WIXLIB

EMTRFamily Health InternationalFederal Ministry of EducationFederal Ministry of HealthFemale Genital MutilationFinancial Management Information SystemFirst Expired-First OutGeneral PractitionerGlobal Alliance for Vaccines and ImmunizationGlobal Fund against AIDS, Tuberculosis and MalariaGlobal Health InitiativesGood Hygienic PracticesGovernment of EthiopiaGregorian CalendarHealth and Health Related IndicatorsHealth Care FinancingHealth Commodity Supply SystemHealth Education CentreHealth Emergency Preparedness and ResponseHealth Extension and Education CentreHealth Extension ProgrammeHealth Extension WorkersHealth Management Information SystemHealth Pooled FundHealth Population and NutritionHealth Sector Development ProgrammeHIV Counselling and TestingHIV/AIDS Prevention and Control OfficeHSDP Harmonization ManualHuman Immunodeficiency VirusHuman Resource Management Information SystemHuman Resources DevelopmentHuman Resources for HealthInformation Communication TechnologyInformation, Education and CommunicationInsecticide Treated NetIntegrated Disease Surveillance and ResponseIntegrated Management of Childhood IllnessesIntegrated Management of Newborn and Childhood IllnessesIntegrated Refresher TrainingInternational Development Association (World Bank)International Health PartnershipIntra-Uterine DeviceIron/Folic AcidJapan International Cooperation AgencyJohn Snow IncorporatedJoint Core Coordinating CommitteeJoint Review MissionJoint United Nations Programme on HIV/AIDSLogistics Management Information SystemMaking Pregnancy SaferManual Vacuum AspirationMaternal and Neonatal Mortality and MorbidityMaternal Mortality RatioMaternal Neonatal Child HealthMaternal Neonatal HealthMédecins Sans Frontières (Doctors without Borders)Medical Association of Physicians in Private PracticeMid-Term ReviewEthiopia MTR HSDP III Final, Executive Summary, 4-5-2009vii

SDPRPSIDASSSCMillennium Development GoalMinistry of Capacity BuildingMinistry of EducationMinistry of Finance and Economic DevelopmentMonitoring and EvaluationMultiple Drug ResistanceNational Drug PolicyNational Health AccountsNational Health Communication StrategyNational Nutrition PolicyNational Nutrition StrategyNon Governmental OrganizationNorwegian Agency for International DevelopmentNucleus Health CentreOral Contraceptive PillOral Rehydration SaltsOut Patient DepartmentParticipatory Hygiene and Sanitation TransformationPeople Living With HIV/AIDSPerformance Package FundPharmaceutical Fund and Supply AgencyPharmaceutical Logistics Master PlanPharmaceutical Supply and Logistic DepartmentPharmaceuticals and Medical Supplies Import and DistributionPhysical Assets Management Information SystemPlan for Accelerated and Sustained Development to End PovertyPlanning and Programming DepartmentPopulation Services InternationalPostnatal CarePoverty Reduction Strategy PaperPresident's Emergency Plan for Aids ReliefPrevention of Mother to Child TransmissionPrimary Health CarePrimary Health Care UnitProcurement and Logistics Management SystemProgramme Action PlanProtection of Basic ServicesPublic Expenditure ReviewPublic Finance ManagementPublic Private PartnershipRapid Diagnostic TestRational Drug UseRegional Health BureauRegional Joint Steering CommitteeRegional Training CentreReproductive HealthRevolving Drug FundRoyal Netherlands EmbassySave the Children UKSexually Transmitted InfectionSocial Health InsuranceSouthern Nations Nationalities and Peoples RegionSpecial PharmacySupply Chain Management SystemSurgery, Antibiotic, Face washing and Environmental ImprovementSustainable Development and Poverty Reduction ProgrammeSwedish International Development AgencySupport Systems Steering CommitteeEthiopia MTR HSDP III Final, Executive Summary, 4-5-2009viii

