and ultimately, that they have a better health status. To achieve these results, the Health Extension Programme will act as a primary vehicle for prevention, health promotion, behavioural change communication and basic curative care. It will effectively implement the already defined 16 essential packages. Health centres will serve as a first curative referral centre for Health Posts and will provide health care that will not be available at the HPs through ambulatory and some cases of inpatient admissions. Health centres, primary hospitals and general hospitals will be the main hubs for the reduction of maternal mortality by providing BEmONC and CEmONC. Referral and specialised hospitals are meant for the handling of more complicated and sophisticated health care, including the clinical management of non-communicable diseases. The health system will be mobilised to give enhanced attention to attendance of delivery by skilled health workers, PMTCT, TB case detection, environmental management of malaria, and prevention and detection of non-communicable diseases. The family planning programme will focus on ensuring contraceptive security and provision of long lasting and permanent contraception. Antenatal care with four visits per pregnancy will be mainstreamed at all service delivery levels. WASH will be integrated with other service delivery modalities and will be implemented at all levels of the health care system. SO – C2: Improve community ownership This strategic objective aims to empower community to produce its own health. It is to ensure the involvement, engagement and empowerment of the community via the implementation of Health development army (HDA).The expected outcome is community empowerment for continuity and sustainability of health programmes. HDA is the key strategy to scale up best practices by organizing and mobilizing families. The HDA will be a network created between five household and one model family to influence one another in practicing healthy life style. This H SD P IV 46 network of families will be provided technical support and training by HEW’s to implement the packages of HEP. HDA will help to expand the successful HEP deeper in to communities and families. These HDA’s will help improve community ownership. They will be engaged in the promotion and prevention activities at household and community level, including the regular coordination of structured Community Dialogue Sessions, with the guidance of the HEWs. Communities will be represented on governance boards of all public sector health facilities. Local government councils, HEWs and Development army will have extensive responsibilities for social mobilisation, increasing the community’s awareness of their health rights and responsibilities, and for creating an enabling environment. SO ­ F1: Maximize resource mobilization and utilization This strategic objective sets out a proactive approach to the mobilisation of resources from domestic and international sources. It includes enhancing pool funding; addressing collection and use of revenues by health institutions; and establishing a risk pooling mechanism. It also includes attention to effective and efficient use of resources; sound financial management and performance-based financing; as well as equitable and evidence-based allocation of resources to priority interventions and programmes in the health sector. The ultimate outcomes of this strategic objective will be: • Ensuring that adequate resources are mobilised & available for financing the health sector; • There is equitable resource allocation; • Significant improvements in resource absorptive capacity & decreased wastage of resources;, • Ensuring financial protection of the citizens. Health administrations at all levels will undergo capacity building to enhance their competence at using evidence for planning and active negotiation with administrative councils to increase government allocations to health. Technical support will be given to sub-national levels to enable facility-based revenue generation and use, as well as proper implementation of the exemption and waiver system. Facility governance will be strengthened to ensure accountability for the use of funds, and for the accessibility and quality of health services. The MoH will mobilise Technical and financial resources for appropriate piloting, evaluation and scaling up of community-based health insurance (CBHI). The necessary institutional framework will be established and extensive promotion conducted for rapid scaling up of social health insurance (SHI). Networking and experience sharing will be promoted among health facilities for implementing comprehensive health financing reforms. Government, in collaboration with development partners, will ensure financial protection for the poor by allocating funds and by improving effectiveness and transparency of the exemption and waiver system. Government and development partners will dialogue extensively to enhance aid effectiveness. MoH and sub-national health administrations will improve their capacities for mobilising resources and managing aid, including for reducing fiduciary risks, and for better accounting and liquidating of donor funds. HSDP-IV will achieve these outcomes through strengthening existing linkages with MoFED, BoFED and WoFED; enhancing evidence-based planning and H SD P IV 47 relating resource allocation to evidence of local needs; building human resource capacity numbers and skills for better programme implementation and resource absorption; simplifying the disbursement and accounting for funds; and establishing sound procurement procedures and systems. Development partners will be urged to reduce tying aid and to simplify fund management; this will help to reduce transaction costs and improve budget absorption as agreed in the IHP+ Compact. The Integrated Financial Management Information System (IFMIS) will be designed, pilot tested and implemented at all levels of the health system in collaboration with MoFED, BoFED and WoFED. The IFIMS will improve the use of funds for planned activities, and provide timely and complete physical and financial reports on the use of funds to all stakeholders. SO ­ P1: Improve quality of health services By this objective, the MoH aims to ensure that health services at all levels are being provided according to quality standards. These standards address: • Speed of delivery, • Harmonise at service delivery point by integrating vertical programmes • A holistic approach to avoid missed opportunities in service delivery, • Effectiveness of the services • Patient safety, ethical and professionalism in service delivery, and • Availability of the required inputs (HR, finance, pharmaceuticals, etc.) The expected outcome is a health system that satisfies the community’s health care needs through the delivery of relevant, safe and optimum quality health services in an integrated and user-friendly manner. SO – P2: Improve public health emergency preparedness & response This strategic objective aims for improvements in how the health system copes with existing and emerging disease epidemics, acute malnutrition, and natural disasters of national and international concern. The desired coping responses include improved health risk identification, early warning, response and recovery from the disasters. The expected outcome of the strategic objective is early verification, rapid response and containment of public health emergencies. The specific strategies that will be put in place include: • Community involvement; • Resource mobilisation; • Integrated communications & information systems across multiple sectors; • Advanced operational readiness assessment; • Multi-sectoral coordination for emergency preparedness & response; • Comprehensive training & evaluation to all involved; & • Application of proper ICT. These strategies will contribute towards an effective early warning, preparedness, response, recovery and rehabilitation system. SO – P3: Improve pharmaceutical supply and services This objective is designed to increase the availability of pharmaceuticals (medical equipment and products for prevention, diagnosis and treatment) at an affordable price and in usable condition, ensuring an uninterrupted and adequate supply to health facilities. It also aims to achieve improved rational drug use H SD P IV 48 and a significant reduction in pharmaceutical wastage. The intended outcome will be adequate availability of the right pharmaceuticals at the right place and at the right time in the right condition and used properly by patients and clients. The MoH will provide for capacity building activities at all levels to enhance management quality and effectiveness of the Revolving Drug Fund (RDF). More resources will be mobilised to improve the per capita expenditure on drugs. Pharmaceuticals will be procured in bulk and delivered directly to service delivery points by PFSA. Pharmaceutical hubs and warehouses will be constructed and strategically located to improve proximity and efficiency in distribution. Alternative approaches, including outsourcing, will help ensure cost effectiveness in the transportation of pharmaceuticals to service delivery points while maintaining quality of the products. The ILMIS (Integrated Logistics Management Information System) will be improved and integrated with the HMIS and stock management of health facilities to improve forecasting and quantification of pharmaceuticals. Regular operational research will be conducted to improve efficiency of the supply chain management on a continuous basis. Patients and health workers will be involved in improving the rational use of drugs. SO – P4: Improve regulatory system This strategic objective is on ensuring safety in the delivery of health services, products and practices. It has several specific critical elements, including: • Prevention of professional malpractice; • Strengthening quarantine services; • Enhancing environmental health activities; • Enforcing regulations & prevention of drug abuse; • Controlling institutional solid & liquid waste disposal. The expected outcome is compliance with the health law and regulatory standards leading to community safety, healthy environment, and increased community confidence in the safe delivery of health services. HSDP-IV aims to achieve this outcome through effective implementation of the Health and Health Related Regulatory Process. The design of the process has included development of comprehensive standards for all levels of health institutions along with standard operating procedures for premises, practices, products and personnel. There will be extensive capacity building under HSDP-IV towards realizing effective regulation in the sector. The implementation of this strategic objective will include the following key activities: • Enhance community involvement in health & health related services & products regulation; • Undertake demand reduction & supply management activities for drugs prone to abuse; • Improve efficiency of hygiene & environmental health control activities; • Promote health regulatory laws; • Issue special permits for import, export, manufacturing, distribution, wholesale & storage of substances; • Post-marketing surveillance; & • Comprehensive capacity building. H SD P IV 49 SO – P5: Improve evidence­based decision making by harmonization and alignment This strategic objective will support improved evidence-based decision making through enhanced partnership, harmonisation and alignment, including integration of projects and programmes at the point of health service delivery. It will comprehensively address identification of health system bottlenecks; research; HMIS; performance monitoring; quality improvement; surveillance; use of information for policy formulation, planning, and resource allocation. The expected outcomes of the strategic objective are proper generation and use of evidence at all levels of the health system to respond to critical health problems of the community; to realise the one-plan, one-budget and one-report approach; and to effectively integrate and align health programmes and projects. A mechanism will be put in place to prioritise research according to public health importance. All research studies in the health sector will conform to the Algiers Declaration to improve efficiency and effectiveness in the use of evidence from the research. To improve financing for M&E, a minimum of 15% of vertical funds will be allocated to scaling up an integrated M&E system; resources for scaling up the HMIS will also be leveraged from partners implementing projects / programmes at facility levels. Commitment of the government will be secured through institutionalising and sustaining M&E at facilities, and at the sub-national health administrations by increasing resource allocation. MoH will provide start up support to regions for scaling up the HMIS (tools, training, etc.). M&E units at all levels will promote and monitor the use of information for decision making and service quality improvement. Data from different sources will be triangulated to validate incoming information and enhance accuracy and credibility. MoH will institutionalise and support the dissemination of best practices toward enhancing the use of evidence for decision making. Technology will be implemented after pilot testing and in-depth evaluation for appropriateness and sustainability. MoH will work very closely with Ministry of Education, universities and partners in accelerating pre-service trainings for health information technicians (HITs) and epidemic intelligence officers. At Woreda level, evidence-based planning will be undertaken annually to improve decision making, particularly for continuously improving health programmes and health care delivery. HSDP-IV will build on these efforts to achieve the “one” principles of harmonisation and alignment at national and sub-national levels. Government leadership will take forward the agenda of harmonisation and alignment by improving the transparent, accountable and socially equitable use of donor funds. Development partners are expected to develop strategies to ensure the predictability of funding; delegate decision-making power to country offices; and to make effective use of the government systems and processes for planning, implementation, monitoring and evaluation. Both government and development partners will make every effort to achieve value for money by improving resource allocation for priority health interventions; to avoid creating gaps and overlaps in financing; and to conduct regular independent evaluations. Both will make a commitment and adhere to principles of harmonisation and alignment and use the lessons learnt from such processes for continuous improvement. H SD P IV 50 SO – CB 1: Improve health infrastructure This strategic objective covers many technical issues, consisting of: • Expanding, equipping, furnishing, maintaining and managing health and health related facilities; • Expanding use of relevant technologies including health information technology; • Development of infrastructure for pharmaceutical supplies; • Technology transfer; and • Vaccine production. The expected outcome of this strategic objective will be health and health related facilities that are well built, maintained, equipped, furnished, using appropriate technologies and located within a reasonable distance from the intended beneficiary population. Capacity will be built in the health sector to conduct preventive maintenance, outsource and manage contracts. SO – CB 2: Improve human capital and leadership This strategic objective entails: leadership development; human resource planning, development and management including recruitment, retention and performance management; community capacity development; and technical assistance management. The expected outcome of the strategic objective is adequate availability of skilled and motivated health staff committed to work and stay in a well-managed sector. HSDP-IV will use a mix of strategies to achieve these outcomes, including: • Ensuring demand driven production of human resources; • Maximising use of available resources in producing key categories of health workers for which there is scarce supply; • Improving inter-sectoral collaboration in HRD; • Enhancing private sector involvement in HRH development; • Enhancing quality assurance in the training of health professionals; • Using appropriate ICT to enhance quality & efficiency of medical education; • Improving geographic distribution of HRH; • Strengthening the regulatory system; & • Enhancing cost-effectiveness in staff retention & motivation schemes. H SD P IV 51 3.5.2 Health sector strategy map Figure 13. Health Sector Strategy Map Co m m un ity (C ) CI: Improve access to health services C2: Improve community ownership F1: Improve Financial Mobilisation and Utilisation Fi na nc e ( F) P4: Improve Regulatory System P1: Improve Quality of Health Services P5: Improve evidence based decision making, harmonisation, and alignment P2: Improve Public Health Emergency Preparedness and Response P3: Improve pharmaceutical supply and services In te rn al Bu sin es s P ro ce ss es (P ) Ca pa cit y Bu ild in g (C B) CB1: Improve human capacity & leadership CB2: Improve health infrastructure Mission: - To reduce morbidity, mortality and disability and improve the health status of the Ethiopian people through providing and regulating a comprehensive package of promotive, preventive, curative health services via a decentralised and democratised health system Vision: - To see healthy, productive, and prosperous Ethiopians 3.6 Performance indicators, targets & strategic initiatives 3.6.1 Sector core performance indicators & targets The table below (Table 8) summarises the priorities and targets of the HSDP IV. Sector core performance indicators and targets are listed under each strategic objective. Table 8. Summarised priorities and targets of HSDP-IV Priorities Impact Outcome Vehicles Blood lines Maternal & Newborn Health MMR 267/100,000 CPR= 66% Deliveries attended by skilled birth attendants= 62% Health Post 1: 3000-5000 population Health Centre 1:15,000-25,000 population (rural) 1:40,000 urban Primary Hospital 1: 60,000-100,000 population General Hospital 1: 1,000,000-1,500,000 population Comprehensive Specialised Hospital 1: 3.500,000- 5,000,000 population • Health Extension Program • Health Development Army • Supply chain management • Regulatory system • Harmonisation & Alignment • Health Care Financing • Human Resource Development • Health Information System • Continuous quality improvement program • Referral system Child Health U5MR 68/1000 IMR 31/1000 Fully Immunised= 90% Pneumonia treatment = 81% HIV/AIDS HIV incidence 0.14 ART =484,966 PMTCT= 77% TB Mortality from all forms of TB = 20/100,000 TB case detection (All forms) 75% Malaria Lab confirmed Malaria incidence <5 per 1000 Pregnant women who slept under LLIN the previous night =86% Increase proportion of U5 children who slept under LLITN the previous night = 86%. Nutrition Stunting prevalence 30% 3.6.2 Directions of HSDP­IV Many of the listed initiatives and programmatic interventions were under implementation before HSDP-IV. The majority of these activities will continue to be implemented as per the agreed strategic directions. This section, however, outlines the strategic directions that will attract more attention. Health Extension Programme HSDP III registered remarkable achievements in scaling up rural HEP coverage, particularly through putting in place the necessary infrastructure, i.e., HPs, equipment, and staff like HEWs and Health Extension Supervisors. Hence, HSDP-IV will focus on the following aspects of HEP: 1 Scaling up Urban & Pastoralist HEP; 2 Maintaining coverage and improving quality of HEP in rural areas. 