J.3_Appendix_3.0_-_Health_Sector_Transformation_Plan.pdf

Health Sector Transformation Plan

The Federal Democratic Republic of Ethiopia Ministry of Health

HSTP

HSTP

2015/16 - 2019/20

(2008-2012 EFY)

October 2015

Contents Acronyms

Foreword by the Minister of Health

Executive summary

Chapter 1: Introduction

Chapter 2: Country Context

Chapter 3: Performance of the Health Sector Development Programme (HSDP) – Situational Assessment

3.1. Community Ownership – the center of remarkable achievement

3.2. Health Status – Impact and Outcome Analysis

3.2.1. Overall health outcome: Life Expectancy and Demographic Dividend

3.2.2. Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health (RMNCAYH) ...23

3.2.2.1. Maternal and child health MDG performance

3.2.2.2. Child health services

3.2.2.3. Maternal health services

3.2.2.4. Family Planning:

3.2.2.5. Adolescent and youth friendly reproductive health

3.2.3. Nutrition

3.2.4. Prevention and control of major disease burdens

3.2.4.1. HIV/AIDS, Tuberculosis and Malaria - MDG 6 Performance

3.2.4.2. HIV/AIDS Prevention and Control Services

3.2.4.3. Tuberculosis and Leprosy Prevention and Control services;

3.2.4.4. Malaria Prevention and Control Services

3.2.4.5. Non-Communicable Diseases (NCD)

3.2.4.6. Mental Health

3.2.4.7. Injuries

3.2.4.8. Neglected Tropical Diseases - NTDs

3.2.4.9. Eye Health

3.2.5. Hygiene and environmental sanitation

3.2.6. The unfinished agenda to further improve health status

3.3. Processes and Inputs

3.3.1. Health Extension Program

3.3.2. Process of improving quality and access to health services

3.3.3. Public Health Emergency Preparedness and Response

3.3.4. Health Information System

3.3.5. Health workforce

3.3.6. Pharmaceuticals Supply Chain and Logistics Management

3.3.7. Infrastructure and ICT

3.3.8. Health Care Financing

3.3.9. Regulation

3.3.10. Leadership, Management and Governance

3.4. Situational Analysis from perspective of Equity

3.5. Lessons Learned from HSDPs

3.6. Key successes and their contributing factors in the health sector

Chapter 4: Health Sector Transformation Plan

4.1. The Structure of HSTP:

4.2. The Policy Framework

4.3. The Health Sector Strategic Assessment

4.3.1. Vision of the Health Sector:

4.3.2. Mission of the Health Sector

4.3.3. Core Values and Guiding Principles of the Health Sector:

4.3.4. Strengths, Weaknesses, Opportunities and Threats - SWOT Analysis

4.3.5. Stakeholder Analysis

4.4. Strategy of HSTP

4.4.1. Customer Value Proposition

4.4.2. Strategic Themes and Strategic Results

4.4.3. Strategic Perspectives

4.4.4. The Health Sector Strategic Management House

4.5. Strategic Objectives (SO) and Strategy Map

4.5.1. List of Strategic Objectives

4.5.2. Objective Commentary

4.5.3. Strategy Map

4.6. Performance Measures and Strategic Initiatives

4.6.1. C1: Improve Health Status

4.6.2. C2: Enhance Community Ownership

4.6.3. F1: Improve efficiency and effectiveness

4.6.4. P1: Improve Equitable Access to Quality Health Services

4.6.5. P2: Improve Health Emergency Risk Management

4.6.6. P3: Enhance Good Governance

4.6.7. P4: Improve Regulatory System

4.6.8. P5: Improve Supply Chain and Logistic Management

4.6.9. P6: Improve Community Participation and Engagement

4.6.10. P7: Improve Resource Mobilization

4.6.11. P8: Improve Research and Evidence for Decision-Making

4.6.12. CB1: Enhance use of Technology and Innovation

4.6.13. CB2: Improve Development and Management of HRH

4.6.14. CB3: Improve Health Infrastructure

31.1.1. CB4: Enhance Policy and Procedures

4.7. The Transformation Agenda

4.7.1. Quality and Equity in Health Care

4.7.2. Information Revolution

4.7.3. Woreda transformation