EDTechnical and Vocational Education Training SchoolTerms of ReferenceTetanus ToxoidTherapeutic Feeding ProgrammeTotal Fertility RateTraditional Birth AttendantTraining of TrainerTuberculosisUnder Five Mortality RateUnited NationsUnited Nations Children’s FundUnited Nations Development ProgrammeUnited Nations Fund for Population ActivitiesUnited Nations High Commission for RefugeesUnited States Agency for International DevelopmentUnited States DollarUniversal Salt IodizationVoluntary Counselling and TestingVolunteer Community Health WorkerWater Sanitation and HygieneWereda Health OfficeWereda Joint Steering CommitteeWereda Office of Finance and Economic DevelopmentWomen of Reproductive AgeWorld Food ProgrammeWorld Health OrganizationZonal Health DepartmentZonal Office of Finance and Economic DevelopmentConversion Rate:1 USD 9, 56 Birr (May/June EFY 2001, GC 2008)1 Euro 14, 96 Birr (May/June EFY 2001, GC 2008)Ethiopia MTR HSDP III Final, Executive Summary, 4-5-2009ix

CalendarsThe Ethiopian Fiscal Year / EFY (or Ethiopian Calendar / EC) refers to the Ethiopian FiscalYear, starting on 7th July in the European calendar. Currently, June 2008 corresponds with theend of EFY 2000. The overall correspondence between Ethiopian and European fiscal years isgiven in the table below, based on the Gregorian and Ethiopian Calendars:Table 1.1Gregorian and Ethiopian 01/022002/032003/042004/052005/062006/072007/08EFY 1985EFY 1986EFY 1987EFY 1988EFY 1989EFY 1990EFY 1991EFY 1992EFY 1993EFY 1994EFY 1995EFY 1996EFY 1997EFY 1998EFY /14EFY 2000EFY 2001EFY 2002EFY 2003EFY2004EFY 2005EFY 2006EFY 2007HEALTH DEVTHSDP YEARSNAT DEVTPLANSHEALTHPOLICY1993BASELINEi-PRSPHSDP IPRSPHEALTHSDPRPPOLICY OF THEHSDP IITRANSITIONALHSDP IIIPASDEPGOVERNMENTEFY Ethiopian Fiscal Year; GC Gregorian Calendar; EC Ethiopian CalendarEthiopia MTR HSDP III Final, Executive Summary, 4-5-2009x

National Level Indicators, June 2008 (2000 EC)SerialNo.CategoryBaselineHSDP IIIEFY 1997TargetHSDP IIIEFY 2003CurrentStatus MTREFY 1999Comments1,643 million3,250 million3,920 million(in EFY 2000)Birr 19.10(USD 2,0)Birr 91.70(USD 9,60)Birr 28.00(USD 3)Ratio of budget allocation toutilization/expenditure85%NA78%4Essential drug stock-out rateEssential Drug AvailabilityNANA0%100%Improving5HMIS completeness andtimeliness reporting rateNA80%6Level of HSDP IIIharmonization with the “oneplan, one report and onebudget” principleThis policywas not yetdefined in1997NAImplementationinitiated7Primary health servicecoverage72%100%109%8Health service utilization rateOPD / pp / yr0.300.660.32The HSDP III target is to double the share of health as a proportion of totalGovernment budget (domestic spending and direct budget support), the baseline isgiven as an absolute amount rather than a percentage.The HSDP III target is to increase total per capita health expenditure from USD 5.6 toUSD 9.6. This can only be determined through a National Health Account. Per capitapublic health expenditure is estimated at ETB 28 (USD 3)No target was set for this indicator in HSDP III but an increase in utilization isdesirable. There is a high level of utilization in the recurrent budget but less in thecapital budget, mainly due to the multi-year nature and delays in capital expenditure.HSDP III sets a target for essential drug availability to increase from 75% to 100%.During health centre and hospital visits, periodic shortages of essential drugs are stillreported, but the situation is improving due to the special pharmacies. However, thereis no routine information system to monitor this indicator.Currently it is difficult to estimate the performance of this indicator as not all healthfacilities are using a common HMIS reporting format due to implementation of thepilot HMIS.FMOH and Development Partners have signed a Code of Conduct, and are workingthrough joint steering committees. All partner plans are aligned with HSDP III andFMOH policy, however, there are still many reporting formats for the different sourcesof funding. Although figures are available for budgeting purposes, expenditure is notcaptured.Funding through channel 3 remains off-budget.There is little progress in alignment with government systems.Although it appears that the target has been reached by over 9%, this figure is likelyinflated, due likely errors in the nominators/denominators. However, as a result of theaccelerated expansion of the primary health service coverage plan in Ethiopia, manyregions will reach the 100 % target.The HSDP III target is to increase per capita health service utilization rate from 0.30to 0.66. Currently OPD utilization rate is used and is at 0.32. In most hospitals visited,1Input23ProcessIndicatorsGovernment budgetallocation to the healthsector: ETBTotal per capita healthexpenditure (GOE):Ethiopia MTR HSDP III Final, Executive Summary, 4-5-2009xi