3. Extensive implementation of Health Development army Quality of health care ‘Quality of Health Care’ is a measure of the degree to which health services for individuals and populations increase the likelihood of the desired health outcomes consistent with current professional knowledge. The delivery of quality health services is central to improving the health status of the population. In addition, satisfying patients and clients is the primary goal of the Government’s reform programme. HSDP-IV will focus on a comprehensive and continuous quality monitoring mechanism that will enable all levels of the health system (including both management and service delivery) to look at all aspects of performance and H SD P IV 53 quality of services. Inputs, processes and outcomes of the health care system will be monitored for quality, and the mechanism will also seek to involve all managers and every health care worker in the on-going processes of quality improvement at all levels of the health system. Improving the quality of services will be realised through scrupulous implementation of tools, manuals and standards. Rigorous implementation of the Performance Monitoring and Quality Improvement Standard Operating Procedure, and the Health Regulatory Processes will be crucial to ensure adherence to standards by all actors in the sector. The Health and Health-Related Regulatory Process is designed to effectively monitor the adherence to quality standards by all health service providers. It focuses on professional practice, quality of both products and the premises of service delivery. Regulation of health services will be enhanced by also putting in place an independent inspection arrangement. This role will facilitate implementation of the Health Service Regulatory Core Process for properly regulating health services and taking any necessary corrective measures. The inspections will include regular monitoring of premises, personnel, practices and products to ensure adherence to agreed standards. The Quality of Health service applies a three-pronged approach to improving quality of health services. These are supply side interventions, demand side interventions and regulatory aspect. The supply side interventions include providing adequate numbers of skilled and motivated professionals; strengthening the supply chain management system to ensure an adequate and uninterrupted supply of pharmaceuticals at the point of service delivery. It also includes improving the fiscal health of service institutions through implementing health care financing (HCF) reforms. The relevant reforms are those regarding allocation of adequate resources for procuring commodities, maintaining infrastructure, creating conducive environment for patients/clients and motivating health human resources. An internal quality assurance mechanism will be established through effectively implementing the Performance Monitoring and Quality Improvement Standards and Tools at all levels of the health system. Demand side interventions will promote active and inclusive participation of the community. Community participation works to improve the quality of services by guaranteeing that patients’ and clients’ opinions are heard and their satisfaction with services is optimised. Community members will therefore be included in health facility governance boards; a patients’ rights charter will be developed; and regular surveys on client satisfaction will be conducted. Community involvement in planning, implementation, monitoring and evaluation of health interventions will be enhanced. The quality of curative and rehabilitative services will be addressed at each level and point of service delivery. All facilities will organise service delivery into inpatient services, outpatient services and emergency medical care. All patients will pass through screening/triage for prioritisation. In the case of health emergencies, the patient will be referred directly to emergency medical care and will be able to receive immediate attention and treatment. H SD P IV 54 Scaling up of civil service reform HSDP-IV will focus on the following aspects of the Civil Service Reform: 1 Enhancing commitment of leadership at all levels of the system; 2 Building implementation capacity; 3 Continuous improvement of BPR processes; 4 Scaling up best practices. Special attention to critical programmes Despite high expectations, HSDP III’s performance on some programmatic targets remained unsatisfactory. Some of these included having skilled attendants at delivery, PMTCT and TB case detection. In consequence, HSDP-IV will increase attention to these programmes, with the intention of achieving greater political commitment, better allocation of resources and closer follow up. Human Resources Development HSDP-IV will accord due attention to: 1 Reinforcing & institutionalising HRH legal frameworks aligned to the overall health policy & the decentralised health system of the country; 2 Achieving a positive balance between production versus loss of health staff in order to attain the right numbers & skills mix of health workers; 3 Improving availability of key HRH categories at all levels through scaling up pre-service training of professionals in scarce supply (current & projected), e.g., medical doctors, IESOs & midwives; 4 Developing & institutionalising human resource management systems at all levels of the decentralised health system; 5 Improving motivation & retention of HRH through implementing evidence-based financial & non-financial incentives; 6 Ensuring that in-service trainings are standardised & support the health & management workforce career progression & skill development. Health Infrastructure HSDP-IV will introduce a shift in the infrastructure focus as follows: 1 Expansion & conversion of selected HCs to become primary hospitals, enabling them to provide emergency surgical services including Comprehensive Emergency Obstetric Care; 2 Preventive maintenance & rehabilitation of existing health facilities (HPs, HCs, & hospitals); 4 Prioritising construction of logistic hubs to ensure effective storage & distribution of pharmaceuticals. 3 Completing construction of 16 blood banks, thereby meeting facility needs & contributing to achieving MDG5 for availability of adequate & safe blood supply; Ethiopia is among the top-ranking countries for national investment in ICT infrastructure. HSDP-IV will focus on making good use of this opportunity to enhance accessibility and quality of care. The use of ICT for health will focus on four main areas: 1 Implementing tele-education to support & assist hospitals & new universities engaged in accelerated training of health professionals; this will help fill gaps in capacity to handle expanded training. 2 Scale up tele-medicine to more universities & hospitals based on lessons learnt.. This will enable patients to get specialised services in areas where there are scarcities of specialists. 3 Also crucial for ICT is e-HMIS, which will include appropriate ICT at HC level, electronic health information transfer, & electronic medical records (EMR). Scale up EMR to hospitals based on lessons H SD P IV 55 learnt from Hospital who successfully implemented. 4 Introducing mHealth in health extension program. This will fulfill the communication need of HEWs such as referral, supply chain management, and information sharing. Special attention to regions needing special support Four Regions needing special support, i.e., Afar, Somali, Beneshangul-Gumuz and Gambella, present unique challenges for health service delivery and health system development. These regions are characterised by poor infrastructure, hardship environmental conditions, and pastoral or semi-pastoral populations. HSDP I, II and III have emphasised the need for regionally tailored approaches and support to bring them to equal footing with the rest of the country. HSDP-IV will continue and further strengthen the special support provided to these regions through various mechanisms already in place. These include: 1 Participate in multi-sectoral planning under the coordination of the Ministry of Federal Affairs; 2 Develop & implement a contextualised health service standard including pastoralist HEP, HC relevant to population ratio, staffing pattern & hardship allowances; 3 Provide special support for health planning, budgeting, implementation, monitoring & evaluation of health programmes; 4 Provide needs-based capacity building to ensure sustainability. Climate changes and health: Global warming and climate change have emerged as major issues in the past two decades. Climate change could jeopardise achievements of the MDGs, including the health-related goals, and undermine efforts of the health sector to improve public health and reduce health inequalities. Among the potential health effects of climate change are heat stress and heat stroke; trauma; respiratory diseases from air pollution; vector-borne and zoonotic diseases, water- and food-borne diseases, mental distress and illness, and others. To address these likely effects, the MoH will raise community awareness, initiate trainings to health professionals and researchers on the health effects of climate change, ensure that systems are in place to detect and track climate change induced health problems, make the necessary preparations to respond to, and manage climate change associated risks. The MoH will be engaged in these activities in collaboration with the Environmental Protection Authority. Gender mainstreaming Government has a strong focus on gender mainstreaming to be addressed in all political, economic and societal spheres so that women and men participate and benefit equally from development. It expects gender-aware planning, i.e., assessments and reflections on the implications of plans and actions for women and men in all areas and at all levels. It is a strategy for incorporating the concerns and experiences of both women and men as integral dimensions in the H SD P IV 57 1.3 Scale up BEmONC, CEmONC. 1.4 Conduct maternal death Auditing 1.5 Service Integration with emphasis on RH-HIV integration, (in particular FP- HIV prevention linkages through common messages & dual protection) & harmonised approach among all partners. 1.6 Referral system including paediatric referral system. 1.7 Routine immunisation & wild polio eradication. 1.8 Establish newborn corners and ICU in PHCU 1.9 Expand community & facility IMNCI. 1.10 Enhanced Youth Friendly services. 1.11 Capacity building on program management for maternal & child health services. 1.12 Health Extension Programme 1.13 Special, locally relevant & effective maternal & child health intervention to pastoralist areas SO C.1.2: Nutrition Targets 1. Increase proportion of severely malnourished under-5 children that are adequately managed from 23% to 91%. 2. Achieving malnutrition cure rate > 75%, defaulter rate < 15% & mortality rate < 5% in Therapeutic feeding programmes (TFPs) (inpatient & outpatient therapeutic programme). 3. Increase proportion of children 6-59 months old given Vit-A supplements every 6 months from 95% to 99% 4. Increase proportion children 2-5 years receiving de-worming every 6 months from 86% to 96% 5. Increase proportion of pregnant women supplemented with iron during their pregnancy from 10% to 86% 6. Decrease wasting prevalence among children under-5 from 11% to 3%; & stunting prevalence from 47% to 30% 7. Increase proportion of newborns breastfed within one hour of birth (initial breastfeeding) from 69% to 92% 8. Increase proportion of 0-6 month old infants on exclusive breast feeding from 49% to 70% 9. Increase percentage of 6-9 month old infants on complementary food & continued breastfeeding from 54% to 65% 10. Reduce prevalence of anaemia in women of childbearing age (15-49 ) from 27% to 12% 11. Increase households using iodised salt from 4% to 95% Initiatives 1. Sustain Enhanced Outreach Strategy (EOS) with Targeted Supplementary Food (TSF) & transition EOS into HEP 2. Health facility nutrition services 3. Community-Based Nutrition (CBN). 4. Micronutrient interventions 5. Essential Nutrition Actions/Integrated Infant & Young Feeding counselling services 6. Institutional strengthening for nutrition policy & programme implementation & monitoring. 7. Health Extension Programme SO C.1.3: Hygiene & environmental health Targets: 1. Increase proportion of households using latrine from 20% to 82% 2. Increase proportion of villages (Kebeles) free of open defecation from 15% to 80% 3. Increase proportion of households using household water treatment & safe storage practices from 7% to 77% H SD P IV 58 Initiatives: 1. Proper & safe excreta disposal system 2. Proper & safe solid & liquid waste management 3. Water supply safety measures 4. Food & hygiene safety measures 5. Healthy home environment 6. Arthropods & rodent control 7. Personal hygiene 8. Health Extension Programme SO C.1.4: Prevention & control of major communicable diseases Reduce incidence & prevalence of HIV/AIDS Targets: 1. Provide HCT (VCT+PITC) to 9.27 million people annually 2. Increase percentage of people aged 15- 24 using condom consistently with non- regular partners from 59% to 95% 3. Increase proportion of eligible children who are receiving ART to 95% 4. Increase proportion of eligible pregnant women receiving ART to 95% 5. Increase proportion of eligible adults receiving ART from 53% to 95% 6. Increase number of patients ever started on ART from 246,347 to 484,966 7. Increase number of STI cases treated from 39267 to 180,000. 8. Reduce incidence of HIV in adults from 0.28% to 0.14% 9. Increase proportion of population aged 15-49 years with comprehensive knowledge of HIV/AIDS from 22.6% to 80% Initiatives 1. Strengthen enabling environment (capacity building, community empowerment, leadership and governance, mainstreaming, coordination and partnership) 2. Strengthen HIV prevention which includes: 2.1 Intensifying the implementation of HIV/AIDS programmes (community conversation, school based and out of school interventions, addressing most at risk population, strengthened prevention with HIV positives and in development schemes and corridors) 2.2 Reduce vulnerability of HIV infection among vulnerable and risk groups (through addressing gender inequality, income generation, girls education, fight against harmful traditional practices, stigma and discrimination, and integration of safety net programs with HIV/AIDS) 2.3 Increasing access and utilisation of services (HCT, STI, Condoms, Universal precaution and blood safety, circumcision and post exposure) 3. Create access and quality of chronic care and treatment (through enhancing service integration, laboratory, referral, availability of essential commodities OI, ARV drugs and reagents, Strengthen public private partnership and addressing human resource issue) . 4. Strengthen care and support to mitigate the impact of AIDS 4.1 Strengthening the involvement of local communities in the care and support of HIV/AIDs 4.2 Enhancement on the provision of standardized care and support to OVC &PLHIV 4.3 Strengthening income generation activities to sustain the program 5. Health Extension Programme H SD P IV 59 Targets: 1. Increase TB case detection rate (All forms) to 75% Emphasis of HSDP IV TB Case detection will be enhanced through: • Effective use of HEP as a vehicle to detect new cases, contact tracing & treatment follow up. • Strengthened laboratory network. • Improving information systems, including notification & referral routines. • Correct estimation & regular updating of the TB burden. 2. Increase TB treatment success rate from 84% to 90% 3. Put 100% of confirmed MDR TB cases on correct second line Anti-TB treatment regimen 4. Increase proportion of PLHIVs screened for TB from 15% to 80% 5. Increase Tuberculosis Cure Rate from 67% to 85% Initiatives 1. Expansion of Community DOTS through maximum use of HEP 2. Strengthen case detection & management: 2.1 Ensure early case detection, & diagnosis through quality-assured bacteriological diagnosis. 2.2 Provide standardized treatment with supervision, & patient support. 2.3 Ensure effective drug supply & management. 3. Addressing TB/HIV, MDR-TB & Leprosy; 3.1 Scale-up collaborative TB/HIV activities. 3.2 Scale-up prevention & management of multidrug-resistant TB (MDR-TB). 3.3 Address needs of TB contacts, & of poor & vulnerable populations. 3.4 Strengthen early detection of leprosy at community & facility level 4. Engaging all care providers, 4.1 Involve all public, voluntary, corporate & private health care providers. 4.2 Promote the use of the International Standards for Tuberculosis Care (ISTC). 5. Enabling & promoting research. 5.1 Implementation of operational research on the effectiveness of DOTS expansion & TB/HIV collaborative strategies 6. Health Extension Programme Reduce incidence & prevalence of malaria Targets: 1. 85% of children under 5 years old with fever in last 2 weeks who received diagnosis within 24 hours from onset of fever 2. Reduce lab confirmed (RDT/Microscopy) malaria case fatality ratio to less than 2% 3. Reduce lab confirmed (RDT/Microscopy) malaria incidence per year to less than 5 per 1000 population per year 4. Increase proportion of households in malarious areas who own at least one LLITN from 65.6% to 90%. 5. Increase proportion of pregnant women who slept under LLITN the previous night from 42.5% to 86%. 6. Increase proportion of U5 children who slept under LLITN the previous night from 41.2% to 86%. 7. Proportion of households in IRS-targeted areas that were sprayed in the last 12 months from 55% to 77%. Initiatives 1. Early diagnosis & treatment of cases 1.1 Improve the capacity of health workers in the diagnosis & case management of Malaria at health post level according to the national Guideline. 1.2 Improve the capacity of health workers in the management & diagnosis of severe malaria at health centre & hospital levels according to national guidelines. 1.3 Ensure the availability of essential commodities for the diagnosis & treatment of malaria 2. Selective vector control (LLITN, IRS, Environmental management) H SD P IV 60 2.1 Geographical targeting & flexible distribution strategies for LLITN 2.2 Procurement, distribution & storage of insecticide & spray materials & implementation of IRS via Health Extension Program; & ensure public acceptance, practice, & participation in IRS programs 2.3 Environmental compliance 3. Health Extension Programme Reduce Incidence & prevalence of other communicable disease Targets 1. Decrease prevalence of leishmaniasis from 9.7% to 7% in males & from 4.5% to 2% in females. 2. Decrease prevalence of lymphatic filariasis from 23.7% to 16% in males & from 18.5% to 11% in females. Initiatives 1. Complete mapping in the distribution of all NTDs (leishmaniasis, L.filariasis, schistosomiasis, soil transmitted helminthiasis). 2. Integrated approach & co- implementation of intervention packages 2.1 Develop programme management & coordination guideline for NTDs. 2.2 Design & develop nationally appropriate guideline prevention, early detection, diagnosis & registry for cancers. 2.3 Advocacy, Social Mobilisation & Sensitisation for NTDs programme implementation 2.4 Develop & sustain partnership & collaboration for integrated NTDs control 2.5 Enhance integrated supportive supervision, research, monitoring & evaluation of NTDs programmes. SO C.1.5: Prevention & control of non­communicable diseases Targets: 1. Increase cataract surgical rate (CSR) from 460 to 1,000 per 1,000,000 per year 2. Decrease national blindness prevalence from 1.6% to 1%. 3. Halt the incremental change in prevalence of high blood pressure among adults at 25% in urban & 5% in rural 4. Halt the incremental change in prevalence of type 2 diabetes mellitus at 1-3% 5. Increase proportion of health facilities providing integrated mental health services from 10% to 50% Initiatives 1. Integrated approach & co- implementation of intervention packages 1.1 Develop programme management & coordination guideline for NCDs. 1.2 Design & develop nationally appropriate guideline on prevention, early detection, diagnosis & registry for cancers. 1.3 Advocacy, Social Mobilisation & Sensitisation for NCDs programme implementation with emphasis on major risk factors (Alcohol, smoking, diet & exercise) using the existing health extension program; Develop & sustain partnership & collaboration for integrated NCDs control 1.4 Enhance integrated supportive supervision, research, monitoring & evaluation of NCDs programmes. 1.5 Mental health service integration into all routine health service delivery system 2. Strengthen routine & outreach cataract surgery with emphasis to reaching inaccessible areas H SD P IV 61 SO C2: Improve community ownership Targets 1. Increase proportion of model households graduated from 25.6% to 85% 2. 100% of households networked in health development army 3. Increase proportion health facilities with boards where communities are represented to 100%. Initiatives 1. Strengthening Health Extension Program 2. Strengthen community empowerment/conversation & social Mobilisation programme through focused training & supervision of Development Army to facilitate Integrated Community Dialogue (with emphasis on HIV/AIDS, Malaria, TB, Maternal & child, Nutrition & Environmental health) 3. Information, Education & Communication /Behavioural change communication 4. Pursue communication & social mobilisation to be gender sensitive, empower women & advocate for women led Kebele health committee / Development Army 5. Strengthen governance & leadership of public health facilities 6. Regulatory information delivery SO F1: Improve resource mobilization & utilization Targets 1. Increase per capita expenditure on health from 16.1 USD to 32.2 USD. 2. Increase government expenditure on health budget as a proportion of total budget from 5.6% to 15% 3. Increase proportion of public health facilities retaining & using their revenue from 20% to 100% 4. Increase proportion of people enrolled in health insurance from 1% to 50% 5. Increase health budget utilisation rate to 90% Initiatives 1. Establish Community based & Social Health Insurance. 2. Strengthen Facility Revenue Retention & utilisation. 3. Enhance waiver & exemption system 4. Proactive resource mobilisation 5. Establish private wings in public hospitals 6. Establish Integrated Financial Management Information System 7. Financial accountability & management program 8. Result Based Financing Schemes. 9. Strengthen resource mapping SO P1: Improve quality of health services Targets 1. Increase customer satisfaction index from 50% to 100% 2. Increase bed occupancy rate from 50.8% to 85% 3. Decrease average length of stay from 6.7 days to 5 days. 4. Increase outpatient attendance per capita from 0.2 to 0.7 5. Increase % of emergency patient receiving emergency care in less than 5 minutes from 50% to 100%. Initiatives 1. Strengthen emergency management system. 2. Implement Quality management such as Nursing standard, laboratory standard, Infection Prevention, Medical record standard, etc. 3. Provision of safe & adequate blood for transfusion H SD P IV 62 4. Establishing a well functional referral system 5. Regulatory service to both public & private sector institutions 6. Performance monitoring & quality standard operational procedures process 7. Integrate related health programs at management & service delivery levels SO P2: Improve public health emergency preparedness & responses Targets 1. Improve proportion of epidemics controlled with zero mortality to 50%. Initiatives 1. Active Surveillance & Epidemic Control 2. Vulnerability assessment & risk analysis; 3. Capacity building (intelligence officers. national stockpile system, etc.) 4. Response & recovery operations (including emergency nutrition response) SO P3: Pharmaceutical supply & services Targets 1. Decrease procurement lead time (average time between order & delivery from supplier) from 240 to 120 days 2. Decrease proportion of health facilities with stock-out for essential drugs from 35% to 0%. 3. Increase proportion of patients with adequate information on dispensed drugs from 68% to 100%. 4. Reduce percentage of stock wasted due to expiry from 8.2% to 2%. 5. Decrease percentage of prescriptions containing antibiotics from 58% to 25% 6. Increase percentage of dispensed drugs adequately labelled from 43% to 90% Initiatives 1. Quantification/forecasting & procurement system 2. Pharmaceutical storage & inventory control system 3. Pharmaceutical hubs & transport system. 4. Revolving drug fund management system 5. Integrated Pharmaceuticals Fund & Supply Management Information System (IPFSMIS) 6. Strengthen rational drug use. SO P4: Improve regulatory system Targets 1. Accredit to hospitals annually 2. Increase proportion of licensed/certified health institutions & food establishments to 100%, respectively 3. Increase number of registered & licensed traditional medicine providers to 80 4. Increase of GMP qualified local pharmaceutical manufacturers to 17 Initiatives 1. Inspection & licensing 2. Product quality assessment & registration 3. Strengthen Quality Quarantine service 4. Medico legal service SO P5: Improve evidence­based decision making by enhanced harmonisation & alignment Targets 1. Increase timeliness & completeness of HMIS reports from 57% to 90%. 