4.7.4. An agenda for developing Caring, Respectful and Compassionate health professionals 117

Chapter 5: HSTP Costing and Financing

5.1 Costing

5.2 Fiscal Space Analysis and Fnancing Projections

5.3 Funding Gap

Chapter 6: HSTP Implementation Arrangement

6.1. Health Service Delivery Arrangement

6.2. HSTP Governance

6.3. Planning and Budgeting

6.4. Inter-sectoral Collaboration and Public-Private Partnership

6.5. Risk Mitigation Strategy

Chapter 7: HSTP Monitoring and Evaluation Framework

7.1. Measuring progress towards Universal Health Coverage: the focus on equity and quality 150

7.2. Transforming data into information and information into action: the data cycle

Annex 1: The Indicators and Targets for HSTP Monitoring

Acronyms

AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ARI Acute Respiratory Illness ART Anti-Retroviral Therapy ARV Anti-Retroviral BCC Behavioral Change Communication BPR Business Process Reengineering CDC Communicable Disease Control C-IMCI Community Integrated Management of Childhood Illnesses CSOs Civil Society Organizations DHS Demographic and Health Survey DNA PCR Deoxyribonucleic Acid Polymerase Chain Reaction EDHS Ethiopian Demographic and Health Survey EFY Ethiopian Fiscal Year EHNRI Ethiopian Health and Nutrition Research Institute EmONC Emergency Obstetrics and Newborn Care eMTCT Elimination of Mother-To-Child Transmission of HIV EOC Emergency Operations Center EPHI Ethiopian Public Health Institute EPI Expanded Program on Immunization EQA External Quality Assurance ESPA+ Ethiopia Service Provision Assessment Plus FDRE Federal Democratic Republic of Ethiopia FMHACA Food, Medicine and Health Care Administration and Control Authority GDP Gross Domestic Product GIS Geographic Information System GOE Government of Ethiopia GTP Growth and Transformation Plan HDA Health Development Army HCT HIV Counseling and Testing HEP Health Extension Programme HEWs Health Extension Workers HIS Health Information System HIV Human Immunodeficiency Virus HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome HMIS Health Information Management System HR Human Resource HSDP Health Sector Development Programme HSS Health System Strengthening HSTP Health Sector Transformation Plan ICCM Integrated Community Case Management

ICT Information Communication and Technology IDSR Integrated disease surveillance and response IEC Information Education Communication IFMIS Integrated Financial Management System IHP International Health Partnership IMNCI Integrated Management of Newborn and Childhood Illnesses IMR Infant Mortality Rate IPFS MIS Integrated Pharmaceuticals Fund and Supply Management Information

System IRS Indoor Residual Spray IRT Integrated Refresher Training ISS Integrated Supportive Supervision ITN Insecticide Treated Net IYCF Infant and Young Child Feeding JANS Joint Assessment of National Health Strategies JCCC Joint Core Coordinating Committee JSC Joint Steering Committee KM Knowledge Management KMC Kangaroo Mother Care LB Live Births LLIN Long Lasting Insecticidal Net LMIC Lower Middle Income Countries M&E Monitoring and Evaluation MARPs Most At Risk Populations MCH Maternal and Child Health MDG Millennium Development Goal MDG PF MDG Performance Fund MDGs Millennium Development Goals MDSR Maternal Death Surveillance and Response MICs Middle Income Countries MIS Malaria Indicator Survey MMR Maternal Mortality Ratio MNCH Maternal, Neonatal, and Child Health MOFED Ministry of Finance and Economic Development MoH Ministry of Health MTCT Mother-To-Child Transmission of HIV NBB National Blood Bank NCD Non Communicable Disease NGO Non-Governmental Organization NHA National Health Accounts NMR Neonatal Mortality Rate OHT OneHealth Tool OI Opportunistic Infections OOP Out of Pocket