SerialNo.CategoryIndicatorsBaselineHSDP IIIEFY 1997TargetHSDP IIIEFY 2003CurrentStatus MTREFY 1999CommentsAdmission / 100 persons / yr1.6NA0.2Contraceptive Acceptor Rate(CAR) / ContraceptivePrevalence Rate (CPR)Proportion of births attendedby skilled health personnel21%45%28%12%32%16%11Pentavalent coverage(DPT3)70%80%73%12ART coverageNA150,00073,00013NANASee comments14Performance and coverageof community conversationsat different levelPMTCT servicesNAHosp 100%HC 70%See comments15ITNs coverage rateNA20 millionSee comments1617Inpatient case fatality ratesTB: Case Detection RateTB: Treatment success RateImprovement of sanitationaccess rateInstitutions staffed as normsDr / Pop RatioNurse / Pop RatioMidwives / WRA RatioHEW / Pop RatioNA34%81%20%NA50%NA80%1: 67,8211 : 6,0821 : 13,6821 : 26,6871 : 14,000NA1 : 6,7591 : 2,500NA32%85%50%See commentsSee comments1 : 79,2671 : 5,9281 : 19,7341 : 8,608this rate has not increased in recent years. A underreporting is identified as one ofthe reasons, it seems necessary to explore further for possible reasons.The HSDPIII plans to expand family planning service coverage from 21% to 45%.There is a problem to use this coverage figure to monitor progress of CPR, the latteris only being collected through EDHS.The HSDP III target is to increase deliveries attended by skilled birth attendants from12% to 32%. Data from the regions suggest that the great majority of women do notdeliver in a health facility in the presence of skilled health personnel.The original HSPD III target was to increase DPT3 coverage from 61% to 90%.Findings from the regions show that this is on target. Various problems were reportedwith staffing, supervision and maintenance of the cold chain but if these areaddressed then coverage can be achieved.The HSDP III target was to provide ART to 150,000 people. Current estimates arethat over 73,000 are on ART and numbers are increasing.Though no target was set for this objective the review found plenty of evidence thatcommunity conversations are well established and that the health sector is increasingusing this forum to mobilize communities.The HSDP III target is to have PMTCT services available in 100% of hospitals and70% of health centres. Currently many regions have reached the target for hospitalsand through the accelerated expansion plan will soon reach health centre target also.Over 20 million ITNs have been distributed throughout malaria endemic parts. Astudy is underway to assess ITN utilization but it was unavailable at the time of theMTR.Not availableTreatment success rates are improving in most regions but low detection rates arestill a major concern and require follow-up.The HSDP III target is to increase latrine coverage from 20% to 80%. In manyregions coverage had reached over 50% and plans for expansion are in place.There is a need to revise staffing standards as per designation of health facilities.HSDP III sets some norms, such as 1 HEW to 2,500 people, increase ratio ofmidwives to WRA from 1:13,682 to 1:6,759. Results in EFY 1999 show the Dr/PopRatio and the Midwives/WRA Ratio both decreasing, while Nurse/Pop Ratio andHEW/Pop Ratio are improving.9Output101819OutputEthiopia MTR HSDP III Final, Executive Summary, 4-5-2009xii

Administrative Map of Ethiopia: Regions and Zones, 2007Ethiopia MTR HSDP III Final, Executive Summary, 4-5-2009xiii