2. Improve correspondence between data reported & recorded from 15% to 90%. 3. Maintain proportion of Woredas with evidence-based plan aligned vertically & horizontally at 100% 4. Increase proportion of partners implementing “one-plan” to 100% H SD P IV 63 5. Increase proportion of Health Development Partners providing funds through MDG-PF to 75% 6. Increase proportion of partners using the national M&E framework Initiatives 1. Advocacy on Harmonisation & Alignment 2. Regular Short & medium term resource mapping 3. Regular evaluation of adherence to the principles of harmonisation & alignment 4. Integrate related health programs at management & service delivery levels 5. Institutionalize Monitoring & Evaluation of health programs 6. Conduct Research for program improvement 7. Strengthen district heath management system to institutionalize evidence based planning 8. Strengthen the generation & use of strategic information within the context of health system strengthening. 9. Evidence based problem solving comprehensive support to Pastoralist areas. 10. Respond to the health impacts of climate change through tracking of up to date information. SO CB1: Improve health infrastructure Targets 1. Maintain health post to population ratio at 1:5,000 2. Maintain health centre to population ratio at 1:25,000 3. Increase primary hospital to population ratio to 1:100,000 4. Increase general hospital to population ratio to 1: 1,000,000 5. Increase specialised hospital to population ratio to 1: 5,000,000 population 6. 100% of health facilities fully equipped & furnished as per the standard 7. 10 new vaccines adopted & used 8. Implement EMR in all hospitals 9. Implement e-HMIS in all Woredas and Health Facilities Initiatives 1. Health Facility Construction program 2. Health Facility rehabilitation and upgrade projects 3. Health Facility Maintenance program 4. Cold Chain management and medical equipment maintenance 5. EMR, e-HMIS, M-Health, networking, telemedicine and tele-education programmes. 6. Technology transfer & dissemination 7. Technical and financial support for Pastoralist area focused health facility expansion 8. Build regional medical equipment maintenance workshop SO CB2: Improve human capital & leadership Targets 1. Improve health workforce ratio from 0.7 per 1,000 to 1.7 per 1,000 population 2. Improve physician to population ratio from 1:37,996 to 1:5,500 3. Increase number of trained and deployed midwifery from 2,002 to 8,635 Initiatives 1. Scale up Training & development in line with staffing requirement detailed in the annex with focus on medical doctors, IESO, anaesthesia professionals, midwives & HITs. Major initiatives with this regard include 1.1 Establish/expand innovative, technology assisted medical & health science training program 1.2 Transforming selected hospitals with potential into medical & health science training college H SD P IV 64 1.3 Team based training of midwives, anaesthesia professionals & IESO to address the BEmONC & CEmONC at PHCU level 1.4 Enhance the availability of HITs through generic & work integrated training programs 1.5 Effective coordination mechanism of service sector (employer) with education sector & training centres 2. Conduct Integrated Refresher Training (IRT) for Health Extension Workers 3. Effective & targeted staff retention mechanisms developed & implemented 4. Development, scale up & implementation follow up of web based HRIS 5. Establish an HRH leadership & management development centre & relevant training programs & operational research 6. Regular review of HRH plan in view of unforeseeable changes as well as wider political & economic changes 7. Establish Continuous Professional Development Program (CPD) 8. Regular update of curricula for competence-based programs in pre- service education 9. Implement the agreed TA guideline Chapter Costing and Financing HSDP-IV4 H SD P IV 66 Chapter 4. Costing and Financing HSDP­IV The Government of Ethiopia and its development partners have made considerable progress toward achieving the MDGs. The health sector of Ethiopia has introduced and is vigorously pursuing the implementation of evidence-based high-impact intervention packages at all levels of the health care system. These include HEP packages at the family and community level, and expansion of outreach services and medium to high level clinical care which are known to have positive impacts on the population by improving the coverage for health care. However, there are still major bottlenecks remaining that need to be tackled in the next five years of HSDP-IV implementation. There is strong evidence that the primary obstacles blocking fast and sustainable targeted health gains are lack of resources and weak implementation capacity. There are also low levels community utilisation for some existing interventions despite their proven effectiveness, which implies the need for more work with communities to increase demand and timely utilisation of available services at each level of the health care system. Therefore, to attain the MDGs in the coming five year period, the health expenditure will need to be increased and the HSDP-IV costing has been prepared taking this into consideration. 4.1 Costing methodology The costing exercise considers the Government’s firm commitment to reach the MDGs. Costing for the HSDP-IV has been conducted using the Marginal Budgeting for Bottlenecks (MBB) tool, which is an evidence-based result-oriented planning and budgeting tool that uses knowledge about the impact of existing interventions on health in a country. MBB helps to conduct bottleneck analysis based on country evidence. The bottleneck analysis was conducted as part of the SWOT and Stakeholder analysis to set national coverage targets for interventions to be reached by 2014/15. A summary of the bottleneck analysis is included in Annex 3. 4.2 Costing scenarios and assumptions for HSDP­IV Ethiopia has made significant progress in expanding health services and improving health outcomes over the years through the HSDPs. At the time of creating this plan, however, the analysis of progress toward MDG 1, 4, 5, 6 & 7 shows that further strengthening is needed for health systems and more improvements in quality of health care. In response, government is planning to continue and expand the range of high impact interventions to be provided to Ethiopians at community, outreach and clinical service delivery levels. The costing estimate is based on two scenarios and provides a detailed costing analysis and results for both of them. Each scenario calls for a certain level of reinforcement of the cornerstones of the health system or the coverage H SD P IV 67 determinants. A proportion of bottleneck reduction is considered to formulate the two scenarios with separate set of coverage targets as detailed in Annex 3,1a – 1c, many of the interventions exhibit low coverage levels. The assumptions implied in defining the scenarios are: Base­case scenario: The base-case scenario also assumes that there would be no compromising of the plan to achieve the MDGs by the year 2015. This scenario considers universal access to health centre, staffing, equipping and availing drugs and supplies to HCs as per the standard. There would be strengthening for supply chain management system to make HCs fully functional and provision of Basic Emergency Obstetric Care and essential newborn care. In addition, selected HCs would be upgraded to primary hospitals to provide ambulatory and inpatient services, including emergency surgery, caesarean section and blood transfusion services. Existing general and specialised hospitals would also be strengthened. This scenario considers the already achieved targets for infrastructure and HRH and uses them as a springboard for facilitating further health gains. These include the already achieved universal PHC coverage through rapid development of HPs at the community level, Health centres and the planned expansion and scale up of primary hospitals. It also considers the rapid development and deployment of more than 30,000 HEWs at the community level and over 5000 health officers at health centre and hospital levels. This scenario includes strategies to enhance performance of the health extension programme through skills upgrading of health extension workers, model family graduation, supportive supervision, and introduction of community-based pneumonia treatment, as well further improving the quality of health services given at community level. It would also strengthen the pastoral and urban health extension programme. This scenario anticipates reaching a high level of coverage with an ambitious reduction in existing bottlenecks of up to 80% over the coming five years. For services, the base-case scenario aims at reaching: • BEmONC and CEmONC services in HCs & hospitals - 100% • ART treatment - 85%, • Full immunisation - 90%; • Coverage in clean and safe delivery by HEWs - 38% • Coverage of deliveries by skilled attendants - 62%. • Model Household graduation - 85%, • Latrine utilisation - 82%, • ITN ownership and use by households - 90% & 86%, respectively This scenario is projected to achieve the MDG target in maternal health through a 54.8% reduction in MMR from the current levels. This scenario is also projected to achieve the MDG target in child health through reduction of under- five mortality by 33.8% from the current levels. H SD P IV 68 Best­case scenario: This scenario follows the MDGs Needs Assessment (2005) that assumes a condition of no financial constraint. It projects fulfilling the commitment of the health sector to improve and sustain quality of health service delivery, embracing prevention and control of communicable diseases, and improving the quality of clinical care for acute and chronic health problems. It also assumes ensuring universal access to quality clinical care, with access to advanced treatment at all levels of the health care delivery system. The best-case scenario focuses mainly on evidence-based high level clinical care and the protection of patient rights in accessing the needed health care services. 4.3 Cost and impact of scaling­up Figure 14 (below) presents the additional costs and mortality reduction impacts for the two scenarios. Base-case scenario stipulates the need to mobilise an additional US$ 11.96 per capita per year on average over the five years. The investment is estimated to reduce under-five mortality by 33.8% and maternal mortality by 54.8%. Ethiopia would be able to achieve the health MDGs with the implementation of the base-case Scenario. Table 9. Additional cost and mortality reduction estimates 2010/11 – 2014/15 Base-case Scenario Best-case Scenario Under five mortality reduction 33.8% Under five mortality reduction 46% Maternal mortality reduction 54.8% Maternal mortality reduction 56.6% Cost per capita per year in US$ 11.96 Cost per capita per year in US$ 13.96 Figure 14. Progress towards MDGs and additional cost per capita The best-case scenario calls for a higher supplemental investment of US$ 13.96 per capita per year, but it would result in much higher reductions in mortality – H SD P IV 69 bringing down under-five mortality by 46% and maternal mortality by 56.6%. In terms of resource mobilisation, however, the best-case scenario calls for almost doubling the current Total Health Expenditure by the end of HSDP-IV. The additional cost estimate has been translated into total budget estimates for the five years. In calculating the total budget estimates, the additional cost estimates are added to the baseline health sector spending for FY 2009/10. The health spending for 2009/10 was consolidated from resource mapping that gathered data about all resources from Government and development partners, both on- and off-budget. The fiscal year 2009/10 total health spending from Government and development partners was estimated at US$ 883.06 million. The summation of additional cost plus fiscal year 2009/10 spending was done only for the recurrent portion, so as not to double count capital costs incurred in the past. The results are presented by level of service delivery, recurrent capital investment distributions, and HSDP-IV programme areas. Total budget for the five years is estimated at US$ 8.83 billion under the base- case scenario and US$ 10.828 billion for the best-case scenario. This represents an average annual increase of public health spending by 9% over the coming five years from the current base of US$ 883.06 million in the base-case scenario, and 13.5% increase under the best-case scenario. Level of service delivery: A substantial proportion of the total budget estimate is allocated to make existing health facilities fully functional and improve quality of care at all levels of service delivery points. In both the base-case and best-case scenarios about 43% of the total budget is allocated to strengthen services at clinical level, including health centres, district and general hospitals. The investment is intended to enhance obstetric services with appropriate equipment, supplies and skills of the health workers. It also targets improvement in the quality of services available for maternal-newborn health, child health, nutrition, malaria, HIV/TB and non-communicable diseases. Over 45% of the total investment is aimed at sustaining and strengthening the Health Extension Programme including the outreach services from health centres for immunisation and family planning. About 15% of the total investment envisaged is to further strengthen the health management and administrative capacity from Woreda Health Office, Regional Health Bureaus, to Ministry of Health. (See Figure 15, below also Annex 6). H SD P IV 70 Figure 15. Allocation of total budget estimates by level of service delivery Recurrent and capital investment allocations: In line with the decision to shift focus from expansion to service delivery and quality of care, a substantial proportion of the total budget estimate over the five years periods, 78% in the base-case and 55% in the best-case Scenarios, is allocated to recurrent costs for covering salary, skill upgrading, supportive supervision, maintenance, and monitoring and evaluation. Only 22% in the base-case and 45% in the best- case scenario of the total budget estimate is for capital investment, mainly to strengthen infrastructure capabilities for obstetric care. (See table 10) Table 10. Budget estimate by scenario, service delivery, investment & recurrent costs (US$ mill) Service delivery Baseline 2010/11 2011/12 2012/13 2013/14 2014/15 Total % Base-case Scenario Population oriented schedulable services 63.39 351.06 125.27 137.31 152.49 167.51 933.64 33 District, provincial, national governance & management 119.78 195.03 193.87 215.70 247.68 279.45 1,131.73 11 Family oriented community- based services 181.76 527.17 568.60 567.44 615.00 655.68 2,933.89 43 Individual oriented clinical services 418.97 603.74 619.33 742.08 868.34 993.74 3,827.25 13 Totals 883.06 1,677.01 1,507.07 1,662.54 1,883.51 2,096.38 8,826.50 100 Capital investment 628.74 581.01 382.68 347.83 337.83 327.41 1,976.76 22 Recurrent 254.32 1,095.99 1,124.39 1,314.71 1,545.68 1,768.96 6,849.74 78 Best-case Scenario Family oriented community- based services 181.76 637.48 746.21 801.66 877.21 938.51 4,001.07 37 Population oriented schedulable services 63.39 389.65 196.52 179.25 194.75 209.99 1,170.17 11 Individual oriented clinical services 418.97 603.74 1,374.19 1,293.37 1,741.76 1,545.03 6,558.09 61 District, provincial, national governance & management 119.78 195.03 193.87 215.70 247.68 279.45 1,131.73 10 Totals 883.06 1,419.30 2,104.19 2,083.38 2,654.80 2,566.38 10,828.05 100 Capital investment 482.75 640.56 1,252.67 1,016.02 1,004.37 988.67 4,902.29 45 Recurrent 400.31 778.74 851.52 1,067.36 1,650.42 1,577.71 5,925.76 55 H SD P IV 71 Budget estimates allocations to programme areas: in the base-case, 48% of the budget is allocated to strengthening service delivery component of HSDP-IV; followed by expansion and strengthening health infrastructure and resources 37%; and leadership and governance 15%. The three major disease programmes, i.e., prevention and control of malaria, HIV/AIDS, and TB/leprosy account for 30% of the total budget estimate. (See table 11) Table 11. Base-case scenario: estimated budget by HSDP-IV programme areas (US$mill) Programmatic areas Baseline 2010/11 2011/12 2012/13 2013/14 2014/15 Total % Base-case Scenario 1. Leadership & governance 33.85 181.47 193.90 259.95 330.56 396.39 1,362.27 15 1.1 Community Empowerment 6.78 17.48 29.95 34.31 37.85 40.07 159.65 2 1.2 Monitoring & Evaluation, & Operational Research 7.36 15.36 24.05 29.35 33.53 36.57 138.85 2 1.3 System Strengthening & Capacity Development 19.71 148.63 139.91 196.29 259.19 319.74 1,063.76 12 2. Strengthening service delivery 626.12 738.73 801.56 819.06 885.90 949.44 4,194.69 48 2.1 Maternal-Newborn & RH- Adolescent Health 31.27 50.63 74.50 95.53 115.80 135.15 471.62 5 2.2 Child Health 25.06 37.95 43.01 45.04 48.46 51.24 225.70 3 2.3 Nutrition 6.38 13.56 19.89 22.91 25.29 26.63 108.27 1 2.4 Hygiene & Environmental Health 7.87 16.87 28.66 34.58 38.54 40.55 159.21 2 2.5 Prevention & Control of Malaria 111.45 240.53 202.06 137.51 120.79 103.46 804.36 9 2.6 Prevention & Control of HIV- AIDS 276.25 193.91 213.75 233.60 253.44 273.29 1,167.98 13 2.7 Prevention & Control of TB & Leprosy 152.72 131.96 137.04 141.70 146.22 150.61 707.53 8 2.8 Prevention & Control of Other Communicable Diseases 0.24 12.09 24.01 35.92 47.83 59.75 179.60 2 2.9 Prevention & Control of Non- Communicable Diseases 0.27 15.86 31.52 47.18 62.84 78.50 235.89 3 2.10 Public Health Emergency Management 0.45 6.54 7.07 7.10 7.49 7.76 35.97 0 2.11Public Health Nutrition Research, Quality Assurance 14.16 18.81 20.05 18.01 19.19 22.51 98.57 1 3. Expand & strengthen health infrastructure & resources 223.09 756.81 511.60 583.53 667.05 750.55 3,269.54 37 3.1 Expansion of PHC Facilities 39.48 273.94 32.62 44.17 55.71 67.25 473.69 5 3.2 Hospital Infrastructure 30.11 178.51 202.74 226.97 251.20 275.44 1,134.86 13 3.3 HR Salaries & Training 54.33 116.60 154.12 189.99 229.10 268.20 958.01 11 3.4 Pharmaceutical & Medical Equipment 97.00 184.51 115.65 112.74 118.18 123.62 654.71 7 3.5. Health Care Financing 2.17 3.24 6.47 9.67 12.86 16.04 48.27 1 Total 883.06 1,677.01 1,507.07 1,662.54 1,883.51 2,096.38 8,826.50 100 In the best-case scenario 56% of the budget is allocated to strengthening service delivery component of HSDP-IV; 31% for expansion and strengthening health infrastructure and resources: and leadership and governance 13%. Malaria, HIV/AIDS, and TB and leprosy are given a 40% share of the total estimated budget for the five years period. (See table 12) Table 12. Best-case scenario: estimated budget by HSDP-IV programme areas (US$mill) Programmatic areas Baseline 2010/11 2011/12 2012/13 2013/14 2014/15 Total % Best -case Scenario 1. Leadership & governance 33.85 190.97 203.40 269.45 340.06 405.89 1,409.78 13 1.1 Community Empowerment 6.78 22.56 35.03 39.39 42.93 45.16 185.08 2 1.2 Monitoring & Evaluation, & Operational Research 7.36 19.77 28.46 33.77 37.94 40.99 160.93 1 1.3 System Strengthening & Capacity Development 19.71 148.63 139.91 196.29 259.19 319.74 1,063.76 10 2. Strengthening service delivery 626.12 1,118.68 1,181.50 1,199.00 1,265.84 1,329.38 6,094.41 56 2.1 Maternal-Newborn & RH- Adolescent Health 31.27 72.07 95.95 116.98 137.25 156.59 578.84 5 2.2 Child Health 25.06 54.30 59.36 61.38 64.80 67.58 307.42 3 2.3 Nutrition 6.38 16.75 23.08 26.10 28.48 29.82 124.22 1 2.4 Hygiene & Environmental Health 7.87 18.06 29.84 35.76 39.72 41.73 165.11 2 2.5 Prevention & Control of Malaria 111.45 273.97 235.50 170.94 154.23 136.90 971.53 9 2.6 Prevention & Control of HIV- AIDS 276.25 367.94 387.79 407.63 427.48 447.32 2,038.17 19 2.7 Prevention & Control of TB & Leprosy 152.72 257.19 262.27 266.93 271.45 275.84 1,333.68 12 2.8 Prevention & Control of Other Communicable Diseases 0.24 12.27 24.19 36.10 48.01 59.93 180.50 2 2.9 Prevention & Control of Non- Communicable Diseases 0.27 16.06 31.72 47.38 63.04 78.70 236.90 2 2.10 Public Health Emergency Management 0.45 6.99 7.52 7.55 7.94 8.21 38.22 0 2.11Public Health Nutrition Research, Quality Assurance 14.16 23.06 24.30 22.26 23.44 26.76 119.81 1 3. Expand & strengthen health infrastructure & resources 223.09 767.67 522.47 594.40 677.91 761.42 3,323.87 31 3.1 Expansion of PHC Facilities 39.48 273.94 32.62 44.17 55.71 67.25 473.69 4 3.2 Hospital Infrastructure 30.11 178.51 202.74 226.97 251.20 275.44 1,134.86 10 3.3 HR Salaries & Training 54.33 127.47 164.99 200.85 239.96 279.07 1,012.34 9 3.4 Pharmaceutical & Medical Equipment 97.00 184.51 115.65 112.74 118.18 123.62 654.71 6 3.5. Health Care Financing 2.17 3.24 6.47 9.67 12.86 16.04 48.27 0 Total 883.06 2,077.32 1,907.38 2,062.85 2,283.82 2,496.69 10,828.05 100 4.4 Financing gap The most significant constraints against rapid scale up of health interventions are the prevailing inadequacy and inefficiency in the resource mobilisation and allocation for health. Baseline and target coverage of high interventions are included in the cost calculations for the two scenarios seen in Annex 6. Taking into consideration the current poverty levels and the pace of the country’s economic growth, it is projected that there will be a significant financing gap that will need additional resource mobilisation, with the consequence that a substantial proportion of the required resources may have to come from development partners. The contribution of Government to HSDP-IV is expected to follow an upward pattern with expected rise in allocation from US$ 249 million in 2009/10 to US$ 307 million in 2014/15. As indicated in the figure 16 (below), the projected resource commitment by 14 development partners in the coming five years of HSDP- IV periods will show some decline, especially in the last three years of H SD P IV 74 funding gap. In addition, the gap widens over time, as most development partners are not able to accurately predict for the later years of HSDP-IV. The financing gaps over the coming five years amount to US$ 4.337 billion for the base-case scenario and US$ 6.339 billion for the best case scenario. This represents