OPD Out-patient Department OVC Orphans and Vulnerable Children PASDEP Plan for Accelerated and Sustainable Development to End Poverty PFSA Pharmaceuticals Fund and Supply Agency PHC Primary Health Care PHCU Primary Health Care Unit PHEM Public Health Emergency Management PLHIV People Living With HIV PMQI Performance Monitoring and Quality Improvement PMTCT Prevention of Mother to Child Transmission PNC Post Natal Care PPA Public Procurement Agency PPP Purchasing Power Parity PRSP Poverty Reduction Strategic Paper QA Quality Assessment RHBs Regional Health Bureaus RMNCAYH Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health SAM Severe Acute Malnutrition SBA Skilled Birth Attendants SHI Social Health Insurance SLMTA Strengthening Laboratory Management Towards Accreditation SNNPR Southern Nations & Nationalities and Peoples Region SO Strategic Objective SRH Sexual and Reproductive Health STD Sexually Transmitted Disease STI Sexually Transmitted Infection TB Tuberculosis TT Tetanus Toxoid U5MR Under Five Children Mortality Rate UHC Universal Health Coverage UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNICEF United Nations Children’s Fund USAID United States Agency for International Development VCT Voluntary Counseling and Testing VERA Vital Events Registration Agency VIA Visual Inspection with Acetic Acid VNRBDs Voluntary, non-Remunerated Blood Donations WBP Woreda Based Planning WHO World Health Organization WMS Welfare Monitoring Survey WoHO Woreda Health Office ZN Ziehl–Neelsen

Foreword by the Minister of Health

Ethiopia has implemented successive Health Sector Development Plans (HSDPs) since 1997 in four phases. During this period, our country has made huge strides in improving access to health services and improvements in health outcomes. Ethiopia’s health indicators have been remarkably improved from one of the worst in Sub-Saharan Africa to amongst the stand out performers in just two decades. The lives of millions of children have been saved, millions of new infections and death from communicable diseases such as HIV, malaria, and tuberculosis have been averted. All this was done while building a health system that can sustain the gains over the long term.

Despite the impressive progress made, Ethiopia still has high rates of morbidity and mortaility from preventable causes.

There is also disparity in uptake and coverage of high impact interventions amongst different regions and woredas. The quality of health care in terms of improving patient safety, effectiveness, and patient-centeredness, in both public and private facilities, is often inconsistent and unreliable.

The health sector transformation plan, in line with our country’s second growth and transformation plan (GTPII), has set ambitious goals to improve equity, coverage and utilization of essential health services, improve quality of health care, and enhance the implementation capacity of the health sector at all levels of the system. A focus in quality and equity requires a shift in the status quo to drive improvements at national scale over the next five years. A national health care quality strategy will be developed to guide our investment towards safer, more effective, more accessible, and more equitable care for every Ethiopian by 2020. We will also produce annual reports about the state of health inequality in Ethiopia to bring political attention and accountability in the sector.

Reproductive, maternal, newborn, child, adolescent health and nutrition will continue to be top priority for the next 5 years. As indicated in the sustainable development goals (SDG), Ethiopia will intensify RMNCAH interventions to end preventable maternal and child deaths by 2030. The targets set in the HSTP are in line with the global aspirations.

The fight against communicable diseases is not over yet. We will focus on the most at risk population groups to combat HIV. The fast-track cities initiative towards 90-90-90 will also be implemented to reach all people living with HIV, put and retain them in treatment, and achieve viral suppression. Efforts will also be strengthened to improve case detection and cure rate of all forms of TB. The risk of multi-drug resistant TB is also on the rise. In addition to prevention strategies, investments will be made to improve access to diagnostic and treatment facility. Ethiopia aspires to achieve subnational elimination of malaria from its mid and low lands in the eastern part of the country. While malaria control measures will be scaled up and sustained, the country will implement strategies to pave the way for malaria-free Ethiopia by 2030. The government of Ethiopia has demonstrated its political committment to fight neglected tropical diseases. Further integrated investments will be made to significantly reduce the burden of NTDs.