Executive Summary1. OVERALL HSDP III PERFORMANCEIntroductionBetween the 5th May and 7th June 2008 (EFY 2000), the year of the Ethiopian Millennium, amultidisciplinary team of 38 national and nine international consultants studied the mid-termperformance of the HSDP III (1998-2003). The team worked on the basis of a Terms ofReference (TOR), endorsed by the Joint Core Coordinating Committee (JCCC) and theCentral Joint Steering Committee (CJSC). In the first week, the team reviewed a multitude ofdocuments and prepared (with relevant inputs from JCCC) an exhaustive questionnaire (bylevel and by component).In the second and third week, six teams with experts in service delivery, support systems andfinance/governance visited and interviewed responsible staff in all the regions and in the twocity administrations. They also visited training institutions, regional Bureaus of Finance andEconomic Development (BOFED) and other relevant authorities. In all regions, care wastaken to visit at least two Weredas (a strong versus a weak one). Interviews were conductedwith health managers at all levels, Health Extension Workers (HEW), trainers of HEWs andmidwives. Feedback was provided on findings, challenges, conclusions andrecommendations to all Heads and their staff in the 11 regional health bureaus (RHB).During the visits, all teams drafted their regional reports, using a pre-established format. Thesame format was used during their debriefings with the RHB staff.Back in Addis Ababa (week four), the teams debriefed each other in the presence ofrepresentatives of the Federal Ministry of Health (FMOH), Development Partners and CivilSociety Organizations. The regional reports were circulated among all team members(Annex II). This formed the basis for the zero draft of the main report. The main report wasinternally discussed and validated by all team members in week five. Finally, the key findingsof the main report’s first draft were presented to the FMOH Management Team and theJCCC.Limitations of the MTRReviewing a complete sector that provides health care and support to more than 80 millionpeople in a period of five weeks is by definition limited in scope and depth. Other limitationsrelate to the lack of information on the functioning of the private and NGO sectors, the highturnover of health staff, and the inability to travel to the more remote and poorer areas of thecountry. Finally, in some instances, the reliability of national and regional data appearedquestionable. Nevertheless these are the only sources available, along with the Ethiopianand Demographic Health Survey (EDHS). For these reasons, gaps or incomplete informationmay be found in various parts of the report.AcknowledgementsThe MTR team would like to express its gratitude to the Minister of Health, His Excellency DrTedros Adhanom G/yesus for his dedicated leadership and stimulating support to the reviewprocess. Gratitude goes also to the two State Ministers, His Excellency Dr Kebede Workuand His Excellency Dr Shiferaw Teklemariam for their time and their vision on theperformance and future of HSDP. Warm thanks goes to all staff of the Ministry, the RHBs,the zonal health departments (ZHD), the Wereda health offices (WORHO) and the HEWsworking at kebele level for taking the time to respond to the multitude of questions. We havetried to bring their views and concerns as much as possible into this report.Ethiopia MTR HSDP III Final, Executive Summary, 4-5-2009xiv

Leadership and VisionIn reviewing the HSDP III performance over the last 2½ years, the MTR team found thathealth staff at all levels, demonstrated a strong commitment and vision to achieve itsobjectives. The FMOH, under the inspiring leadership of His Excellency, the Health Minister,his two State Ministers and his team of senior managers, has shown dedicated leadershipand an impressive dynamism. With its concerted energy, the FMOH has set in motion a widevariety of innovations that are now in the process of being implemented. These innovationsinclude: the Business Process Re-engineering (BPR) of some of the most importantdepartments, the Civil Service Reform Programme (CSRP), the accelerated expansion of thehealth infrastructure (health posts and health centres), the massive training and deploymentof HEWs, the start of an impressive bottom-up planning exercise by the WORHOs (the ‘CorePlan’) and the development of a community health insurance strategy for the country. Inaddition, important management initiatives have been put in place, such as the weekly,senior, management meetings, the bi-monthly meetings with all the heads of the RHBs andthe improvements in hospital management. Together, these initiatives have led to the settingof very ambitious targets, summarized by His Excellency, the Health Minister as follows: “Inthis initial phase we aim for High Speed, Big Volume and Minimal Quality”.From a bird’s eye view of the health sector, the MTR team concludes that the FMOH hasinitiated bold and courageous steps, aimed at achieving the HSDP III targets. FMOH hasshown committed leadership and impressive management practice over the last three years.Many examples of these initiatives will be discussed in the following sections of this report,but first the question, asked by His Excellency

Ethiopia MTR HSDP III Final, Executive Summary, 4-5-2009 v Figures Figure 2.1 Funding for Family Health 24 Figure 2.2 Ethiopia New Sputum Smear PTB Case Detection Trend 1998-2000 (EC) 40