an annual average funding gap of US$ 867.40 million and US$ 1,267.71 million for the base-case and best-case respectively. A disaggregated analysis of the financing gap by programme areas confirms the inequity in the health sector. The major financing gap remains high in health systems, including expansion and strengthening pharmaceuticals followed by maternal-newborn health and child health. See table 13 (below) for the full detail of the funding gap in the best case scenario. Figure 18. Funding gap over the coming five years period in Million US$ Based on the information compiled from 14 development partners substantial amount of the commitment for the coming years is concentrated in few vertical disease specific programmes. About 85% of the development partners projected commitments are for HIV/AIDS, TB and malaria. Although these diseases seemed well funded in previous years, there are still huge gaps to scaling the support out to the lower services delivery level. Table 13. Total budget, projected commitment & funding gap by programme areas Total budget estimate Projected resources committed Funding gap 2010/11-2014/15 Base-case Scenario Best-case Scenario Base-case Scenario Best-case Scenario 1. Leadership & governance 1,362.27 1,409.78 439.40 922.88 970.38 1.1 Community Empowerment 159.65 185.08 72.61 87.05 112.47 1.2 Monitoring & Evaluation & Operational Research 138.85 160.93 54.83 84.02 106.10 1.3 System Strengthening & Capacity Development 1,063.76 1,063.76 311.95 751.81 751.81 2. Strengthening service delivery 4,194.69 6,094.41 3,076.65 1,118.04 3,017.76 2.1 Maternal-Newborn & RH-Adolescent Health 471.62 578.84 154.49 317.13 424.35 2.2 Child Health 225.70 307.42 76.01 149.69 231.41 2.3 Nutrition 108.27 124.22 14.31 93.96 109.91 2.4 Hygiene & Environmental Health 159.21 165.11 34.69 124.52 130.42 2.5 Prevention & Control of Malaria 804.36 971.53 566.13 238.23 405.41 2.6 Prevention & Control of HIV-AIDS 1,167.98 2,038.17 1,395.12 -227.13 643.05 2.7 Prevention & Control of TB & Leprosy 707.53 1,333.68 662.01 45.52 671.67 2.8 Prevention & Control of Other Communicable Diseases 179.60 180.50 72.53 107.07 107.97 2.9 Prevention & Control of Non-Communicable Diseases 235.89 236.90 72.33 163.56 164.58 2.10 Public Health Emergency Management 35.97 38.22 0.11 35.86 38.11 2.11Public Health/Nutrition Research & Quality Assurance 98.57 119.81 28.93 69.64 90.88 3. Expansion & strengthening health infrastructure & resources 3,269.54 3,323.87 973.45 2,296.09 2,350.42 3.1 Expansion of PHC Facilities 473.69 473.69 145.38 328.31 328.31 3.2 Hospital Infrastructure 1,134.86 1,134.86 144.94 989.92 989.92 3.3 HR Salaries & Training 958.01 1,012.34 454.04 503.97 558.30 3.4 Pharmaceutical & Medical Equipment 654.71 654.71 219.74 434.97 434.97 3.5. Health Care Financing 48.27 48.27 9.37 38.91 38.91 Total 8,826.50 10,828.05 4,489.50 4,337.00 6,338.55 4.5 Financing channels and arrangements for HSDP­IV Three channels of funding currently operate in the country, which also work for the health sector. These are: Channel 1a (un-earmarked): this the disbursement channel used by Government itself. At each administrative level, the specialised finance bodies control the release of funds and report upwards on their utilisation. This is the channel that is used by donors providing budget support and Protection of Basic Services (PBS) component-I. Channel 1b (earmarked): this channel is an earmarked fund transferred through MoFED, with funds from each donor being tagged (with a two figure code), and sent to the region and zone/Woreda (with a location code). The funds are reported on and accounted for separately, and used to pay only for activities agreed by the particular donor, often according to its specific procurement and disbursement procedures. H SD P IV 76 Channel 2: this is a channel whereby the Regional and Zonal/Woreda finance bodies are by-passed. Sector units at each administrative level expend and account for funds. There are variations on this channel. Some DPs centralise disbursement responsibility at the Federal level (so that even regional contractors are paid centrally). Other donors have worked directly with regional and/or Woreda administrations. Channel 3: in this financing channel, DPs usually carry out any procurement and pay the contractor directly. Government merely agrees to, and budgets for, what is to be provided by the donor, and ensures that the expenditures are included in any overall HSDP accounting and auditing. In-addition to the above three channels, there are two channels which operate specifically in the health sector. These are: Technical Assistance Pooled Fund: this fund was established in 2005 by five DPs to provide support to MoH; it fills a critical gap in capacity and is the first pooling arrangement in the health sector. It provides support in technical assistance, sector reviews, operational research, and other activities at MoH level. Currently, the fund is being managed by UNICEF. The MDG Performance Fund: the MDG Performance Fund and Multi-donor Trust Fund (MDTF) have also come to operation during HSDP III. MDG Performance Fund is described in HSDP-III and started working in 2007. A huge financing gap in health systems, maternal health, and the particular nature of health services – a large number of public good elements in service delivery and a high proportion of recurrent inputs bought internationally (medicines, commodities and equipment) – warrants the establishment of a strong Federal MOH Level MDG Performance Package Fund to support the implementation of HSDP. The MDG-PF will help to finance four thematic areas: a) Health extension programme, b) Service delivery (MNCH), c) Public health commodity procurement and d) Health systems strengthening. For further details on management of the MDG-PF, see Joint Financing Arrangement. 4.6 Preferred channels of financing HSDP­IV For the health sector, the preferred modes are mainly: i) Channel 1a - the block- grant to Woreda (currently supported by Protection of Basic Services Component 1); and ii) the MDG Performance Fund (“MDG Fund”, currently supported by the seven signatories of the JFA). These channels are preferred due to their lower transaction costs for the government. It also provide flexible resources, consistent with one plan and budget concept, to provide additional finance to underfunded areas of HSDP. 4.7 Application of “one­budget” to channels and mechanisms The main purposes of implementing a “one budget” approach at all levels of the health system are to: 1) Ensure that various channels and funding mechanisms finance “one plan”; and 2) Reduce the transaction costs for the government that arise when dealing with multiple channels and financing mechanisms. H SD P IV 77 There has been only listless progress in the sector, however, in moving toward these financing mechanisms. In response, the HSDP Harmonisation Manual has proposed interim processes that will partially address these challenges. Accordingly, “one-plan financing” could be realised by applying the following procedures: • Making sure that all project support is aligned with priorities in the sector; • Providing information regarding project activities and funds allocated to local Government in the locations where the project is implemented to ensure that project activities are incorporated in the “one-plan” at that particular level of the health system; • Ensuring regular negotiation and discussion between local Government and project managers to allow flexibility, and to avoid gaps and overlaps; • Promoting accountability and coherence through joint monitoring and evaluation (with local Government and other stakeholders) of project implementation. H SD P IV 78 Chapter Management arrangement of HSDP-IV5 H SD P IV 80 Chapter 5. Management arrangement of HSDP­IV This chapter describes the mandates of the different levels of the health system. It also elaborates on the planning, governance, procurement, financial management, monitoring and evaluation processes that apply to HSDP IV. 5.1 Governance structure The current system for HSDP joint governance and coordination has evolved incrementally over the past twelve years, with a number of ad hoc modifications driven by changes in both the international aid architecture and the funding arrangements used within Ethiopia. Over the years, the system has become increasingly complex and required revision of some of the structures. Most of the governance structures of HSDP III were functional but some were not as active as they were supposed to be. The governance structures are now revised in order to strengthen and rationalize the structures. The resulting modified governance structure is summarised here and the details are explained in the HSDP Harmonisation Manual (HHM). Joint Consultative Forum The Joint Consultative Forum (JCF) is the highest governing body and will serve as a joint forum for dialogue on sector policy and reform issues between GoE, DPs and other stakeholders; it will oversee the implementation of the IHP, allocation and utilisation of MDG-PF, Protection of Basic Services (PBS), GAVI and all other donor supported projects. This highest body will ensure effective linkages between development partners, regional bureaus and other sectors and will be chaired by the Minister of Health and co-chaired by HPN co-chairs. Joint Core Coordinating Committee The Joint Core Coordinating Committee (JCCC) will continue to be the technical arm of the JCF and also the Policy, Plan and Finance General Directorate. The major functions of the JCCC will be to give operational oversight; to monitor the implementation of all pooled funds, including the Health Pooled Fund, GAVI, MDG-PF; to organise and coordinate the monitoring, review and evaluation missions and meetings of HSDP and to facilitate the implementation of the findings and recommendations of these meetings and missions. It will also undertake other technical assignments as instructed by the JCF. In addition, the JCCC will analyse and agree to MoH recommendations on the allocation or reprogramming of funding, which will be linked with reviewing quarterly financial and activity plans and reports. It will be chaired by the Director General of the Policy, Plan and Finance General Directorate. The members will be MoH – including Planning, Program & Finance - General Directorate (PPF-GD) and other Directors as needed, and 6 individuals from HPN, to include the managing agent of the TA pool fund plus one co-chair (to be nominated by HPN and agreed by MOH). H SD P IV 81 In-addition to these governance structures, the Global Fund Country Coordinating Mechanism (CCM) and the International Coordinating Committee (ICC) for the EPI activities, will remain as is and may be strengthened or merged with other functional bodies as appropriate in the future. 5.2 Inter­sectoral collaboration & public private partnership In order to reach the MDGs, Ethiopia will have to not only ensure the provision of high quality health care services, but also to address the environmental factors and health determinants that contribute to the society’s collective health and illness. Health determinants are the range of personal, social, economic, and environmental factors that influence the health status of individuals or populations. Improvement in the national health status cannot be fully achieved by only treating and managing diseases and injuries, but it also requires the collective actions of a wide range of actors outside the health sector, such as agriculture, infrastructure, education, environmental protection, etc. Health care provision, as well, cannot be the exclusive domain of the public sector, but needs to mobilise the collaborative efforts of public/private partnership through engaging with the NGO sector and private for profit health providers. One of the biggest organisational and operational challenges facing the health sector is bringing all of these different actors together for a common pursuit and towards improving health through concerted action against major public health problems, and providing adequate amounts and quality of care. Key sectors and mechanisms for inter-sectoral actionable collaboration during implementation of HSDP-IV are indicated as follows: • Collaborate with MoE in training health workers and school health promotion. • Collaborate with Ministry of Water Resources to ensure availability of adequate and clean water supply. • Collaborate with Ministry of Agriculture on nutrition, prevention and control of communicable diseases. • Collaborate with Ministry of Finance on improving resource allocation to the health sector. • Collaborate with the media in public health awareness creation and dissemination of health messages and information to the general public. • Collaborate with Ministry of Youth and Sports in adolescent health services. • Collaborate with Ministry of Women Affairs to ensure gender equality and maternal and child health services. • Collaborate with Ministry of Transport on the reduction and prevention of road traffic accidents and improvement in efficient referrals of the injured. Public Private Partnership will be enhanced through collaborative endeavours on selected health sector priority programmes and health system issues, such as: • Collaborate with private sector on the expansion of health infrastructure, local production of pharmaceuticals, provision of health services, training of health professionals and mobilisation of resources for the health sector. • Collaborate with professional associations on improving quality of health services and reducing professional malpractices. H SD P IV 82 The HSDP-IV plan is that inter-sectoral collaboration will take place at different levels of the health system through formal government institutions (such as regional and Woreda councils) and health sector governance structures (such as JCF, RJSC and WJSC). The major hallmark for intersectoral collaboration is the operationalisation of joint planning, implementation, monitoring and evaluation at all levels of the health system, as described in key MoH documents (such as the HSDP Harmonisation Manual). A complete set of manuals and tools will be developed to also guide public/private partnerships in health. 5.3 Health service delivery arrangement The Ethiopian health service is now restructured into a three tier system. These levels are: a) The primary care level has three kinds of service points – health posts, health centres and primary hospitals. • The Health Posts, Health Centres and primary Hospital are organised into PHCUs, which is composed of a HC, five satellite HPs and Primary Hospital. Taken together, the PHCU provides services to a population of about 100,000 persons. • Each Health Post (HP) is staffed with two HEWs, and is responsible for a population of 3-5,000 persons. The HEWs are expected to spend less than 20% of their time in health posts, and more than 80% of their time is meant to be spent on community outreach programme visits to households, especially mothers and children. The HEWs provide 96 hours of training to households on the selected packages of HEP and follow the household’s practices before certification and graduation of the household. HEWs also provide selected health care services, including family planning, EPI, outpatient therapeutic programme (OTP), clean delivery and essential newborn care services, diagnosis and treatment of malaria, diagnose and treatment of pneumonia, and management of diarrhoea and dehydration using ORS. • A HC has an average of 20 staff. It provides both preventive and curative services. It also serves as a referral centre and practical training institution for HEWs. The HC has an inpatient capacity of 11 beds. Rural HCs serve populations up to 25,000 persons; urban HCs serve up to 40,000 persons. • A Primary Hospital provides inpatient and ambulatory services to an average population of 100,000. In addition to what a HC can provide, a primary hospital provides emergency surgical services, including Caesarean Section and gives access to blood transfusion service. It also serves as a referral centre for HCs under its catchment areas, and is a practical training centre for nurses and other paramedical health professionals. A primary hospital has an inpatient capacity of 35 beds. On average, a Primary Hospital has a staff of 53 persons. b) The secondary care level is comprised of General Hospitals. • A General Hospital provides inpatient and ambulatory services to an average of 1,000,000 people. It is staffed with an average of 234 H SD P IV 83 professionals. It serves as a referral centre for primary hospitals. It has an inpatient capacity of 50 beds and serves as a training centre for health officers, nurses and emergency surgeons, as well as other categories of health workers. c) The tertiary care level is comprised of Specialised Hospitals. • A specialised hospital serves an average of five million people. It is staffed with an average of 440 professionals. It serves as a referral general hospitals and has an inpatient capacity of 110 beds. Figure 19. Ethiopian Health Tier System 5.4 Health planning The Ethiopian health planning is composed of two planning cycles. The first and most significant reference planning cycle is the five year strategic planning called the HSDP. It serves as a guiding blueprint on which all other plans are developed, e.g., Regional Health Plans, etc. The second is the Woreda based annual planning cycle that translates the five year HSDP into the annual Plan of Work with details of achievable targets, strategies and interventions under the different levels of the health care system. In this respect, the commitment of the GoE to strengthen the implementation of “one-plan” in the health sector will continue throughout the HSDP-IV period. The following are the principles underpinning the planning process, which apply to all stakeholders operating in the health sector at all levels. Government ownership and leadership of all health planning processes: This means that the MoH, RHBs, ZHDs, WoHOs at all levels of the health system own the process, and have the responsibility to organise and lead the planning sessions and other processes. H SD P IV 84 Consultation with all stakeholders: All stakeholders in the overall health system, including governmental, health development partners (DPs) NGOs, CSOs, private sector, etc., will take part in the planning process in a spirit of partnership and will have roles to play and responsibilities to assume. Linkage to resource mapping from all stakeholders at that particular levels of the health system: All stakeholders (government, donors, NGOs, etc.) will avail their expected resource commitments to the health sector every three years and confirm the same every year. The resources need to be disaggregated by thematic and geographic areas to enhance evidence-based planning and decision-making at all levels of the health system. Approval of the plan and budget by the relevant local government authority through the formal political process: A comprehensive health plan will be presented to the council/parliament of the local government to ensure government ownership, provide a clear picture of activities and resources in the health sector as well as to improve evidence-based government resource allocation at all levels of the health system. Maintenance of vertical (federal regional zonal Woreda) and horizontal linkage: all levels of the health system will ensure that plans for their level (including the activities of all stakeholders operating at that particular level) will address national priorities while also considering local priorities. The targets set at a particular level of the health system will also be consistent with a cumulative average of the targets set by the lower levels reporting to that particular level of the health system. It is also important that the activities of all stakeholders operating at a particular health system level are incorporated into the health plan of that level of the system. Both strategic and annual planning are the results and consultations of top down and bottom up processes. The top down process ensures alignment of national priorities and targets with that of the regions and Woredas. It also helps to create consistency between the health sector plans and PASDEP and MDGs. The bottom up process ensures that the priorities and targets of regions and districts take local capacity into account. The details of planning process including the calendar of events, the role of stakeholders can be found in HSDP Harmonisation Manual (HHM). It is important to note that annual Woreda based plans are developed in two stages: the core plan and comprehensive plan. The core plan is about achieving national targets whilst the comprehensive plan is the core plan plus activities that are related to local health priorities. The Core Plans are the result of district level planning, which is then compiled at the regional level and eventually consolidated to produce the Sectoral National Annual Health Plan by the MoH. This document is presented to the Annual Review Meeting (ARM) of the health sector each year. 5.5 Financial management and auditing The financial management of HSDP-IV will be aligned with existing government procedures. The GOE has set uncompromising standards of financial management for the funds that are part of the block grant/direct budget H SD P IV 85 support. Various studies have confirmed that the basic systems are already in place to ensure adequate control of public funds. In Ethiopia, the accounting system is sufficiently developed to track different sources of funding all the way to final uses. The challenge remains on how to routinely monitor and report funding by HSDP component. It is envisaged that this will be facilitated through the harmonisation of budget coding outlined in the Financing Plan. The Ethiopian budget system separates recurrent from capital expenditure as a strategic principle to distinguish the on-going operational costs of government services from the discrete investment expenditures that add up to government assets. This distinction is blurred, however, due to the long tradition of including external support within budget category 5. At present, the capital budget is composed of two different components: i) GOE capital resources from domestic revenues; and ii) loans and grants/loans coming from external sources, both bilateral and multilateral. Traditionally, all external funding is recorded under the capital budget, regardless of the nature of expenditure being supported by such funds. In theory, the GOE accounting system enables the collation of financial data in sufficient detail to at least report on an ex post basis. In HSDP- IV, a continued work will be undertaken to enhance financial management reporting. Although regional states have a substantial degree of autonomy, the Federal Government takes the lead in setting financial management standards. The regions are also required to report their expenditure in the formats and at the times specified by MoFED. MoFED has overall responsibility for the management of public funds, including federal subsidies to the regional states. The Federal Office of the Auditor General (FOAG) is the supreme auditing institution of Ethiopia, with responsibility for auditing all federal funds, including subventions to the regional states. It is directly accountable to the Council of the Peoples Representatives. The Integrated Financial Management Information System (IFMIS), which is contracted out, is expected to bring remarkable improvements to the financial management, quality and speed of reporting for all stakeholders from all levels of the health system. In fact, Integrated Financial Management Information System (IFMIS) is a system that will facilitate the linkage of financial expenditure (performance) with physical implementation performance, thereby enhancing the efficiency and effectiveness of health programme management at all levels. The system, which will ultimately be automated as a web-based programme, will provide access to information on physical performance and financial expenditure status of health programmes up to the level of districts. In line with the desire to move increasingly toward pooled funding and budget support, various harmonised procedures, such as the MDG Performance Fund, have been put in place to minimise additional transaction costs for Government. 