Non communicable diseases and injury are also on the rise and fast becoming major public health problems. Prevention strategies will be designed and implemented by integrating the interventions into existing health infrastructure. National scale up and integration of mental health services into primary health care will also be implemented.

The promotion of hygiene and sanitation through the health extension program will be strengthened to scale-up open defecation free kebeles. A national sanitation marketing strategy will be implemented to generate demand and create access to supplied for construction of improved latrines. A special attention will be given for urban sanitation and a multisectoral approach will be used to address the complex sanitation isssues in our cities.

A significant investment will be made to improve our capacity for health emergency risk management.

The investment will focus on creating capability to prevent, detect, and contain potential outbreaks.

We will build workforce with the aim of boosting the standing and surge capacity to manage health emergencies in our country.

In the HSTP, we have identified four interrelated transformation agendas. These are transformation of quality and equity of health care, woreda transformation, a movement towards compassionate, respectful, and caring health professionals, and information revolution. We believe that the successful implementation of the transformation agendas will help achieve the stretched targets we set in the

HSTP.

The HSTP builds upon the sucesses and challenges of the successive HSDPs implemented over the last 20 years. With the endorsement of SDGs, and global focus on sustainable development, I believe that Ethiopia is well positioned to push for attainement of these global development goals. As the chinese saying goes, ‘May you live in interesting times.’ This is indeed an interesting time. Hence, I call up on our people, health professionals, civil societies, development partners and all stakeholders to put a coordinated effort to realize the HSTP goals.

I have no doubt that with the unwaivering political committment of our government, engagement and ownership of health programs by the community, the steadfast committment of our health workers for our people, and the support of our development partners, we will prevail in succeding to meet the HSTP goals.

Kesete-Birhan Admasu

Minister

Executive summary In the past two decades, the Government of Ethiopia has invested heavily in health system strengthening guided by its pro-poor policies and strategies resulting in significant gains in improving the health status of Ethiopians. As a result, Ethiopia has done remarkably well in meeting most of the MDG targets.

Among the notable achievements include achievement of MDG-4 with a 67 percent drop in under-five mortality from the 1990 estimate, that contributed to an increase in average life expectancy at birth from 45 in 1990 to 64 in 2014. A 69 percent decrease in maternal mortality from a high estimated base of 1400 per 100,000 live births. An improvement in contraceptive prevalence rate from 3% to 42% has led to a drop in total fertility rate from 7.7 in the 1990s to 4.1 in 2014.

Mortality and morbidity due to HIV/AIDS, Tuberculosis and malaria has reduced markedly. Death due to malaria has declined with a significant decrease in admissions and deaths of under-five children by 81% and 73% respectively. Generalized malaria outbreak has not been witnessed for the last decade. HIV new infection has dropped by 90% and mortality cut by more than 50% among adults. Besides, Ethiopia is one of the few sub-Saharan African countries with “rapid decline” of mother-to-child transmission of HIV,with a reduction by 50% of new HIV infections among children between 2009 and 2012. Similarly the country has achieved the targets set for tuberculosis prevention and control. Mortality and prevalence due to Tuberculosis has declined by more than 50% and incidence rate is falling significantly. The decline in mortality was profound from 2005 onwards partly due to TB/HIV collaborative activities, including the initiation and scaling up of free ART services.