5.6 Procurement and logistics management The aim of a procurement procedure is to acquire goods and services in the most economic, efficient and transparent possible manner. Although the objectives, targets and initiatives of the pharmaceutical logistic management H SD P IV 86 system have been indicated in topics presented earlier, it is worth elaborating the core activities of the Agency. These are: Selection and quantification: PFSA procures and distributes dugs and pharmaceuticals on the basis of the approved Essential Pharmaceuticals List. This list is developed and updated utilising the Ethiopian Essential Health Services Package and the Standard Treatment Guidelines, in order to match products to the primary health care programme, and focus resources on essential and vital products. A Logistics Management Information System (LMIS) will be finalised, pilot tested and implemented in the public health sector. The data from this LMIS will be the basis for forecasting / quantifying results for the essential pharmaceuticals of the public sector system. Financing: the Revolving Drug Fund (RDF) capacity will be enhanced to ensure adequate supply of the essential pharmaceuticals. It will be capitalised by Government/MOH and donor funds. The RDF covers operational expenses, capital replacement, and expansion; it also protects against inflation and losses due to various factors including expiration of drugs. Health facilities will retain user fee revenues and use them to procure pharmaceuticals. In the long run, the purchaser (health insurance agency) will be expected to be the provider of funds to health institutions to procure health commodities from the nearest hub. Procurement: PFSA undertakes bulk procurement based on a medium term rolling procurement plan that will be prepared in collaboration with programme departments, Regions/Cities, and DPs. Procurement will be made according to the procurement legislation and procedures, which are expected to include a domestic preference allowance for national manufacturers. All suppliers must be approved by the Food, Medicine and Health Service Administration and Control Agency (FMHACA) and products must be registered or have a specific exemption. Participation of local manufacturers will be stimulated. In addition to pharmaceuticals, the PFSA will also be in charge of procuring and distributing equipment, medical supplies, contraceptives, vaccines, other PF commodities, etc based on an agreed administrative/management fee. Meanwhile, PFSA will have the flexibility of selectively using DPs that have comparative advantages to procure and distribute pharmaceuticals, as deemed necessary. Distribution (storage and transport): distribution will utilise a network of 16 hubs/ warehouses, with locations based on population density and operational feasibility. Regular orders from health institutions will be packaged and delivered by the hubs. The average transport costs will be included in the commodity sales price. Inventory management: a robust inventory control system will be established in the public sector health facilities. The hubs and central warehouses will have automated inventory control tools to quickly process orders, manage stock according to best practices, provide security, and limit wastage and expiry. These warehouses will be physically organised following a standard model so that inventory management practices are enhanced (at minimum, through separate receiving, quarantine, storage, and dispatch areas). H SD P IV 87 Integrated Pharmaceuticals Fund and Supply Management Information System (IPFSMIS): after finalisation and roll-out, the IPFSMIS will enhance information gathering and use for logistics-related decision making at all levels of the PFSA and health facilities. The IPFSMIS network will connect the central PFSA warehouse with major and secondary hubs and then with health facilities. Two-way information flow will help the PFSA to get data on stock availability, consumption and new requirements from all health facilities, and thereby strengthen needs-based procurement and demand-driven distribution. The IPFSMIS implementation project has identified the operational requirements at all level and its implementation will help the Agency to capture data from source at hub level and to compile for decision making and interventions. 5.7 Monitoring and evaluation The monitoring plan for HSDP-IV will draw significant lessons from the previous experiences, which suffered from insufficient and poor quality of information for planning, monitoring and evaluation purposes. In order to improve M&E, the monitoring and evaluation system is designed as part of the Policy, Planning and M&E Process and will be implemented at all levels of the health system. A single results-based framework with a small number of indicators to make the monitoring and evaluation process effective and efficient will be agreed for the national level M&E system. Routine administrative report (HMIS) While patient cards and registers are designed to capture all patient-related data, reports will be based on the sector-wide indicators that have been jointly agreed and endorsed by the Government and DPs. Commensurate resources will be allocated to put in place the human resources, tools and equipment needed for the proper documentation, compilation, analysis, use and timely reporting of routine facility data as per the standard. All stakeholders operating in the health sector should support and use the HMIS for programme monitoring. The indicators are shown in Annex 8 of this document. Each health facility and administrative level will put in place the necessary institutional mechanisms (HMIS technician, or team) as per the standard indicated in the new design of HMIS. Data from client-patient records will be collected from health facilities. The data will be aggregated and analysed to compare performance versus plans for the facility’s own consumption. Facilities will supply data to the relevant administrative levels through the routine reporting mechanism as per the HMIS reporting calendar. Validation of the data is done through performance monitoring, Integrated Supportive Supervision (ISS), surveys and regular inspections. Performance monitoring and quality improvement The Quality Improvement Process is a performance monitoring activity in which health facilities (hospitals, health centres and health posts) use locally available data generated during health service provision for a continuous process of measurement, reflection and improvement. The Performance Monitoring and H SD P IV 88 Quality Improvement Standard Operating Procedure has been endorsed as part of the Policy planning, monitoring and evaluation Process. Evaluation/operational research Evaluation: Programme evaluations usually focus on process issues, e.g., examining the appropriate execution of programme components, or on outcome issues, e.g., examining the worth of implementing an intervention or any of its components. Operational research: It is technically impossible to obtain all health and health-related data needed for adequate decision making exclusively through the HMIS. Hence, regular demand side and supply side surveys will be conducted to capture selected sets of data and triangulate various sources for improving the accuracy of information about the outcomes and impacts of health interventions. The major principles that underpin this activity are: 1) the data sets need to be mutually agreed between the Government and DPs; 2) the surveys should be conducted by/under the leadership of Government in defined and logical frequency; 3) timing of the surveys should align with the Government calendar; and 4) DPs should provide adequate resources (financial and technical). Manuals and tools produced for evaluation/operational research will be used during the implementation of HSDP-IV. Integrated Supportive Supervision (ISS) and inspection Integrated Supportive Supervision is a process of guiding, helping, training, and encouraging staff to improve their performance in the provision of high-quality health services. It emphasises the use of integrated tools for all priority programmes and empowering of health service providers at all levels. 5.8 Key indicators for results framework at national level Indicators with targets for each strategic objective are listed in Chapter 3, section 3.6 and a comprehensive list of indicators to monitor all programmatic areas in HSDP-IV is included in Annex 8. The following is a selected list of indicators that should be routinely available on an annual basis (or more frequently). Listing the indicators below does not imply that other indicators will not be made available. In selecting these indicators, reference is made to HMIS indicators, various programmatic indicators, and the result framework agreed upon as part of IHP+. Details about methods, frequency and responsible bodies for collecting these indicators are found in Annex 8. MNCH 1. Contraceptive acceptance rate 2. ANC coverage at least one visit & four visits 3. Proportion of deliveries attended by skilled health attendants 4. Proportion of deliveries attended by HEW 5. Post-natal care coverage 6. Proportion of deliveries of HIV+ women that receive full course of ARV prophylaxis 7. Immunisation coverage: Pentavalent 3, Rotavirus, Pneumococcal, measles and fully immunised 8. Protection at birth against neonatal tetanus 9. Health facility with services like PMTCT, BEmONC, CEmONC, IMNCI, Youth friendly services Disease prevention and control 10. HCT testing rate H SD P IV 89 11. Cumulative number of PLHIV ever started on ART 12. Proportion of patients who are currently on ART 13. TB case detection rate (all forms) 14. TB cure rate 15. TB treatment success rate 16. Proportion of MDR TB cases put on second line Anti-TB treatment regimen 17. Proportion households in malarious areas possess at least one LLITN 18. Proportion of households in IRS targeted areas that were sprayed in the last twelve months Nutrition 19. Children 6-59 months given vitamin A every 6 months 20. Children 2-5 years de-wormed every 6 months Hygiene and environmental health 21. Proportion of households using household water treatment and safe storage practice 22. Proportion of households utilising latrine Health infrastructure 23. Functional Health facility to population ratio (by type) 24. Number of health facilities upgraded (by type) 25. Proportion of health facilities with functional infrastructure 26. Number of hospitals implementing EMR Human resources 27. Health staff to population ratio by category Pharmaceutical supply and services 28. Health facilities with stock-out for essential drug Community ownership 29. Proportion of model households graduated 30. Proportion of health facilities with boards where communities are represented Quality health services 31. Customer satisfaction index 32. Outpatient (OPD) attendance per capita 33. Bed Occupancy Rate 34. Average length of stay (ALOS) 35. Proportion of hospitals with designated emergency unit Public health emergency preparedness and response 36. Proportion of epidemics controlled with zero mortality Evidence-based decision making 37. Proportion of partners implementing “one-plan” 38. Proportion of partners providing funds throgh MDG-PF 39. Completeness and timely submission of routine health and administrative reports Resource mobilisation and utilisation 40. Percentage of government budget allocated for health 41. Facilities retaining and utilising revenue (by type) 42. The ratio of health budget utilisation to allocation H SD P IV 90 5.9 Risk mitigation One of the major risks that the HSDP-IV may face is insufficiency of financial resources. As indicated in the costing chapter, there is US$ 4.34 billion gap to achieve the MDGs. To address this risk, the strategic objective on resource mobilisation and utilisation clearly states how effectively and efficiently resources will be mobilised and utilised. As such, there will be proactive resource mobilisation from external sources using the different mechanisms stated in the resource mobilisation BPR. Internally, developing health insurance is expected to increase financing to the health sector. Improving community ownership and strengthening public-private partnership are additional mechanisms that will improve health care financing, as well as improving utilisation of quality health care services. More details of the risks anticipated for the supply and demand side are identified and solutions to tackle them are well addressed in chapter three (SWOT and stakeholder analysis, strategic objectives and strategic initiatives). Annex Section H SD P IV 93 Measures allow the organisation to track results against targets, and to celebrate success and identify potential problems early. Finally, Strategic Initiatives translate strategy into a set of high-priority projects that need to be implemented to ensure the success of strategy. Engaged leadership and interactive, two-way communication are the cornerstones of a successful management system. Once the strategic thinking and necessary actions are determined, annual program plans, projects and service level agreements can be developed and translated into budget requests. The nine steps of the framework are: Step one of the scorecard building process starts with an organisation assessment of mission (organisations purpose) and vision, organisation challenges (pains) and enablers, and organisation values. In Step Two, strategies, including strategic themes, strategic results, and perspectives, are developed by the MoH-RHB joint steering committee and the executive committee to focus attention on customer needs and their value proposition. In Step Three, strategies are decomposed into strategic objectives that are linked in cause-effect relationships to produce a strategy map (Step Four) for each strategic theme. As part of Step Four, theme strategy maps are then merged into an overall organisational strategy map that shows how the organisation creates value for its customers and stakeholders. In Step Five, performance measures are developed for strategic objectives, and in Step Six, strategic initiatives are developed that support the strategic objectives. To build accountability throughout the organisation, performance measures and strategic initiatives are assigned to owners and documented in data definition tables. At the conclusion of Step Six, the sector-wide balanced scorecard is built. Steps Seven through Nine of the process involve the implementation of the scorecard throughout the organisation. These steps are interpreted in to action through operational plan. In Step Seven, the implementation process begins by applying performance management software to get the right performance information to the right people at the right time to be useful and used. This automation of the scorecard adds structure and discipline to the system; helps transform disparate corporate data into information and knowledge; and helps communicate performance information. During Step Eight, directorate scorecards are developed to support the objectives on the organisation scorecard, and then team and individual scorecards are developed. This process of translating the corporate scorecard into divisional units is referred to as cascading. Cascading translates high-level strategy into consistent lower-level objectives, measures, and operational details and is the key to organisation alignment around strategy. Performance measures are developed for all objectives at all organisation levels. As the scorecard management system is cascaded down through the organisation, objectives become more operational and tactical, as do the performance measures. Accountability follows the objectives and measures, as ownership is defined at each level. An emphasis on results and the strategies needed to produce results is communicated throughout the organisation. In Step Nine, an Evaluation of the completed scorecard is done. Evaluation addresses questions related to whether or not our strategies are working, whether we are measuring the right things or not or if our environment has changed. A n n ex 2 : C h al le n ge s & g ap s of H SD P II I & li n k ag es to H SD P ­I V Ar ea s Ch all en ge s Re co m m en da tio ns St ra te gi es Ma ter na l, Ne on ata l, Ch ild & Ad ole sc en t He alt h La ck of 24 /7 se rvi ce s i n m os t h ea lth fa cil itie s, es pe cia lly in HC s & un av ail ab ilit y o f H EW s o n w ee ke nd /ni gh t Lo w qu ali ty of se rvi ce pr ov isi on (L on g w ait ing tim e, po or co un se llin g s er vic e, lac k o f p riv ac y) Ina de qu ate or ga nis ati on of ho sp ita l s er vic es to eff ec tiv ely ha nd le em er ge nc ies . Sh or tag e o f a de qu ate & sa fe blo od Po or de liv er y r oo m en vir on me nt & po or at titu de of he alt h wo rke rs Se rvi ce in ac ce ss ibi lity & tr an sp or tat ion pr ob lem Ab se nc e o f s ep ar ate ne on ata l u nit s i n m os t h os pit als W ea k r efe rra l s ys tem , s er vic e i nte gr ati on & su pp or tiv e su pe rvi sio n. Sh or tag e, hig h t ur no ve r, & ins uff ici en t s kil l o f m idw ive s & de liv er y a tte nd an ts du e t o p oo r q ua lity of tr ain ing Sl ow pr oc ur em en t & di str ibu tio n o f m ed ici ne s & su pp lie s lea din g t o s ho rta ge at se rvi ce de liv er y p oin t & P oo r sto ck m an ag em en t La ck of F P me tho d m ix Hi gh un me t n ee d f or F P Lim ite d a va ila bil ity of ad ole sc en t & yo uth fr ien dly re pr od uc tiv e h ea lth se rvi ce s La ck of aw ar en es s & m isc on ce pti on on R H & ch ild he alt h s er vic es R eli gio us & cu ltu ra l p ro ble ms & tr ad itio na l pr ac tic es /be lie fs Lo w he alt h s ee kin g b eh av iou r Ins uff ici en t r es ou rce s Pr ov ide ro un d t he cl oc k d eli ve ry se rvi ce s i n H Cs . Im pr ov e q ua lity of se rvi ce pr ov isi on Im ple me nt Em er ge nc y T ria ge A ss es sm en t & T re atm en t (E TA T) . Pr ov ide C om pr eh en siv e E me rg en cy O bs tet ric & Ne on ata l C ar e ( CE mO NC ) a t h os pit als , s ele cte d H Cs . Ac ce ler ate co mp let ion & fu nc tio na lity of ne w blo od ba nk s. En su re pr ov isi on sk ille d d eli ve ry se rvi ce s i n a ll H Cs Es tab lis h s ep ar ate ne on ata l u nit s i n h os pit als . En ha nc e r efe rra l s ys tem Im pr ov e c on tra ce pti ve lo gis tic s i nfo rm ati on sy ste m Im pr ov e a va ila bil ity of lo ng ac tin g c on tra ce pti ve s Sc ale up qu ali ty tra ini ng fo r m idw ive s & im pr ov e s kil ls of HE W s b y s tre ng the nin g c lea n & sa fe de liv er y t ra ini ng s En su re m oti va tio n s ch em e & re wa rd fo r b es t pe rfo rm an ce s St re ng the n s up ply ch ain m an ag em en t s ys tem , e ffe cti ve LM IS & pr oc ur em en t Ex pa nd & In teg ra te FP se rvi ce w ith ot he r s er vic es Em po we r w om en & en co ur ag e m ale in vo lve me nt in FP Pr ov ide ad ole sc en t & yo uth fr ien dly R H se rvi ce s. Inc re as e a wa re ne ss th ro ug h s oc ial m ob ilis ati on & co mm un ity co nv er sa tio n Ra pid ro llo ut of pn eu mo nia tr ea tm en t & ot he r c om mo n ch ild ho od ill ne ss es th ro ug h H EP . En su re pr ov isi on IM NC I s er vic es in al l H Cs Re so ur ce m ob ilis ati on (a dv oc ate m or e r es ou rce flo w tow ar ds m ate rn al he alt h) St re ng the n f ac ilit y b as ed m ate rn al, ne wb or n, ch ild & ad ole sc en t h ea lth se rvi ce s. Im ple me nt BP R in all he alt h f ac ilit ies . Int ro du ce tr ain ing of em er ge nc y m ed ici ne by 20 10 to im pr ov e e me rg en cy m ed ica l s er vic e St re ng the n B as ic & Co mp re he ns ive E mO NC Im pr ov e r efe rra l s ys tem , in clu din g p ae dia tric re fer ra ls. Im pr ov e c on tra ce pti ve lo gis tic s i nfo rm ati on sy ste m Im pr ov e a va ila bil ity of lo ng ac tin g c on tra ce pti ve s St re ng the n m ult isp ec tra l c oll ab or ati on on ne wb or n, ch ild & ad ole sc en t h ea lth pr og ra mm es . Sc ale up m idw ife tr ain ing Ca pa cit y b uil din g o n p ro gr am me m an ag em en t fo r ma ter na l & ch ild he alt h s er vic es . Inc re as e n et fin an cia l & no n- fin an cia l in ce nti ve s f or ra re sk ill pr ofe ss ion als to be as sig ne d i n r ur al ar ea s St re ng the n s up ply ch ain m an ag em en t ( inc lud ing so cia l ma rke tin g) St re ng the n l og ist ic ma na ge me nt inf or ma tio n s ys tem s. Sc ale up F P pr og ra mm e w ith fo cu s o n l on g- ter m op tio ns St ro ng er R H- HI V int eg ra tio n, (e .g. , F P- HI V pr ev en tio n lin ks th ro ug h c om mo n m es sa ge s & du al pr ote cti on ) En ha nc e Y ou th Fr ien dly se rvi ce s. La un ch S oc ial M ob ilis ati on St re ng the n I MN CI se rvi ce at fa cil ity & co mm un ity le ve ls. St re ng the n r ou tin e i mm un isa tio n. St re ng the n p ro ac tiv e r es ou rce m ob ilis ati on En ha nc e c oo rd ina tio n & ha rm on ise d a pp ro ac h a mo ng all pa rtn er s. Di se as e Pr ev en tio n & Co ntr ol Ine ffe cti ve us e o f H EP fo r p re ve nti on & co ntr ol of TB lea din g t o l ow co mm un ity aw ar en es s & de ma nd fo r se rvi ce 38 . W ea k d iag no sti c l ab or ato ry se rvi ce s. Po or fo llo w up on H Cs to st ar t D OT S se rvi ce En su re ef fec tiv e u se of H EP fo r p re ve nti on & co ntr ol of ma jor co mm un ica ble di se as es . E xp an sio n o f D OT S se rvi ce to al l H Ps / c om mu nit y DO TS & to al l H Cs En ha nc e l ab or ato ry ca pa cit y a t a ll l ev els as pe r t he B PR Ex pa nd & en ha nc e D OT S via m ax im um us e o f H EP fo r ca se de tec tio n, co nta ct tra cin g & tr ea tm en t fo llo w up . Up gr ad e l ab or ato ry ne tw or ks , & im ple me nt Pr ac tic al Ap pr oa ch to Lu ng H ea lth (P AL ) En su re ea rly ca se de tec tio n, & dia gn os is thr ou gh Ar ea s Ch all en ge s Re co m m en da tio ns St ra te gi es Ina cc es sib ilit y o f A FB di ag no sti c s er vic es Po or di ag no sti c s kil l & (h igh pr op or tio n o f s me ar ne ga tiv e & E PT B) Po or re fer ra l li nk ag es be tw ee n H P & HC s Ina de qu ate co mm un ity pa rtic ipa tio n o n e nv iro nm en tal ma na ge me nt of ve cto r c on tro l; l ow IR S co ve ra ge & re sis tan ce to D DT . Lo w us ag e o f IT Ns by ho us eh old s i n s om e a re as . Re cu rre nt ma lar ia ep ide mi cs & ou tbr ea ks di ve rtin g att en tio ns fr om pr ev en tio n c on tro l p ro gr am . Sh or tag e o f H IV te st kit s & su pp lie s & po or st oc k ma na ge me nt Ina de qu ate m an ag em en t & su pp or t to P MT CT le ad ing to low co ve ra ge . Lo w pe rfo rm an ce of P MT CT /M NC H /S RH se rvi ce s i n ur ba n & se mi ur ba n h ea lth po sts . W ea k i nte gr ati on of A NC w ith P MT CT Sh or tag e o f O I d ru gs Lo w pe rfo rm an ce of S TI se rvi ce s & T B/ HI V co lla bo ra tio n Sl ow im ple me nta tio n o f p ro gr am me s t o t ac kle N CD s de sig n & ex pa nd A FB di ag no sti c s er vic es to al l H Cs & ho sp ita ls Int en sif y r efe rra l li nk ag e & fe ed ba ck Int ro du ce P IT C for T B (a cti ve ca se fin din g s tra teg ies ) t o all O PD vi sit or s, PL HI V, ho us eh old vi sit s b y H EW s, Ex pa nd M DR –T B ma na ge me nt to all te rtia ry lev el ho sp ita ls. En ha nc e e mp ha sis on en vir on me nta l m an ag em en t sp ec ific all y s tre ng the n I RS Inc re as e e mp ha sis on In for ma tio n, Ed uc ati on & Co mm un ica tio n / B eh av iou ra l C ha ng e C om mu nic ati on (IE C/ BC C) to tr an sla te hig h l ev els of ne t o wn er sh ip int o u tili sa tio n. Ra pid ly im ple me nt Pu bli c H ea lth E me rg en cy Ma na ge me nt Co re P ro ce ss at al l le ve ls. St re ng the n e ffe cti ve LM IS & pr oc ur em en t & E ns ur e av ail ab ilit y o f H IV te st kit & su pp lie s En ha nc e i nte gr ati on of H CT & P MT CT in R H se rvi ce s a s pe r B PR de sig n. Im pr ov e a va ila bil ity of O I/S TI dr ug s Im pr ov e T B HI V co lla bo ra tio n Ex pa nd P MT CT se rvi ce s a t a ll h ea lth fa cil itie s l ev el Inc re as e a wa re ne ss th ro ug h c om mu nit y c on ve rsa tio n & ma ss m ed ia qu ali ty- as su re d b ac ter iol og y Im pr ov e i nfo rm ati on sy ste ms , in clu din g n oti fic ati on & re fer ra l ro uti ne s. Sc ale -u p c oll ab or ati ve T B/ HI V ac tiv itie s. Sc ale -u p p re ve nti on & m an ag em en t o f m ult idr ug - re sis tan t T B (M DR -T B) . Co mm un ity em po we rm en t & m ob ilis ati on Se lec tiv e v ec tor co ntr ol (IT N, IR S, E nv iro nm en tal ma na ge me nt) Ea rly di ag no sis & tr ea tm en t o f c as es of m ala ria . St re ng the n D ise as e S ur ve illa nc e b y i mp lem en tin g P ub lic He alt h E me rg en cy M an ag em en t ( PH EM ) C or e Pr oc es s a t a ll l ev els . St re ng the n s up ply ch ain m an ag em en t St re ng the n l og ist ic ma na ge me nt inf or ma tio n s ys tem s Be tte r a cc es s & qu ali ty of ch ro nic H IV /A ID S ca re & tre atm en t ( en ha nc e s er vic e i nte gr ati on , la bo ra tor y, re fer ra l, a va ila bil ity of es se nti al co mm od itie s, pu bli c pr iva te pa rtn er sh ip & ad dr es s h um an re so ur ce is su e) En ha nc e P MT CT se rvi ce th ro ug h i nte gr ati on w ith M NC H & lin ka ge w ith H EP . Ex pa ns ion of ro uti ne H IV te sti ng du rin g A NC St re ng the n c om mu nit y m ob ilis ati on & m ale in vo lve me nt Es tab lis h p ro gr am me m an ag em en t & co or din ati on str uc tur e f or co ntr ol of NC Ds Ad vo ca cy , S oc ial M ob ilis ati on & S en sit isa tio n f or N CD s pr og ra mm e i mp lem en tat ion De ve lop & su sta in pa rtn er sh ip & co lla bo ra tio n f or int eg ra ted N CD s c on tro l He alt h Ex ten sio n Pr og ra m Ina de qu ate sk ill ba se d t ra ini ng s o f H EW s, pa rtic ula rly on co nd uc tin g d eli ve rie s. At trit ion & ab se nc e o f H EW s f ro m the ir c atc hm en t a re as ; Sl ow ca re er de ve lop me nt for H EW s; La ck of co mm un ity ow ne rsh ip Lo w pe rfo rm an ce in co mp let ion of m od el ho us eh old tra ini ng du e t o p oo r f oll ow -u p Lo w W AS H fac ilit ies at H P lev el & ina de qu ate En ha nc e s us tai ne d c om mi tm en t o f le ad er sh ip to pr og ra mm e i mp lem en tat ion . En ha nc e c oo rd ina ted In teg ra ted R efr es he r T ra ini ng . As se ss & im pr ov e e ffe cti ve ne ss of In teg ra ted S up po rtiv e Su pe rvi sio n ( IS S) m od el be tw ee n W oH O, H Cs , su pe rvi so rs & HE W s; Fin ali se & im ple me nt ca rri er st ru ctu re fo r H EW s; En ha nc e c ap ac ity of pu bli c & pr iva te se cto rs on W AS H. St re ng the n I nte gr ate d R efr es he r T ra ini ng fo r H EW s S tre ng the n s up po rtiv e s up er vis ion & m oti va tio n De ve lop cu rri cu lum & im ple me nta tio n m an ua l fo r c ar ee r de ve lop me nt of HE W s St re ng the n H ea lth E xte ns ion P ro gr am me s En ha nc e c om mu nit y o wn er sh ip via M od el fam ily gr ad ua tio n St re ng the n w ate r s up ply sa fet y m ea su re s Ar ea s Ch all en ge s Re co m m en da tio ns St ra te gi es aw ar en es s. Im pr ov e W AS H kn ow led ge & fa cil itie s a t H P lev el Lin k h ea lth fa cil itie s w ith W AS H to im pr ov e w ate r s up ply Co mm un ity Le d T ota l S an ita tio n & H yg ien e St re ng the n C oo rd ina tio n & co lla bo ra tio n o f s ec tor s Ot he r H ea lth Sy ste m Iss ue s Po or qu ali ty of he alt h s er vic es . Lo w fis ca l s pa ce & po or st aff ab so rp tio n c ap ac ity of he alt h s ys tem Pe rsi ste nt cri tic al fun din g g ap fo r h ea lth sy ste ms . Po or pr ed ict ab ilit y o f d on or fu nd s. Ina de qu ate ca pa cit y f or fu nd liq uid ati on , r ep or tin g & au dit ing of fu nd s i n t he se cto r. Sl ow pr og re ss in ha rm on isi ng do no r p ro ce du re s w ith tho se of G ov er nm en t. Un co or din ate d & m isg uid ed re se ar ch ef for ts am on g va rio us st ak eh old er s Po or di ss em ina tio n & tr an sla tio n t o a cti on of re se ar ch re su lts Sl ow im ple me nta tio n o f H MI S lea din g t o i nc om ple te & inc on sis ten t r ep or tin g. De lay in co ns tru cti on of H Ps & H Cs ; Im ple me nt Pe rfo rm an ce M on ito rin g a nd Q ua lity Im pr ov em en t ( PM QI ) s tan da rd & H ea lth & H ea lth Re lat ed R eg ula tor y C or e P ro ce ss . Im pr ov e b ud ge t a llo ca tio n t o h ea lth se cto r s pe cif ica lly to he alt h s ys tem s Im pr ov e i mp lem en tat ion of he alt h c ar e f ina nc ing (H CF ) re for ms & fin an cia l re so ur ce m ob ilis ati on (F RM ) C or e Pr oc es s. Im pr ov e a cc ou nta bil ity & st re ng the n f ina nc ial ma na ge me nt sy ste m by de sig n & im ple me nti ng Int eg ra ted F ina nc ial M an ag em en t In for ma tio n S ys tem (IF MI S) . Co nti nu es m on ito rin g o f IH P+ C om pa ct. Ef fec tiv e r es ea rch co or din ati on , p rio riti sa tio n, dis se mi na tio n & us e En ha nc e i mp lem en tat ion of H MI S/ M &E sy ste m. Ac ce ler ate co ns tru cti on of H Ps & H Cs . Im ple me nt BP R in all he alt h f ac ilit ies . St re ng the n r eg ula tor y s er vic e t o b oth pu bli c & pr iva te se cto r in sti tut ion s. St re ng the n i ns pe cti on & lic en sin g Im ple me nt pe rfo rm an ce re vie w as pa rt of M& E. Ev ide nc e- ba se d p lan nin g & bu dg et all oc ati on . Sc ale up he alt h c ar e f ina nc ing re for m St re ng the n p ro ac tiv e r es ou rce hu nti ng . Int ro du ce so cia l & co mm un ity he alt h i ns ur an ce . Int ro du ce IF MI S St re ng the n f ina nc ial m an ag em en t & ac co un tab ilit y de ve lop me nt pr og ra m Ad vo ca te on e p lan , o ne bu dg et & on e r ep or tin g f ra me St re ng the n r eg ula r a dh er en ce ev alu ati on . Ef fec tiv e i mp lem en tat ion of R es ea rch & T ec hn olo gy Tr an sfe r C or e P ro ce ss Sc ale up M &E /H MI S. Ac ce ler ate d e xp an sio n o f h ea lth fa cil itie s Nu trit ion Ina de qu ate ca pa cit y o f H EW s & co mm un ity pr om ote rs La ck of su sta ine d p ro mo tio n o n b re as t fe ed ing Ha rm ful tr ad itio ns La ck of In fan t fo rm ula c od e/ pr oc lam ati on La ck of kn ow led ge of m oth er s o n e xc lus ive ly br ea stf ee din g St re ng the n & su sta in pr om oti on of co mm un ity -b as ed nu trit ion Inc re as e a wa re ne ss of he alt h p ro fes sio na ls & mo the rs on br ea st fee din g En ac t c od e o f in fan t fo rm ula im ple me nta tio n Ex pa nd C om mu nit y-B as ed N utr itio n ( CB N) . Su sta in En ha nc ed O utr ea ch S tra teg y ( EO S) w ith Ta rg ete d S up ple me nta ry Fo od (T SF ) & tr an sit ion E OS int o H EP . He alt h F ac ilit y N utr itio n S er vic es . Es se nti al Nu trit ion A cti on s/I nte gr ate d I nfa nt & Yo un g Fe ed ing co un se llin g s er vic es . A n n ex 3 : S u m m ar y of b ot tl en ec k a n al ys is c on d u ct ed fo r H SD P ­I V (L in ki n g k ey i n te rv en ti o n s an d s tr at eg ie s to h ea lt h s ys te m b o tt le n ec ks ) 1 a . F a m il y -o ri e n te d c o m m u n it y -b a se d s e rv ic e s Ma jo r s ys te m b ot tle ne ck s Po ss ib le ca us es Pr op os ed o pe ra tio na l s tra te gi es /so lu tio ns Family Preventive/WASH Services Av ail ab ilit y & ca pa cit y o f H EW s & co mm un ity pr om ote rs Lo w uti lis ati on of se rvi ce s Ina de qu ate ca pa cit y o f H EW s & co mm un ity pr om ote rs Ina de qu ate nu mb er of H EW s & co mm un ity pr om ote rs At trit ion ra te of HE W La ck of co mm un ity ow ne rsh ip Ina pp ro pr iat e c om mu nic ati on ap pr oa ch es Ex pe cta tio n o f s up pli es fo r h ou se ho ld lev el he alt h i nte rve nti on s by th e c om mu nit y IT N no t s uit ab le for ho us ing & w ea the r c on dit ion in so me ar ea s Int eg ra ted R efr es he r T ra ini ng fo r H EW s Su pp or tiv e s up er vis ion Mo tiv ati on (c ar rie r, re wa rd s) En ha nc es co mm un ity ow ne rsh ip via M od el fa mi ly gr ad ua tio n Ac co un tab ilit y m atr ix for co mm un ity em po we rm en t Int er -re gio na l o r lo ca l b es t p ra cti ce ex pe rie nc e s ha rin g St re ng the n h ea lth pr om oti on Co or din ati on & co lla bo ra tio n o f s ec tor s Family neonatal care Av ail ab ilit y e ss en tia l c om mo dit ies Av ail ab ilit y & ca pa cit y o f H EW s Lo w uti lis ati on of se rvi ce s Ina de qu ate su pp ly of cle an de liv er y k its Lo w wa ter su pp ly & po or sa nit ar y s ys tem of he alt h p os ts Ina de qu ate H EW s t ra ine d o n c lea n & sa fe de liv er y, ins uff ici en t sk ill Un av ail ab ilit y o f H EW s o n w ee ke nd /ni gh t Tr an sp or tat ion pr ob lem Lo w qu ali ty of se rvi ce pr ov isi on Lo w he alt h s ee kin g b eh av iou r St re ng the n s up ply ch ain m an ag em en t Lo ca l a ss em ble of ki ts for sa fe & cle an de liv er y Fr eq ue nt & or ga nis ed di str ibu tio n o f k its Lin k w ith W AS H to im pr ov e w ate r s up ply Av ail al ter na tiv e/ so lar po we r St re ng the n & ex pa nd cl ea n & sa fe de liv er y t ra ini ng s St re ng the n h ea lth pr om oti on Im pr ov e q ua lity of se rvi ce pr ov isi on En ha nc e f re e s er vic e Inc re as e c om mu nic ati on /re fer ra l l ink ag e Infant & child feeding Av ail ab ilit y e ss en tia l c om mo dit ies Av ail ab ilit y & ca pa cit y o f H EW s Lo w uti lis ati on of se rvi ce s Ina de qu ate ca pa cit y o f H EW s & co mm un ity pr om ote rs La ck of su sta ine d p ro mo tio n o n b re as t fe ed ing Ina de qu ate pr ofe ss ion al att itu de on ad va nta ge of ea rly fe ed ing Ha rm ful tr ad itio ns La ck of in fan t fo rm ula co de / p ro cla ma tio n La ck of kn ow led ge of m oth er s o n e xc lus ive ly br ea stf ee din g Oc cu pa tio na l in flu en ce St re ng the n & su sta in pr om oti on of co mm un ity -b as ed nu trit ion Inc re as e a wa re ne ss of he alt h p ro fes sio na ls on br ea st fee din g En ac t c od e o f in fan t fo rm ula im ple me nta tio n Ba by -fr ien dly ho sp ita l in itia tiv e Im pr ov e l ow co st tec hn olo gie s t o r ed uc e w or k l oa d o f c ar e g ive rs Community Manageme nt Illnesses Av ail ab ilit y e ss en tia l c om mo dit ies Av ail ab ilit y & ca pa cit y o f H EW s Lo w uti lis ati on of se rvi ce s Ina de qu ate su pp ly & lac k o f c on tin uo us re fill ing of O RS & O RT La ck of kn ow led ge of m oth er s o n a dv an tag e o f r ec om me nd ed ho me flu ids St re ng the n s up ply ch ain m an ag em en t in clu din g s oc ial m ar ke tin g En ha nc e a va ila bil ity & im po rta nc e o f O RT co rn er s St re ng the n p ro mo tio n o f o n a dd itio na l fl uid & fe ed ing fo r c hil dr en wi th dia rrh oe a 1 b . P o p u la ti o n -o ri e n te d s ch e d u la b le s e rv ic e s Ma jo r s ys te m b ot tle ne ck s Po ss ib le ca us es Pr op os ed o pe ra tio na l s tra te gi es /so lu tio ns Preventive care for adolescents & adults Av ail ab ilit y o f s up pli es Av ail ab ilit y/ ca pa cit y o f H ea lth wo rke rs Ac ce ss ibi lity of se rvi ce s Lo w uti lis ati on of se rvi ce s St oc k s up ply pr ob lem La ck of aw ar en es s & m isc on ce pti on Lim ite d f isc al sp ac e f or hi rin g s taf f Re lig iou s & cu ltu ra l p ro ble ms W ea k s er vic e i nte gr ati on & lin ka ge Hi gh un me t n ee d f or F P La ck of F P me tho d m ix Ina de qu ate lo ng ac tin g c on tra ce pti ve s. W ea k c on tra ce pti ve LM IS La ck of de cis ion m ak ing by w om en La ck of co mm un ica tio n s kil ls of he alt h c ar e p ro vid er s Inc re as e c on tra ce pti ve co mm od itie s s up ply Ex pa nd he alt h f ac ilit ies & pr ov isi on of F P se rvi ce s Inc re as e a wa re ne ss th ro ug h s oc ial m ob ilis ati on & co mm un ity co nv er sa tio n Im pr ov e c on tra ce pti ve lo gis tic s i nfo rm ati on sy ste m Im pr ov e a va ila bil ity of lo ng ac tin g c on tra ce pti ve s Int eg ra te FP se rvi ce w ith ot he r s er vic es W om en em po we rm en t & en co ur ag e m ale in vo lve me nt in FP Preventive pregnancy care Av ail ab ilit y o f s up pli es Av ail ab ilit y/ ca pa cit y o f H ea lth wo rke rs Ac ce ss ibi lity of se rvi ce s Lo w uti lis ati on of se rvi ce s Ina de qu ate /in ac ce ss ibl e fu nc tio na l p rim ar y h ea lth fac ilit ies Po or qu ali ty of se rvi ce (L on g w ait ing tim e, po or co un se llin g se rvi ce , la ck of pr iva cy ) Lo w pe rce ive d b en efi t b y p re gn an t w om en Ex pa ns ion of he alt h f ac ilit ies se rvi ce s Inc re as e a wa re ne ss cr ea tio n t hr ou gh so cia l m ob ilis ati on Se rvi ce in teg ra tio n Inc re as e m od el fam ilie s g ra du ati on Im pr ov e i nte r-p er so na l c om mu nic ati on & co un se llin g s kil ls HIV/AIDS prevention & care Av ail ab ilit y o f s up pli es Av ail ab ilit y/ ca pa cit y o f H ea lth wo rke rs Ac ce ss ibi lity of se rvi ce s Lo w uti lis ati on of se rvi ce s Sh or tag e o f H IV te st kit s & su pp lie s Ina cc es sib le se rvi ce W ea k i nte gr ati on of A NC w ith P MT CT La ck of aw ar en es s a bo ut the P MT CT se rvi ce En su re av ail ab ilit y o f H IV te st kit & su pp lie s Pr e- se rvi ce tr ain ing fo r h ea lth pr ofe ss ion als En ha nc e i nte r-s ec tor al pa rtn er sh ip wi th de ve lop me nt pa rtn er s Ex pa nd th e P MT CT se rvi ce s a t a ll h ea lth fa cil itie s l ev el Se rvi ce in teg ra tio n Im pr ov e q ua lity of se rvi ce to cr ea te de ma nd Inc re as e a wa re ne ss th ro ug h c om mu nit y c on ve rsa tio n & m as s m ed ia Preventive infant & child care Av ail ab ilit y o f s up pli es Av ail ab ilit y/ ca pa cit y o f H ea lth wo rke rs Ac ce ss ibi lity of se rvi ce s Lo w uti lis ati on of se rvi ce s Sh or tag e o f s up pli es su ch as va cc ine & in jec tio n m ate ria ls (C old ch ain ) Ge og ra ph ica l lo ca tio n b ar rie rs - T ra ns po rt pr ob lem Co mm un ica tio n p ro ble m of ca re pr ov ide r Lo w va cc ine ef fic ac y m on ito rin g s ys tem Re frig er ato r m ain ten an ce & sp ar e p ro ble m Im pr ov e s up pli es Im pr ov e c old ch ain m an ag em en t & va cc ine st or ag e s ys tem , P ro vid e t ra ini ng on co ld ch ain m an ag em en t Inc re as e a wa re ne ss & so cia l m ob ilis ati on ac tiv itie s Int en sif y r eg ula r C am pa ign to en ha nc e s er vic e c ov er ag e 1 c. I n d iv id u a l o ri e n te d c li n ic a l se rv ic e s Ma jo r s ys te m b ot tle ne ck s Po ss ib le ca us es Pr op os ed o pe ra tio na l s tra te gi es /so lu tio ns Clinical primary level skilled maternal & neonatal care Av ail ab ilit y o f s up pli es Av ail ab ilit y/ ca pa cit y o f H ea lth wo rke rs Ac ce ss ibi lity of se rvi ce s Lo w uti lis ati on of se rvi ce s Ins uff ici en t r es ou rce s Po or st oc k m an ag em en t Pr olo ng ed pr oc ur em en t & di str ibu tio n p ro ce ss La ck of A cc es s t o w ate r s up ply Ina de qu ate nu mb er of tr ain ed m idw ive s Hi gh tu rn ov er of tr ain ed pr ofe ss ion als /po or m oti va tio n Ina cc es sib ilit y Po or qu ali ty of se rvi ce Co nc om ita nt tra dit ion al pr ac tic es /be lie fs Re so ur ce m ob ilis ati on (a dv oc ate m or e r es ou rce flo w tow ar ds m ate rn al he alt h) St re ng the n e ffe cti ve LM IS & pr oc ur em en t Co nti nu ed qu ali ty mi dw ife ry tra ini ng En su re m oti va tio n s kim Sp ee d u p H Cs co ns tru cti on En su re th e p ro vis ion sk ille d d eli ve ry se rvi ce s i n a ll H Cs Im pr ov e q ua lity of se rvi ce Int en sif y A dv oc ac y C om mu nic ati on & S oc ial M ob ilis ati on ( AC SM ) Re wa rd fo r b es t p er for ma nc es Management of Illnesses at Primary Clinical Level Av ail ab ilit y o f s up pli es Av ail ab ilit y/ ca pa cit y o f H ea lth wo rke rs Ac ce ss ibi lity of se rvi ce s Lo w uti lis ati on of se rvi ce s Ins uff ici en t r es ou rce s & po or st oc k m an ag em en t La ck of A cc es s t o w ate r s up ply Ina de qu ate nu mb er of tr ain ed H ea lth pr ofe ss ion als on IM NC I Hi gh tu rn ov er of tr ain ed pr ofe ss ion als /po or m oti va tio n Se rvi ce in ac ce ss ibi lity Po or qu ali ty of se rvi ce Po or at titu de /he alt h s ee kin g b eh av iou r o f c ar e t ak er s Re so ur ce m ob ilis ati on St re ng the n e ffe cti ve LM IS & pr oc ur em en t Co nti nu ed qu ali ty of tra ini ng En su re m oti va tio n s kim Sp ee d u p H Cs co ns tru cti on En su re th e p ro vis ion IM NC I s er vic es in al l H Cs Im pr ov e q ua lity of se rvi ce Int en sif y A dv oc ac y C om mu nic ati on & S oc ial M ob ilis ati on ( AC SM ) Re wa rd fo r b es t p er for ma nc es Clinical first referral illness management Av ail ab ilit y o f s up pli es Av ail ab ilit y/ ca pa cit y o f H ea lth wo rke rs Ac ce ss ibi lity of se rvi ce s Lo w uti lis ati on of se rvi ce s Ins uff ici en t r es ou rce s Po or st oc k m an ag em en t Hi gh tu rn ov er of tr ain ed pr ofe ss ion als /po or m oti va tio n Se rvi ce in ac ce ss ibi lity Po or at titu de /he alt h s ee kin g b eh av iou r o f c ar e t ak er s Po or fo llo w up on H Cs to st ar t D OT S se rvi ce Po or H ea lth se ek ing be ha vio ur fo r e ar ly dia gn os is Po or re fer ra l li nk ag es be tw ee n H P & HC s Pa ss ive ca se fin din g m eth od s Ina cc es sib ilit y o f A FB di ag no sti c s er vic es Po or di ag no sti c s kil l & (h igh pr op or tio n o f s me ar ne ga tiv e & E PT B) Po or ad he re nc e t o c as e f ind ing al go rith ms , P oo r c on tac t tra cin g Ina de qu ate D ru g S en sit ivi ty Te sti ng (D ST ) & se co nd lin e t re atm en t o pti on s Re so ur ce m ob ilis ati on St re ng the n e ffe cti ve LM IS & pr oc ur em en t Ex pa nd D OT S se rvi ce to al l H Cs Ex pa nd th e A FB di ag no sti c s er vic es to al l H Cs & ho sp ita ls Int en sif y r efe rra l li nk ag e & fe ed ba ck In- Pl ac e P IT C for T B (a cti ve ca se fin din g s tra teg ies ) t o a ll O PD vi sit or s, PL HI V, ho us eh old vi sit s b y H EW s, - B uil d t he di ag no sti c & ca se fin din g c ap ac ity of he alt h p ro fes sio na ls Im pr ov e t ra cin g a ll c on tac ts of kn ow n s me ar po sit ive T B ca se s Ex pa ns ion of D OT S se rvi ce to al l H Ps / c om mu nit y D OT S Ad vo ca te to do th e l as t m icr os co py & de cla re cu re to al l s me ar po sit ive T B ca se s Bu ild th e c ap ac ity th e d ru g q ua lity te sti ng ca pa cit y a t c ou ntr y l ev el Ex pa nd D ST se rvi ce & en su re di ag no sis of al l re -tr ea tm en t/c ate go ry II c as es Ex pa nd M DR –T B ma na ge me nt to all te rtia ry lev el ho sp ita ls Annex 4: Projection of human resources requirement HRH Category 2015 2020 Nurses 41,009 49,362 HEW 33,320 41,664 General Practitioner 10,846 14,792 Laboratory Technician 10,608 12,845 Midwife 8,635 9,866 Pharmacy Technician 8,704 9,839 HIT 7,607 8,849 Health Officer 6,345 8,293 Radiographer 1,954 2,796 Pharmacist 2,037 2,779 Dental Professional 1,145 2,385 Public Health Specialist 1,400 2,158 Environmental and occupational health worker 1,595 1,961 Dentist 633 1,770 IESO 996 1,611 Laboratory Technologist 1,133 1,567 Psychiatric Nurse 923 1,360 Biomedical Technician 874 1,256 Obstetrician 820 1,094 Surgeon 847 1,024 Hospital Manager 650 986 Paediatrician 719 940 Internist 730 910 Physiotherapy professional 550 746 Ophthalmologist 304 524 Orthopaedics 283 418 Radiologist 316 415 Psychiatrist 304 410 ENT Specialist 210 349 Anaesthesiologist 233 309 Clinical Pathologist 210 275 Dermatologist 202 273 Total 146,142 183,826 Ranked by required numbers to be reached by 2020 Annex 5: Planning and budgeting calendar Annual planning activities Time-frame Involved parties A Ministry of Health 1 Mapping of next year’s resources at MoH level 10 February All departments of MoH in consultation with MoFED & health partners 2 Develop a draft annual Core Plan & share it with RHBs 28 February All departments of MoH 3 Finalise Core Plan at MoH-RHBs steering committee meeting 9 March MoH-RHBs Joint Steering Committee members 4 Workshop on MoH capital & recurrent budget proposal to MoFED 10 March All departments of MoH 5 Finalisation of MoH capital/recurrent plan & submit to MoFED 23rd March All departments of MoH 6 Set up, orient & deploy teams of Technical Assistance (TAs) to assist RHBs, ZHDs, & WoHOs in the preparation of core plans 13 to 18 March PPD/ MoH 7 Prepare a Sectoral National Annual Plan based on core plans of RHBs, MoH activities & activities of all stakeholders obtained through a consultative process. April 20 PPD/ MoH, partners 8 Revise & finalise Sectoral National Annual Plan based on approved regional/Woreda annual core plans June PPD/ MoH B Regional Health Bureaus 1 Conduct consultation with stakeholders to identify available resources & discuss priorities & targets 15 February RHBs in consultation with BoFED, MoH & health partners in respective regions 2 Based on agreed Core Plan & resources available, regions will prepare a draft Regional Core Plan indicating priorities, targets & key activities & share it with Woredas. March 18 3 Guide & assist WoHOs to complete planning information format produced by MoH March 14-26 RHBs & Technical Assistants 4 Organise & guide Regional Planning Workshops to discuss & refine Woreda annual health plans March 27-April 13 RHBs /ZHDs 5 Consolidate Regional Core Plan & submit to MoH/PPD. April 18 RHBs 6 Revise & finalise regional annual core plan based on approved Woreda, regional & zonal budgets & communicate to MoH/PPD June RHBs C Zonal Health Departments 1 Participate in Regional planning workshop & assist Woredas in preparing their draft annual plans. March 27-April 13 ZHDs 2 Compile & produce zonal core plan April 13-20 ZHDs D Woreda Health Offices 1 Conduct stakeholder consultation to map resources available for next fiscal year February 20-28 WoHOs in consultation with WoFED, Woreda Joint Steering Committees & health partners 2 Complete Woreda profile form for core planning exercise at regional planning workshop. March 14-26 WoHOs & Technical Assistants 3 Participate in regional planning workshop, revise Woreda annual health plan & submit to RHBs/ ZHDs March 27-April 13 WoHOs, RHBs, ZHDs & TAs 4 Use opportunity of regional level workshop to finalise detailed Woreda plan – including core plan, other WoHO activities not in core plan, & activities of stakeholders at Woreda level. March 27-April 13 WoHOs, RHBs, ZHDs & TAs 5 Submit detailed Woreda annual plan to WoFED & Woreda council for approval. April 15 WoHOs 6 Finalise Woreda annual plan based on approved Woreda budget & communicate to RHBs/ZHDs June WoHOs E Health Facilities (Hospitals & Health Centres) 1 Prepare facility annual plan April 5 Facility management in consultation with management boards Annex 6: Budget analysis* in millions USD Annex 6.1: Additional budget by service mode & capital/recurrent costs Baseline 2010/11 2011/12 2012/13 2013/14 2014/15 Total % Base-case Scenario Family oriented community based services 181.76 527.17 568.60 567.44 615.00 655.68 2,933.89 33 Population oriented schedulable services 63.39 351.06 125.27 137.31 152.49 167.51 933.64 11 Individual oriented clinical services 418.97 603.74 619.33 742.08 868.34 993.74 3,827.25 43 District, provincial, national governance & management 119.78 195.03 193.87 215.70 247.68 279.45 1,131.73 13 Total 883.06 1,677.01 1,507.07 1,662.54 1,883.51 2,096.38 8,826.50 100 Capital investment 628.74 581.01 382.68 347.83 337.83 327.41 1,976.76 22 Recurrent 254.32 1,095.99 1,124.39 1,314.71 1,545.68 1,768.96 6,849.74 78 Best-case Scenario Family oriented community based services 181.76 637.48 746.21 801.66 877.21 938.51 4,001.07 37 Population oriented schedulable services 63.39 383.36 190.23 172.96 188.46 203.71 1,138.72 11 Individual oriented clinical services 418.97 603.74 1,374.19 1,293.37 1,741.76 1,545.03 6,558.09 61 District, provincial, national governance & management 119.78 195.03 193.87 215.70 247.68 279.45 1,131.73 10 Total 883.06 1,419.30 2,104.19 2,083.38 2,654.80 2,566.38 10,828.05 100 Capital investment 482.75 640.56 1,252.67 1,016.02 1,004.37 988.67 4,902.29 45 Recurrent 400.31 778.74 851.52 1,067.36 1,650.42 1,577.71 5,925.76 55 Annex 6.2: Estimated added cost of HSDP­IV 2011­ 2015 Programmatic areas Baseline spending Additional funding need under 2009/10 Base case Scenario Best case Scenario 1.1 Community Empowerment 6.79 87.05 112.47 1.2 M&E 7.36 84.02 106.10 1.3 Health System Strengthening 19.71 751.81 751.81 2.1 Maternal-Newborn and RH-Adolescent Health 31.27 317.13 424.35 2,2 Child Health 25.06 149.69 231.41 2.3 Nutrition 6.38 93.96 109.91 2.4.Hygiene and Environmental Health Services 7.87 124.52 130.42 2.5 Prevention & Control of Malaria 111.45 238.23 405.41 2.6 Prevention & Control of HIV-AIDS 276.26 - 227.13 643.05 2.7 Prevention & Control of TB & Leprosy 152.72 45.52 671.67 2.8 Prevention & Control of Other Communicable Diseases 0.24 107.07 107.97 2.9 Prevention & Control of Non-Communicable Diseases 0.27 163.56 164.58 2.10 Public Health Emergency Management 0.45 35.86 38.11 2.11 Public Health / Nutrition Research & Quality Assurance / Food security unit 14.16 69.64 90.88 3.1 Expansion of PHC Facilities 23.48 328.31 328.31 3.2 Hospital Infrastructure 30.11 989.92 989.92 3.3 HR Salaries & Training 54.33 503.97 558.30 3.4 Pharmaceutical & Medical Equipment 97.00 434.97 434.97 3.5. Health Care Financing 2.17 38.91 38.91 TOTAL 867.06 4,337.00 6,338.55 Annex 6.3: Total cost of HSDP­IV in two scenarios bycapital/recurrent Baseline 2010/11 2011/12 2012/13 2013/14 2014/15 Total Base-case scenario Family oriented community based services 181.76 527.17 568.60 567.44 615.00 655.68 2,933.89 Capital investment 73.52 65.63 32.88 12.73 7.80 3.79 122.83 Recurrent 181.76 461.55 535.72 554.71 607.20 651.88 2,811.06 Population oriented schedulable services 63.39 351.06 125.27 137.31 152.49 167.51 933.64 Capital investment 25.64 129.45 26.30 30.24 30.47 30.61 247.07 Recurrent 63.39 221.61 98.97 107.08 122.02 136.90 686.57 Individual oriented clinical services 418.97 603.74 619.33 742.08 868.34 993.74 3,827.25 Capital investment 298.31 265.69 231.38 224.95 222.81 220.02 1,164.86 Recurrent 120.66 338.05 387.95 517.13 645.53 773.73 2,662.39 District, provincial, national governance & management 119.78 195.03 193.87 215.70 247.68 279.45 1,131.73 Capital investment 85.29 120.24 92.12 79.91 76.74 73.00 442.01 Recurrent 34.50 74.79 101.75 135.79 170.93 206.45 689.72 Total 883.06 1,677.01 1,507.07 1,662.54 1,883.51 2,096.38 8,826.50 Capital investment 628.74 581.01 382.68 347.83 337.83 327.41 1,976.76 Recurrent 254.32 1,095.99 1,124.39 1,314.71 1,545.68 1,768.96 6,849.74 Best-case scenario Family oriented community based services 181.76 637.48 746.21 801.66 877.21 938.51 4,001.07 Capital investment 73.52 86.59 76.75 87.70 80.81 71.28 403.13 Recurrent 181.76 550.89 669.45 713.96 796.40 867.24 3,597.94 Population oriented schedulable services 63.39 383.36 190.23 172.96 188.46 203.71 1,138.72 Capital investment 25.64 168.04 97.56 72.17 72.73 73.10 483.60 Recurrent 63.39 215.32 92.68 100.79 115.73 130.61 655.12 Individual oriented clinical services 418.97 603.74 1,374.19 1,293.37 1,741.76 1,545.03 6,558.09 Capital investment 298.31 265.69 986.24 776.24 774.09 771.30 3,573.56 Recurrent 120.66 338.05 387.95 517.13 967.67 773.73 2,984.53 District, provincial, national governance & management 119.78 195.03 193.87 215.70 247.68 279.45 1,131.73 Capital investment 85.29 120.24 92.12 79.91 76.74 73.00 442.01 Recurrent 34.50 74.79 101.75 135.79 170.93 206.45 689.72 Total 883.06 1,419.30 2,104.19 2,083.38 2,654.80 2,566.38 10,828.05 Capital investment 482.75 640.56 1,252.67 1,016.02 1,004.37 988.67 4,902.29 Recurrent 400.31 778.74 851.52 1,067.36 1,650.42 1,577.71 5,925.76 Annex 6.4: Financing gap by programme for 2011­2015 in millions USD Base case scenario Best case scenario 1.1 Community Empowerment 87.05 112.47 1.2 Monitoring & Evaluation and Operational Research 84.02 106.10 1.3 System Strengthening & Capacity Development 751.81 751.81 2.1 Maternal-Newborn and RH-Adolescent Health 317.13 424.35 2.2 Child Health 149.69 231.41 2.3 Nutrition 93.96 109.91 2.4 Hygiene & Environmental Health 124.52 130.42 2.5 Prevention & Control of Malaria 238.23 405.41 2.6 Prevention & Control of HIV-AIDS - 227.13 643.05 2.7 Prevention & Control of TB & Leprosy 45.52 671.67 2.8 Prevention & Control of Other Communicable Diseases 107.07 107.97 2.9 Prevention & Control of Non-Communicable Diseases 163.56 164.58 2.10 Public Health Emergency Management 35.86 38.11 2.11Public Health/Nutrition Research & Quality Assurance 69.64 90.88 3.1 Expansion of PHC Facilities 328.31 328.31 3.2 Hospital Infrastructure 989.92 989.92 3.3 HR Salaries & Training 503.97 558.30 3.4 Pharmaceutical & Medical Equipment 434.97 434.97 3.5. Health Care Financing 38.91 38.91 Annex 7: High impact interventions & indicators High impact interventions & indicators 2010/11-2014/15 1. Family oriented community based services Indicators Baseline Base case scenario Best case scenario ITN for under five children % of children<5 who slept under ITN the previous night 41.2% 86% 86% ITN for pregnant mother % of pregnant women who slept under ITN the previous night 42.5% 86% 86% Quality of drinking water % of households using household water treatment and safe storage practice 7% 77% 88% Hygiene & sanitation % of HHs utilising latrine 20% 82% 93% Hand washing by mothers at critical time %age of mothers practicing hand washing with soap at critical time 13% 43% 88% Indoor Residual Spraying (IRS) % of households covered with IRS (in IRS targeted areas) 55% 77% 88% Clean delivery & essential newborn care % of births attended by HEWs 11% 38% 25% Early breastfeeding & temperature management % of children put to breast within an hour of birth (initial breastfeeding) 69% 92% 92% Exclusive breastfeeding for children 0-6 months % of children exclusively breastfeed for 6 months 49% 70% 70% Continued breastfeeding for children 6-11 months % of children aged 6-11 months receiving breast milk. 75% 75% 85% Complementary feeding % of children 6-9 months receiving complementary food & breastfeeding 54% 65% 84% Oral Rehydration Therapy % of children under five years with diarrhoea receiving ORT 37% 89% 89% Zinc for diarrhoea management % children with diarrhoea who are treated with zinc at community level 0% 62% 75% Zinc for diarrhoea management % of diarrhoea cases treated with zinc 0% 62% 88% Artemisinin-based combination therapy for children % children treated for malaria at community level 3% 21% 29% Artemisinin-based combination therapy for children % of children with malaria receiving ACT 8% 54% 89% Artemisinin-based combination therapy for pregnant women % of pregnant women treated for malaria at community level 5% 16% 22% Artemisinin-based combination therapy for pregnant women % of pregnant women with malaria receiving ACT 15% 49% 88% Artemisinin-based combination therapy for adults % of adults with malaria receiving ACT 4% 12% 19% Artemisinin-based combination therapy for adults % of adults with malaria receiving ACT 15% 48% 88% Malaria treatment with chloroquine % Fever cases in children receiving chloroquine treatment 3% 21% 32% Chloroquine for malaria (P.vivax) % of fever cases in children receiving chloroquine 7% 52% 88% Therapeutic feeding for malnourished children/OTP % of children with SAM receiving therapeutic feeding (HP) 5% 19% 19% Therapeutic feeding for malnourished children % of under 5 children managed for severe acute malnutrition (HC & HOSP) 23% 91% 91% Community-based pneumonia treatment for children % children treated for pneumonia at community level 0% 41% 41% Iodised salt % of HHs using iodised salt 4% 95% 95% Family Planning Contraceptive Prevalence Rate (CPR) 32% 66% 86% Antenatal care % of pregnant women who got ANC 4+ 31% 86% 88% Tetanus (TT) immunisation % of mothers with birth in last 12 months 52% 57% 86% S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 SO C 1 : Im p ro ve A cc es s to H ea lt h S er vi ce s C 1 .1 Im p ro ve M at er n al , N eo n at al , C h il d a n d A d ol es ce n t H ea lt h 1 M at er na l M or ta lit y Ra tio Im pa ct 59 0* 26 7 ED H S Ev er y 5 ye ar s Po pu la tio n 2 M at er na l D ea th (I ns tit ut io na l ) Im pa ct NA Le ss th an 1 H M IS M on th ly Al l H F 3 Un de r- 5 M or ta lit y Ra te Im pa ct 10 1/ 10 00 68 ED H S Ev er y 5 ye ar s Po pu la tio n 4 In fa nt M or ta lit y Ra te Im pa ct 77 /1 00 0 31 ED H S Ev er y 5 ye ar s Po pu la tio n 5 N eo na ta l M or ta lit y Ra te Im pa ct 39 /1 00 0 15 ED H S Ev er y 5 ye ar s Po pu la tio n 6 N eo na ta l D ea th (I ns tit ut io na l) Im pa ct NA Le ss th an 1 H M IS M on th ly Al l H F 7 To ta l F er til ity R at e Im pa ct 5. 4 4 ED H S Ev er y 5 ye ar s Po pu la tio n 8 Ad ol es ce nt F er til ity R at e (p er 10 00 w om en ) Im pa ct 17 % 5% ED H S Ev er y 5 ye ar s Po pu la tio n 9 Co nt ra ce pt iv e Pr ev al en ce R at e Ou tc om e 32 % 66 % ED H S Ev er y 5 ye ar s Po pu la tio n 10 Co nt ra ce pt iv e Ac ce pt an ce R at e Ou tc om e 56 % 66 % 74 % 79 % 81 % 82 % H M IS M on th ly A ll H F 11 CY P (C ou pl e ye ar s o f p ro te ct io n) Ou tc om e 7. 4 m ill io n 8. 9m ill 10 .5 m ill 12 .2 m ill 13 .8 m ill 15 .5 m ill H M IS An nu al ly A ll H F 12 Un m et n ee d fo r F am ily P la nn in g Ou tc om e 34 % 10 % ED H S Ev er y 5 ye ar s po pu la tio n 13 An te na ta l c ar e co ve ra ge – a t l ea st on e vi si t Ou tc om e 68 % 76 % 83 % 88 % 89 % 90 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 14 An te na ta l c ar e co ve ra ge – a t l ea st fo ur v is it Ou tc om e 31 % 53 % 70 % 81 % 83 % 86 % ED H S/ H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 15 Bi rt hs a tt en de d by sk ill ed h ea lth pe rs on ne l Ou tc om e 18 .4 % 36 % 49 % 58 % 60 % 62 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 16 Bi rt hs a tt en de d by H EW (C le an an d sa fe d el iv er y) Ou tc om e 11 % 22 % 30 % 35 % 37 % 38 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 17 M et n ee d fo r e m er ge nc y ob st et ri c ca re Ou tc om e 12 % 69 % 75 % H F Su rv ey 2- 3 ye ar s H F 18 Ea rly P os tn at al C ar e Co ve ra ge Ou tc om e 34 % 52 % 65 % 74 % 76 % 78 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 19 N ew bo rn s w ho re ce iv ed 2 h om e vi si ts in th e fir st o ne w ee k of b ir th Ou tc om e 5% 59 % 65 % H H S Ev er y 2- 3 Ye ar s Po pu la tio n H SD P IV 109 A n n ex 8 : D et ai le d in d ic at or s fo r m on it or in g H SD P- IV q u al it y in d ic at io n S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 20 Ca es ar ea n Se ct io n Ra te ou tc om e 1% 4% 5% 6% 7% 7% H M IS M on th ly Al l H os pi ta ls 21 Ab or tio n Ca re Ou tc om e 54 % 68 % 74 % 79 % 85 % 90 % H M IS M on th ly Al l H F 22 PM TC T Te st in g Ra te Ou tc om e 16 % 42 % 63 % 76 % 79 % 83 % H M IS M on th ly Al l H F 23 PM TC T Pr op hy la xi s Ou tc om e 8% 36 % 56 % 70 % 73 % 77 % H M IS M on th ly Al l H F 24 H IV e xp os ed in fa nt s w ho re ce iv ed H IV te st Ou tc om e 0% 20 % 40 % 60 % 80 % 10 0% H M IS M on th ly Al l H C & H os pi ta ls 25 Pe nt av al en t ( DP T3 -H ep B3 -H ib 3) Im m un iz at io n Co ve ra ge A m on g 1- Ye ar -o ld s Ou tc om e 82 % 88 % 92 % 95 % 96 % 96 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 26 Pn eu m oc oc ca l c on ju ga te d va cc in e fir st d os e (P CV 1) im m un iz at io n co ve ra ge Ou tc om e 0% — 93 % 96 % 96 % 96 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 27 Pn eu m oc oc ca l c on ju ga te d va cc in e th ir d do se (P CV 3) im m un iz at io n co ve ra ge Ou tc om e 0% — 88 % 92 % 95 % 96 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 28 Ro ta vi ru s v ac ci ne fi rs t d os e (R ot a1 ) i m m un iz at io n co ve ra ge Ou tc om e 0% — 93 % 96 % 96 % 96 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 29 Ro ta vi ru s v ac ci ne se co nd d os e (R ot a2 ) i m m un iz at io n co ve ra ge Ou tc om e 0% — 88 % 92 % 95 % 96 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 30 M ea sl es Im m un iz at io n Co ve ra ge Am on g 1- ye ar -o ld s Ou tc om e 77 % 82 % 86 % 89 % 89 % 90 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 31 Fu ll Im m un iz at io n Co ve ra ge Am on g 1- ye ar -o ld s Ou tc om e 66 % 75 % 83 % 88 % 89 % 90 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 32 N eo na te s p ro te ct ed a t b ir th ag ai ns t n eo na ta l t et an us (P AB ) Ou tc om e 42 % 60 % 73 % 82 % 84 % 86 % ED H S / H M IS Ev er y 5 Ye ar s / M on th ly Po pu la tio n/ Al l H F 33 N ew bo rn w ith n eo na ta l s ep si s w ho re ce iv ed tr ea tm en t Ou tc om e 22 % 43 % 58 % 69 % 71 % 74 % H FS 2- 3 ye ar s Al l H F 34 As ph yx ia te d ne w bo rn s w ho a re re su sc ita te d Ou tc om e 7% 34 % 54 % 68 % 71 % 75 % H FS 2- 3 ye ar s Al l H F H SD P IV 110 S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 35 Pr ev al en ce a nd tr ea tm en t o f su sp ec te d pn eu m on ia at fa ci lit y le ve l Ou tc om e 25 % 40 % ED H S Ev er y 5 Ye ar s H C an d H os pi ta l at co m m un ity le ve l b y H EW s Ou tc om e 0% 41 % ED H S Ev er y 5 Ye ar s H P 36 Pr ev al en ce a nd T re at m en t o f f ev er in ch ild re n ag ed < 5 ye ar s Ou tc om e 15 % 78 % 85 % ED H S /M IS Ev er y 5 Ye ar s / 2- 3 ye ar s Al l H F 37 Ch ild re n ag ed < 5 ye ar s w ith d ia rr he a re ce iv in g or al re hy dr at io n th er ap y Ou tc om e 37 % 89 % ED H S Ev er y 5 ye ar s Al l H F 38 Un de r 5 ch ild re n di ag no se d & tr ea te d fo r m al ar ia Ou tc om e 32 % 77 % 82 % H FS 2- 3 ye ar s H F 39 H ea lth F ac ili tie s t ha t P ro vi de In te gr at ed M N CH /P M TC T Se rv ic es Ou tp ut 24 % 54 % 77 % 92 % 96 % 10 0% H M IS An nu al ly H C an d H os pi ta l 40 Av ai la bi lit y of B Em OC Ou tp ut 5% 43 % 72 % 91 % 95 % 10 0% H M IS An nu al ly H C 41 Av ai la bi lit y of C Em OC Ou tp ut 51 % 71 % 85 % 95 % 98 % 10 0% H M IS An nu al ly H os pi ta ls 42 H ea lth F ac ili tie s t ha t P ro vi de S af e Ab or tio n Se rv ic es Ou tp ut 4% 30 % 45 % 55 % 65 % 75 % H M IS An nu al ly H C an d H os pi ta l 43 In te gr at ed C hi ld ho od Il ln es s ca se m an ag em en t ( IC CM ) im pl em en ta tio n co ve ra ge a t h ea lth po st Ou tp ut NA NA 55 % 75 % 85 % 10 0% H M IS An nu al ly H P 44 In te gr at ed M an ag em en t o f N ew bo rn a nd C hi ld ho od Il ln es s (I M N CI ) i m pl em en ta tio n co ve ra ge H ea lth C en te r Ou tp ut 52 % 67 % 84 % 95 % 97 % 10 0% H M IS An nu al ly H C H os pi ta l Ou tp ut 62 % 10 0% 10 0% 10 0% 10 0% 10 0% H M IS An nu al ly H os pi ta ls 45 Ad ol es ce nt a nd Y ou th F ri en dl y RH Se rv ic es (A YF RH S) C ov er ag e Ou tp ut 10 % 45 % 65 % 80 % 90 % 10 0% H M IS An nu al ly H C an d H os pi ta l C 1 .2 Im p ro ve n u tr it io n al s ta tu s 1 Pr ev al en ce o f a ne m ia in w om en Im pa ct 27 % 12 % ED H S Ev er y 5 ye ar s po pu la tio n 2 Un de rw ei gh t p re va le nc e in ch ild re n ag ed < 5 ye ar s Im pa ct 38 % 25 % ED H S Ev er y 5 ye ar s po pu la tio n H SD P IV 111 S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 3 Ch ild re n ag ed < 5 ye ar s s tu nt ed Im pa ct 47 % 30 % ED H S Ev er y 5 ye ar s po pu la tio n 4 Ch ild re n ag ed < 5 ye ar s w as te d Im pa ct 11 % 3% ED H S Ev er y 5 ye ar s po pu la tio n 5 Lo w b ir th w ei gh t ( LB W ) n ew bo rn s Im pa ct 14 % 13 % 12 % 11 % 10 % 9% H M IS M on th ly Al l H F 6 Ch ild re n ag ed < 5 ye ar s un de rw ei gh t Ou tc om e 38 % 35 % 33 % 30 % 28 % 25 % H M IS M on th ly Al l H F 7 Un de r 5 ch ild re n m an ag ed fo r se ve re a cu te m al nu tr iti on a t H F At H ea lth F ac ili ty Ou tc om e 23 % 51 % 71 % 85 % 88 % 91 % H M IS M on th ly Al l H F By H EW s/ OT P Ou tc om e 5% 11 % 15 % 18 % 19 % 19 % H M IS M on th ly Al l H F 8 Se ve re a cu te m al nu tr iti on tr ea tm en t o ut co m e (C =c ur e, D= de fa ul te r, M =m or ta lit y) Ou tc om e NA C= >7 5; D= <1 5% ; M =< 5% C= >7 5; D= <1 5% ; M =< 5% C= >7 5; D= <1 5% ; M =< 5% C= >7 5; D= <1 5% ; M =< 5% C= >7 5; D= <1 5% ; M =< 5% H M IS M on th ly Al l H F 9 In iti al b re as tfe ed in g Ou tc om e 69 % 92 % ED H S Ev er y 5 ye ar s po pu la tio n 10 Ex cl us iv e br ea st fe ed in g un de r 6 m on th s Ou tc om e 49 % 70 % ED H S Ev er y 5 ye ar s po pu la tio n 11 Ch ild re n 6- 9 m on th s r ec ei vi ng co m pl em en ta ry fo od a nd co nt in ue d br ea st fe ed in g Ou tc om e 54 % 65 % ED H S Ev er y 5 ye ar s po pu la tio n 12 Ch ild re n ag ed 6 -5 9 m on th s w ho re ce iv ed tw o do se s o f v ita m in A su pp le m en ta tio n Ou tc om e 95 % 96 % 97 % 98 % 99 % 99 % H M IS An nu al ly Al l H F 13 Io di za tio n of h ou se ho ld sa lt Ou tc om e 4% 95 % ED H S Ev er y 5 ye ar s po pu la tio n 14 Ch ild re n ag ed 2 -5 y ea rs d e- w or m ed Ou tc om e 86 % 88 % 90 % 92 % 94 % 96 % H M IS An nu al ly Al l H F 15 Pr eg na nt w om en su pp le m en te d w ith ir on d ur in g pr eg na nc y Ou tc om e 10 % 41 % 63 % 79 % 82 % 86 % ED H S / H M IS Ev er y 5 Ye ar s / An nu al ly Po pu la tio n/ Al l H F C 1 .3 . I m p ro ve h yg ie n e & e nv ir on m en ta l h ea lt h 1 Po pu la tio n us in g im pr ov ed sa ni ta tio n fa ci lit ie s Ou tc om e 20 % 76 % 82 % ED H S/ S ur ve y Ev er y 5 Ye ar s / 2 - 3 y ea rs Po pu la tio n 2 H ou se ho ld ’s w ith a cc es s t o la tr in e fa ci lit ie s Ou tp ut 60 % 74 % 85 % 92 % 93 % 95 % H M IS An nu al ly W or H O H SD P IV 112 S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 3 H ou se ho ld s u si ng H H w at er tr ea tm en t a nd sa fe st or ag e pr ac tic es Ou tc om e 7% 70 % 77 % Su rv ey 2- 3 y ea rs Po pu la tio n 4 Vi lla ge s ( Ke be lle s) fr ee o f o pe n de fe ca tio n Ou tc om e 15 % 60 % 80 % Su rv ey 2- 3 y ea rs Po pu la tio n C 1 .4 . P re ve n ti on a n d C on tr ol o f M aj or C om m u n ic ab le D is ea se s R ed u ce in ci d en ce & p re va le n ce o f H IV /A ID S 1 H IV in ci de nc e Im pa ct 0. 28 0. 14 2 Pr ev al en ce o f H IV In fe ct io n Im pa ct 2. 4 2. 4 2. 4 Su rv ei lla nc e 2 - 3 ye ar s Su rv ei lla nc e si te s 3 Co nd om U se in y ou ng p eo pl e ag ed 15 -2 4 Ou tc om e 59 % 80 % 95 % ED H S / BS S Ev er y 5 Ye ar s / 2 - 3 y ea rs Po pu la tio n 4 Co m pr eh en si ve k no w le dg e of H IV / AI DS Ou tc om e 22 .6 % 80 .2 % 80 .2 % ED H S / BS S Ev er y 5 Ye ar s / 2 - 3 y ea rs Po pu la tio n 5 H CT (V CT + P IH CT te st in g) Ou tc om e 5. 8 m ill io n 9. 3 m ill io n 9. 3 m ill io n 9. 3 m ill io n 9. 3 m ill io n 9. 3 m ill io n H M IS M on th ly H Fs 6 Tr ea tm en t o f S ex ua lly T ra ns m itt ed In fe ct io ns Ou tc om e 39 26 7 18 0, 00 0 18 0, 00 0 Su rv ey 2 - 3 Y ea rs H Fs 7 Ev er S ta rt ed o n AR T Ou tc om e 24 6, 34 7 32 4, 02 1 37 7, 66 9 43 1, 31 7 45 8, 14 1 48 4, 96 6 H M IS M on th ly H Fs 8 Cu rr en tly o n AR T Pr eg na nt w om en Ou tc om e NA 26 % 35 % 44 % 53 % 95 % H M IS M on th ly H Fs Ch ild re n Ou tc om e NA 54 % 57 % 59 % 61 % 95 % H M IS M on th ly H Fs Ad ul ts (e xc lu di ng p re gn an t w om en ) Ou tc om e 53 % 61 % 70 % 78 % 87 % 95 % H M IS M on th ly H Fs 9 Or ph an & v ul ne ra bl e ch ild re n w ho re ce iv ed ca re & su pp or t Ou tc om e 30 % 35 % 40 % 43 % 45 % 50 % Ad m in R ep or t Qu ar te rly W or H O 10 PL H IV w ho re ce iv ed ca re a nd su pp or t ( co m m un ity ) Ou tc om e 60 ,0 00 70 ,0 00 80 ,0 00 85 ,0 00 95 ,0 00 10 0, 00 0 Ad m in R ep or t Qu ar te rly W or H O 11 H IV + re ce iv in g co -t ri m ox az ol e pr op hy la xi s Ou tc om e 68 % 75 % 80 % 85 % 90 % 95 % H M IS M on th ly H F` R ed u ce in ci d en ce & p re va le n ce o f T B a n d L ep ro sy 1 TB C as e De te ct io n Ra te (A ll fo rm s) Ou tc om e 34 % 50 % 63 % 71 % 73 % 75 % H M IS Qu ar te rly H F 2 TB tr ea tm en t S uc ce ss ra te Ou tc om e 84 % 86 % 88 % 89 % 90 % 90 % H M IS Qu ar te rly H F H SD P IV 113 S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 3 Tu be rc ul os is C ur e Ra te Ou tc om e 67 % 74 % 80 % 83 % 84 % 85 % H M IS Qu ar te rly H F 4 N um be r o f l ab or at or y co nf ir m ed M DR T B pa tie nt s b y cu ltu re & D ST Ou tc om e 83 1, 07 0 2, 05 0 3, 03 0 4, 02 0 5, 00 0 Su rv ei lla nc e Qu ar te rly Su rv ei lla nc e si te s 5 Co nf ir m ed M DR T B ca se s p ut on co rr ec t s ec on d lin e an ti- TB tr ea tm en t r eg im en Ou tc om e NA 10 0% 10 0% 10 0% 10 0% 10 0% Su rv ei lla nc e Qu ar te rly Su rv ei lla nc e si te s 6 Co nf ir m ed M DR T B ca se s i ni tia te d on se co nd li ne a nt i-T B tr ea tm en t w ho h av e cu ltu re a t t he e nd o f 6m on th s o f t re at m en t Ou tc om e NA 95 % 95 % 95 % 95 % 95 % Su rv ei lla nc e Qu ar te rly Su rv ei lla nc e si te s 7 La bo ra to ry -c on fir m ed M DR T B ca se s s uc ce ss fu lly tr ea te d am on g th os e en ro lle d in se co nd li ne a nt i- TB tr ea tm en t Ou tc om e 62 % 80 % 80 % 80 % 80 % 80 % Su rv ei lla nc e Qu ar te rly Su rv ei lla nc e si te s 8 Pr op or tio n of H ea lth P os ts pr ov id in g co m m un ity D OT S se rv ic e Ou tp ut 6% 15 % 23 % 32 % 41 % 50 % H M IS An nu al ly H ea lth P os ts 9 H IV te st in g fo r T B pa tie nt s Ou tc om e 15 % 41 % 54 % 64 % 72 % 80 % H M IS Qu ar te rly H F 10 TB ca se -fi nd in g am on g pe op le liv in g w ith H IV Ou tc om e 3 8% 10 0% 10 0% 10 0% 10 0% 10 0% H M IS Qu ar te rly H F 11 Pr op or tio n of T B ne ga tiv e PL H IV s pu t o n IN H P ro ph yl ac tic T he ra py (I PT ) Ou tc om e 2% 34 % 50 % 66 % 73 % 80 % H M IS Qu ar te rly H F 12 Le pr os y tr ea tm en t c om pl et io n ra te Ou tc om e 91 % 93 % 95 % 96 % 97 % 98 % H M IS Qu ar te rly H F 13 Gr ad e II di sa bi lit y ra te a m on g ne w ca se s o f L ep ro sy Ou tc om e 7% 4% 3% 2% 1% 1% H M IS Qu ar te rly H F R ed u ce in ci d en ce & p re va le n ce o f M al ar ia 1 La b co nf ir m ed (R DT /M ic ro sc op y) m al ar ia ca se fa ta lit y ra tio Im pa ct NA Le ss th an 2% Le ss th an 2% Su rv ey 2- 3 ye ar s Po pu la tio n 2 la b co nf ir m ed (R DT /M ic ro sc op y) m al ar ia in ci de nc e pe r y ea r Im pa ct NA < 5/ 10 00 po pu la tio n/ ye ar < 5/ 1 00 0 po pu la tio n pe r y ea r M IS 2- 3 ye ar s Al l H F 3 Pr ev al en ce o f p ar as ite m ia Ou tc om e NA Le ss th an 1% Le ss th an 1% Su rv ey 2- 3 ye ar s Po pu la tio n H SD P IV 114 S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 4 L ab or at or y- co nf ir m ed m al ar ia ca se s s ee n in h ea lth fa ci lit ie s Ou tc om e 37 0, 00 0 24 6, 00 0 18 4, 00 0 12 2, 00 0 91 ,0 00 60 ,0 00 H M IS Qu ar te rly Al l H F 5 Po ss es si on o f i ns ec tic id e tr ea te d ne ts Ou tp ut 65 .6 0% 8 8% 90 % ED H S/ M IS Ev er y 5 Ye ar s / 2 - 3 y ea rs po pu la tio n 6 M al ar ia d ur in g pr eg na nc y (p re gn an t w om en w ho sl ep t u nd er LL IN th e pr ev io us n ig ht ) Ou tc om e 42 .5 % 8 2% 86 % ED H S/ M IS Ev er y 5 Ye ar s / 2 - 3 y ea rs po pu la tio n 7 Us e of in se ct ic id e- tr ea te d ne ts in U5 ch ild re ns (U 5 ch ild re ns w ho sl ep t u nd er L LI N th e pr ev io us ni gh t) Ou tc om e 41 .2 % 8 2% 86 % ED H S/ M IS Ev er y 5 Ye ar s / 2 - 3 y ea rs po pu la tio n 8 In te gr at ed R es id ua l S pr ay in g of ho us eh ol ds Ou tp ut 55 % 64 % 70 % 74 % 75 % 77 % Ad m in R ep or t An nu al ly W or H O R ed u ce in ci d en ce & p re va le n ce o f o th er c om m u n ic ab le d is ea se s 1 Pr ev al en ce L ei sh m an ia si s i n en de m ic a re as Im pa ct 9. 7% in m al es & 4. 5% in fe m al es 7% & 2 % Sp ec ia l S ur ve y Ev er y 5 ye ar s Po pu la tio n 2 Pr ev al en ce o f l ym ph at ic fi la ri as is Im pa ct 23 .7 % m al es & 18 .5 % fe m al es 16 % & 1 1% Sp ec ia l S ur ve y Ev er y 5 ye ar s Po pu la tio n 3 Pr ev al en ce T ra ch om at ou s tr ic hi as is Im pa ct 3. 10 % 1% Sp ec ia l S ur ve y Ev er y 5 ye ar s Po pu la tio n R ed u ce in ci d en ce & p re va le n ce o f m aj or n on -c om m u n ic ab le d is ea se s 1 Pr ev al en ce o f D ia be te s m el lit us am on g ad ul ts Im pa ct NA 1 -3 % 1- 3% Sp ec ia l S ur ve y Ev er y 2 - 3 ye ar s Po pu la tio n 2 Pr ev al en ce o f h ig h bl oo d pr es su re am on g ad ul ts Im pa ct 31 % in ur ba n an d 10 % in ru ra l 2 5% & 5 % 25 % & 5 % Sp ec ia l S ur ve y Ev er y 2 - 3 ye ar s Po pu la tio n 3 Bl in dn es s p re va le nc e Im pa ct 1. 6% 1% Sp ec ia l S ur ve y Ev er y 5 ye ar s Po pu la tio n 4 H ea lth fa ci lit ie s p ro vi di ng in te gr at ed m en ta l h ea lth se rv ic es Ou tp ut 10 % 26 % 34 % 42 % 46 % 50 % Ad m in re po rt An nu al ly H F 5 Ca ta ra ct su rg ic al ca se s Ou tp ut 46 0 67 6 78 4 89 2 94 6 10 00 H M IS An nu al ly H os pi ta ls H SD P IV 115 S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 SO C 2 : I m p ro ve c om m u n it y ow n er sh ip 1 M od el h ou se ho ld s g ra du at ed Ou tp ut 25 .6 % 50 % 67 % 79 % 82 % 85 % Ad m in re po rt M on th ly W or H O 2 H ou se ho ld s n et w or ke d in h ea lth de ve lo pm en t a rm y In pu t NA 10 0% 10 0% 10 0% 10 0% 10 0% Ad m in re po rt An nu al ly W or H O 3 H ea lth fa ci lit ie s w ith b oa rd s w he re co m m un iti es a re re pr es en te d Ou tp ut 20 % 22 .2 0% 50 % 10 0% 10 0% 10 0% Ad m in re po rt An nu al ly W or H O SO F 1 : Im p ro ve r es ou rc e m ob il iz at io n a n d u ti li za ti on 1 Pu bl ic h ea lth fa ci lit ie s r et ai ni ng an d us in g th ei r r ev en ue In pu ts 20 % 22 .2 0% 50 % 50 % 10 0% 10 0% Ad m in re po rt An nu al ly W or H O 2 Sh ar e of in te rn al re ve nu e ge ne ra te d to to ta l h ea lth b ud ge t In pu ts 9 % 10 % 11 % 12 % 12 .5 % 13 % H M IS An nu al ly W or H O 3 Pr op or tio n of re im bu rs ed a m ou nt ou t o f t ot al p at ie nt fe es w ai ve d In pu ts 70 % 75 % 80 % 85 % 90 % 10 0% H M IS Qu ar te rly W or H O 4 Pe r c ap ita e xp en di tu re o n he al th In pu ts 16 .1 U SD 20 26 28 30 32 .2 U SD H M IS An nu al ly W or H O 5 Ou t- of -p oc ke t e xp en di tu re a s a pe rc en ta ge o f t ot al e xp en di tu re o n he al th Ou tc om e 37 % 2 7% 18 % N H A Su rv ey Ev er y 5 ye ar s Po pu la tio n 6 Pr op or tio n of p eo pl e en ro lle d in H ea lth In su ra nc e (d is ag gr eg at e to fo rm al a nd in fo rm al se ct or ) In pu ts 1% — — 11 .5 % 25 % 50 % Ad m in re po rt An nu al ly H IA 7 H ea lth b ud ge t u til iz at io n Ou tp ut 70 % 78 % 82 % 85 % 88 % 90 % H M IS An nu al ly W or H O 8 Go ve rn m en t e xp en di tu re o n he al th bu dg et a s a p ro po rt io n of to ta l bu dg et Ou tp ut 5. 6% 11 % 12 .5 % 14 % 15 % 15 % H M IS An nu al ly W or H O SO P 1 : I m p ro ve Q u al it y H ea lt h S er vi ce s 1 Be d Oc cu pa nc y Ra te Ou tp ut 50 .8 % 74 % 78 % 82 % 84 % 85 % H M IS Qu ar te rly Al l H F 2 Av er ag e Le ng th o f S ta y Ou tp ut 6. 7 da ys 6. 7 6. 4 5. 7 5. 3 5 da ys H M IS Qu ar te rly Al l H F 3 Ou tp at ie nt A tt en da nc e pe r c ap ita Ou tp ut 0. 2 0. 4 0. 5 0. 6 0. 65 0. 7 H M IS Qu ar te rly Al l H F 4 Cu st om er sa tis fa ct io n in de x ou tc om e 50 % 90 % 10 0% Su rv ey 2- 3 Ye ar s Al l H F 5 Pr op or tio n of h os pi ta ls w ith de si gn at ed e m er ge nc y un it In pu t 50 % 70 % 80 % 90 % 95 % 10 0% Ad m in re po rt An nu al ly H os pi ta ls H SD P IV 116 S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 6 Pr op or tio n of e m er ge nc y pa tie nt ge tt in g em er ge nc y ca re in le ss th an 5 m in ut es Ou tp ut 50 % 90 % 10 0% Su rv ey 2- 3 Ye ar s H F 7 Pr op or tio n of p at ie nt s g et tin g sa fe an d ad eq ua te b lo od tr an sf us io n se rv ic e Ou tp ut 50 % 64 % 71 % 78 % 82 % 85 % Ad m in re po rt An nu al ly H F 8 Pr op or tio n o f s ta nd ar di ze d la bo ra to ri es fo r i nt eg ra te d di se as es a t d iff er en t l ev el s In pu ts 25 % 40 % 50 % 60 % 65 % 70 % Su rv ey An nu al ly H F an d Re gi on al la bo ra to ri es 9 Bl oo d un its d on at ed u nd er th e N at io na l B lo od T ra ns fu si on Se rv ic e (N BT S) . Ou tp ut NA 80 ,0 00 80 ,0 00 80 ,0 00 80 ,0 00 80 ,0 00 Ad m in re po rt Qu ar te rly Bl oo d ba nk SO P 2 : I m p ro ve P u b li c H ea lt h E m er ge n cy p re p ar ed n es s an d R es p on se 1 Pr op or tio n of e pi de m ic s c on tr ol le d w ith z er o m or ta lit y Ou tc om e NA 50 % 50 % 50 % 50 % 50 % Su rv ei lla nc e W ee kl y W or H O SO P 3 : I m p ro ve P h ar m ac eu ti ca l Su p p ly & S er vi ce s 1 Es se nt ia l d ru gs a va ila bi lit y In pu ts 65 % 80 % 90 % 95 % 98 % 10 0% H M IS M on th ly Al l H F 2 H ea lth fa ci lit ie s w ith st oc k ou t f or es se nt ia l d ru gs In pu ts 35 % 5% 0% Su rv ey 2- 3 ye ar s Al l H F 3 Pr oc ur em en t l ea d tim e (a ve ra ge tim e be tw ee n or de r a nd d el iv er y fo r s up pl ie r) In pu ts 24 0d ay s 19 0 17 0 15 0 13 5 12 0 da ys Ad m in re po rt An nu al ly PF SA 4 Pe rc en ta ge o f d is pe ns ed d ru gs ad eq ua te ly la be le d In pu ts 43 % 78 % 90 % Su rv ey 2- 3 ye ar s Al l H F 5 Pe rc en ta ge o f p re sc ri pt io ns co nt ai ni ng a nt ib io tic s In pu ts 58 % 34 % 25 % Su rv ey 2- 3 ye ar s Al l H F 6 Pr op or tio n of p at ie nt s w ith ad eq ua te in fo rm at io n on di sp en se d dr ug s Ou tp ut 68 % 81 % 10 0% Su rv ey 2- 3 ye ar s Al l H F 7 Pe rc en ta ge o f s to ck w as te d du e to ex pi ry Ou tp ut 8. 2% 5% 4. 5% 3. 5% 2. 5% 2% Ad m in re po rt An nu al ly PF SA SO P 4 : I m p ro ve R eg u la to ry s ys te m 1 H ea lth In st itu tio ns L ic en se d/ ce rt ifi ed Ou tp ut NA 10 0% 10 0% 10 0% 10 0% 10 0% Ad m in re po rt An nu al ly FM H AC A H SD P IV 117 S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 2 H ea lth In st itu tio ns in sp ec tio n Co ve ra ge Ou tp ut NA 10 0% 10 0% 10 0% 10 0% 10 0% Ad m in re po rt An nu al ly FM H AC A 3 N um be r o f r eg is te re d an d lic en se d tr ad iti on al m ed ic in e Ou tp ut NA 10 20 40 60 80 Ad m in re po rt An nu al ly FM H AC A 4 N um be r o f A cc re di te d H os pi ta ls Ou tp ut 0 — — 1 2 2 Ad m in re po rt An nu al ly FM H AC A 5 N um be r o f G M P qu al ifi ed lo ca l ph ar m ac eu tic al m an uf ac tu re rs Ou tp ut NA 3 7 10 14 17 Ad m in re po rt An nu al ly FM H AC A SO P 5 : I m p ro ve e vi d en ce d -b as ed d ec is io n -m ak in g th ro u gh e n h an ce d h ar m on iz at io n a n d a li gn m en t 1 Re po rt co m pl et en es s in pu ts 57 % 70 % 77 % 83 % 86 % 90 % H M IS M on th ly W or H O 2 Re po rt T im el in es s In pu ts 57 % 70 % 77 % 83 % 86 % 90 % H M IS M on th ly W or H O 3 Co rr es po nd en ce b et w ee n da ta re po rt ed a nd re co rd ed (L QA S) Ou tp ut 15 % 45 % 60 % 75 % 82 % 90 % H M IS M on th ly H F 4 W or ed as w ith e vi de nc e- ba se d pl an al ig ne d ve rt ic al ly & h or iz on ta lly In pu ts 10 0% 10 0% 10 0% 10 0% 10 0% 10 0% Ad m in R ep or t An nu al ly al l l ev el 5 Pa rt ne rs im pl em en tin g on e pl an In pu ts NA 10 0% 10 0% 10 0% 10 0% 10 0% Su rv ey An nu al ly al l l ev el 6 Pr op or tio n of p ar tn er s u si ng th e na tio na l M & E fr am ew or k (a lig nm en t a nd h ar m on iz at io n) In pu ts NA 10 0% 10 0% 10 0% 10 0% 10 0% Su rv ey An nu al ly al l l ev el 7 H ea lth d ev el op m en ta l p ar tn er s pr ov id in g fu nd th ro ug h M DG P oo l Fu nd In pu ts NA 75 % 75 % 75 % 75 % 75 % Ad m in R ep or t An nu al ly al l l ev el SO C B 1 : Im p ro ve h ea lt h in fr as tr u ct u re 1 Fu nc tio na l F ac ili ty to P op ul at io n ra tio H P to p op ul at io n ra tio Ou tp ut 1: 5, 63 0 1: 5, 00 0 H M IS An nu al ly W or H O H C to p op ul at io n ra tio Ou tp ut 1: 37 ,2 99 1: 2 5, 00 0 H M IS An nu al ly W or H O Pr im ar y H os pi ta l t o po pu la tio n ra tio Ou tp ut 1: 68 8, 74 8 1: 10 0, 00 0 H M IS An nu al ly W or H O 2 N um be r o f f ac ili tie s n ew ly co ns tr uc te d an d up gr ad ed b y le ve l Ge ne ra l h os pi ta ls In pu ts NA 1: 1, 00 0, 00 0 Ad m in R ep or t An nu al ly RH B Re fe rr al h os pi ta ls In pu ts NA 1: 5, 00 0, 00 0 Ad m in R ep or t An nu al ly RH B H SD P IV 118 S. N In d ic at or s T yp e B as el in e Ye ar ly T ar ge t So u rc e P er io d ic it y Le ve l o f d at a Co ll ec ti on 1 2 3 4 5 3 N um be r o f m ai nt ai ne d H ea lth Fa ci lit ie s In pu ts NA 10 0% Ad m in R ep or t An nu al ly RH B 4 N um be r o f e qu ip pe d & fu rn is he d H ea lth F ac ili tie s b y ty pe In pu ts NA 10 0% Ad m in R ep or t An nu al ly RH B 5 H ea lth fa ci lit ie s w ith fu nc tio na l in fr as tr uc tu re In pu ts NA 10 0% Ad m in R ep or t An nu al ly W or H O 6 N um be r o f n ew te ch no lo gi es (v ac ci ne s) a do pt ed a nd u se d In pu ts NA 10 Ad m in R ep or t An nu al ly EH N RI 7 H os pi ta ls im pl em en tin g EM R In pu ts NA 10 0% Ad m in R ep or t An nu al ly H os pi ta ls 8 H ea lth F ac ili tie s i m pl em en tin g e- H M IS (R ep or tin g m od ul e) In pu ts NA 10 0% Ad m in R ep or t An nu al ly W or H O SO C B 2 :I m p ro ve h u m an c ap it al a n d L ea d er sh ip 1 N um be r o f t ra in ed & d ep lo ye d M id w ife ry In pu ts 2, 00 2 8, 63 5 H RI S An nu al ly W or H O 2 H ea lth st aff to p op ul at io n Ra tio Ou tp ut 0. 7/ 10 00 1. 7/ 10 00 H M IS An nu al ly W or H O 3 Ph ys ic ia n to P op ul at io n Ra tio Ou tp ut s 1: 37 ,9 96 1: 5, 50 0 H M IS An nu al ly W or H O H SD P IV 119 H SD P IV 120 Endnotes 1 DHS, 2005 2 MoFED, 2008 Macro economic development report 3 MoFED, 2007/08 Annual Progress Report 4 Ibid 5 WHO, 2010, World Health Statistics 6 Lancet, 2010 7 XXXXX 8 FMoH, 2004/05, HSDP III, (HSDP I & II Overview) 9 Ibid 10 Ibid 11 FMoH, 2008/09 Administrative Report 12 Ibid 13 FMoH, 2009 EmONC Survey Report 14 FMoH, 2008/09 Administrative Report 15 FMoH, 2008/09 ARM Performance Report 16 FMoH and WHO, 2007 Health Facility Survey 17 FMoH, 2007/08 Health and Health Related Indicator 18 FMoH, 2007 Malaria Indicator Survey 19 Ibid 20 HAPCO, 2007 Single point estimate 21 Ibid 22 Ibid 23 FMoH, 2008/09 Administrative Report and HAPCO, 2010 Report 24 USAID, Tuberculosis profile, Ethiopia, 2009 25 FMoH, ARM 2008/09 Report 26 FMoH, March 2010, TB prevention and control programme Annual Bulletin, 27 FMoH, 2010, TB prevention and control programme annual bulletin No 2 28 FMoH, 2008/09 ARM Performance Report 29 WHO, 2007, Community Based Survey of Injuries 30 FMoH Health and health related indicator 31 FMoH, 2009/10 Administrative Report 32 Ibid 33 FMoH, 2010, Policy and Practice Bulletin, Vol. XX 34 WHO Global Health Observatory, apps.who.int/ghodata/, accessed 25 Feb 2011, Africa and global data is from 2009 35 L10k Survey???? 36 FMoH, 2008/09 ARM Performance Report 37 Extract from: FMoH (2010) “Guideline for Building and Implementing a Balanced Scorecard Strategic Planning and Management System” Tables: Figures: Acronyms Preamble Foreword Executive summary Chapter 1. Country profile 1.1 Country context Geography and climate Demographic situation Government and administration Socio-economic situation Educational status 1.2 National health profile 1.2.1 Health status 1.2.2 National health system 1.2.3 Health system organisation Chapter 2. Overview of HSDP I, II and III 2.1 Summaries of past HSDP performance 2.2 Detailed account of HSDP III performance 2.2.1 Health service delivery & quality of care in HSDP III 2.2.1.1 Family Health Service 2.2.1.2 Prevention and control of communicable diseases Malaria and other vector born diseases prevention and control HIV/AIDS prevention and control program TB and leprosy control programme (TLCP) Blindness prevention and control programme Onchocerciasis control and dracunculiasis eradication 2.2.1.3 Prevention and control of non-communicable diseases 2.2.1.4 Integrated Disease Surveillance & Public Health Emergency Management 2.2.1.5 Hygiene & environmental health 2.2.1.6 Health Extension Programme (HEP) 2.2.1.7 Medical services 2.2.1.8 Nutrition 2.2.2 Health sector reform 2.2.3 Health facility construction and expansion 2.2.4 Human resource development 2.2.5 Pharmaceutical services 2.2.6 Health and health related services and product regulation 2.2.7 Harmonisation and alignment One Plan One Budget One Report/One M&E Governance of HSDP 2.2.8 Health care financing Retention and utilisation of revenue Health insurance Trend of expenditure in the health sector 2.2.9 Pastoralist health service 2.2.10 Operational research 2.2.11 Cross cutting issues Gender Chapter 3. Health Sector Development Programme IV 3.1 HSDP-IV planning process, methodology & principles 3.2 The policy framework 3.2.1 National policies and strategies 3.2.2 International policies and goals 3.3 Health sector strategic assessment 3.3.1 Roles of Federal and local governments Mandates of the Ministry of Health Mandates of the Regional Health Bureaus Mandates of Woreda Health Offices The role of Administrative Councils 3.3.2 Mission, vision and core values of the Ethiopian health sector 3.3.3 SWOT analysis for the health sector 3.3.4 Stakeholder analysis 3.4 Strategy of the HSDP-IV 3.4.1 Customer value proposition of HSDP-IV 3.4.2 Strategic themes and strategic results Strategic Theme 1: Excellence in health service delivery and quality of care Strategic Theme 2: Excellence in leadership and governance; Strategic Theme 3: Excellence in health infrastructure and resources; 3.4.3 Strategic perspectives 3.5 Strategic objectives & map for Ethiopian health sector 3.5.1 The ten strategic objectives (SOs) SO - C1: Improve access to health services SO – C2: Improve community ownership SO - F1: Maximize resource mobilization and utilization SO - P1: Improve quality of health services SO – P2: Improve public health emergency preparedness & response SO – P3: Improve pharmaceutical supply and services SO – P4: Improve regulatory system SO – P5: Improve evidence-based decision making by harmonization and alignment SO – CB 1: Improve health infrastructure SO – CB 2: Improve human capital and leadership 3.5.2 Health sector strategy map 3.6 Performance indicators, targets & strategic initiatives 3.6.1 Sector core performance indicators & targets 3.6.2 Directions of HSDP-IV Health Extension Programme Quality of health care Scaling up of civil service reform Special attention to critical programmes Human Resources Development Health Infrastructure Special attention to regions needing special support Climate changes and health: Gender mainstreaming 3.6.3 Performance indicators, targets & initiative by strategic objective SO C1: Improve access to health services SO C.1.1: Maternal, neonatal, child & adolescent health SO C.1.2: Nutrition SO C.1.3: Hygiene & environmental health SO C.1.4: Prevention & control of major communicable diseases SO C.1.5: Prevention & control of non-communicable diseases SO C2: Improve community ownership SO F1: Improve resource mobilization & utilization SO P1: Improve quality of health services SO P2: Improve public health emergency preparedness & responses SO P3: Pharmaceutical supply & services SO P4: Improve regulatory system SO P5: Improve evidence-based decision making by enhanced harmonisation & alignment SO CB1: Improve health infrastructure SO CB2: Improve human capital & leadership Chapter 4. Costing and Financing HSDP-IV 4.1 Costing methodology 4.2 Costing scenarios and assumptions for HSDP-IV Base-case scenario: Best-case scenario: 4.3 Cost and impact of scaling-up 4.4 Financing gap 4.5 Financing channels and arrangements for HSDP-IV 4.6 Preferred channels of financing HSDP-IV 4.7 Application of “one-budget” to channels and mechanisms Chapter 5. Management arrangement of HSDP-IV 5.1 Governance structure Joint Consultative Forum Joint Core Coordinating Committee 5.2 Inter-sectoral collaboration & public private partnership 5.3 Health service delivery arrangement 5.4 Health planning 5.5 Financial management and auditing 5.6 Procurement and logistics management 5.7 Monitoring and evaluation Routine administrative report (HMIS) Performance monitoring and quality improvement Evaluation/operational research Integrated Supportive Supervision (ISS) and inspection 5.8 Key indicators for results framework at national level 5.9 Risk mitigation Annex section Annex 1: How to Build a Balanced Scorecard – Nine Steps to Success Annex 2: Challenges & gaps of HSDP III & linkages to HSDP-IV Annex 3: Summary of bottleneck analysis conducted for HSDP-IV Annex 4: Projection of human resources requirement Annex 5: Planning and budgeting calendar Annex 6: Budget analysis* in millions USD Annex 6.1: Additional budget by service mode & capital/recurrent costs Annex 6.2: Estimated added cost of HSDP-IV 2011- 2015 Annex 6.3: Total cost of HSDP-IV in three scenarios by capital/recurrent Annex 6.4: Financing gap by programme for 2011-2015 in millions USD Annex 7: High impact interventions & indicators Endnotes