The significant gains made are as a result of the political commitment and strong leadership at all levels of government, community engagement and ownership of health programs, and the unprecedented support from development partners. The country’s flagship Health Extension Programme has been the principal vehicle in expanding access to essential health services packages to all Ethiopians, with specific focus on women and children. It has also been the primary vehicles to drive improvements in hygiene and sanitation. More than 38,000 HEWs have been trained and deployed all over the country, availing two HEWs in every Kebele (a cluster of villages). Health extension workers are tasked to transfer knowledge and skills to families they serve so that households have better control over their own health. This philosophy of training and graduating model families, who have demonstrated behaviour change and improved uptake of high-impact health interventions, have been scaled up to reach close 3 million families across the country. A health development army that mobilizes these model families to enhance community engagement and solidarity movements has been established during HSDPIV.

Despite the varying degree of success in different localities, the HDA has proved to be a successful strategy to engage community, identify locally salient bottlenecks that hinder uptake of services, and scaling up best practices.

Over the last 20 years, the country has succesfuly implemented its strategy of expanding and rehabilitating primary health care facilities. To this effect, 16,440 health posts, 3,547 health centers and 311 hospitals have been constructed. In parallel to the construction of health facilities, investment in human resource development and managemnt has been scaled up; reformed supply chain and logistics managment to ensure continuous availability of health commodities at an affordable price in a sustainable manner; and strengthen coordination and partnership.

Though good trends are observed, the country is still facing a triple burden of diseases consisting of communicable diseases, non-communicable diseases and injuries. This burden coupled with the ever increasing demand urges the Government to be increasingly focused on addressing equity in access to health care, quality in health services provision and in strengthening community engagement and ownership in health decision-making and management.

Building on the lessons learned in implementing the earlier plans and to be highly responsive to the current socioeconomic landscape, the Government of Ethiopia has developed Health Sector Transformation Plan (HSTP), which is part of the second Growth and Transformation Plan(GTP II). HSTP is also the first phase of the 20-year health sector strategy called ‘Envisioning Ethiopia’s Path to Universal Health Care through strengthening of Primary Health Care’.

The overall desire of The Government of Ethiopia is to have the highest possible level of health and quality of life for all its citizens, attained through providing and regulating a comprehensive package of promotive, preventive, curative and rehabilitative health services of the highest possible quality in an equitable manner. This goal will be attained by the government’s effort enhanced with community empowerment.

The Health Sector Transformation Plan (HSTP) has three key features: quality and equity; universal health coverage and transformation. The HSTP sets out four pillars of excellence which are believed to help the sector to achieve its mission and vision. These are:

1. Excellence in health service delivery

2. Excellence in quality improvement and assurance

3. Excellence in leadership and governance

4. Excellence in health system capacity

These four areas of excellence are further decomposed in to fifteen strategic objectives categorized under two driver perspectives (business process and learning and growth) and two results (community perspective and financial stewardship). The strategic objectives are linked each other with a cause-effect relationship and every strategic objective has set of performance measures and strategic objectives.

The impact-level targets of HSTP by 2020 is to reduce MMR to 199/100,000LB; reduce under five-year, infant and neonatal mortality rates 30, 20 and 10 per 1,000 live births respectively; reduce stunting, wasting and under-weight in under-5 year to 26%, 4.9% and 13%, respectively; reduce HIV incidence by at least 60% compared with 2010 and achieve zero new infections among children; reduction in number of TB deaths and incidence rate by 35% and 20% respectively compared with 2015 and reduce malaria case incidence and mortality by at least 40% each compared with 2015. It has also set target to stabilize and then reduce deaths and injuries from road traffic accidents.

To acheive these and other impact and outcome targets set for the coming five years, a list of strategic initiatives are set such as:

• High impact interventions of RMNCAYH, nutrition, prevention and control of communicable and non-communicable diseases;

• Initiatives to improve quality and equity,

• Initiatives to improve health emergency risk management: education and information to build culture of health, safety and resilience at all levels; regular risk assessment and early warning;

development of public health risks profile maps for each woreda; emergency preparedness for effective health system response and recovery at all levels; establishing Emergency Operations Center (EOC); developing a national health emergency workforce with the right skill mix to enhance standing and surge capacity of the country to respond to emergencies

• Initiatives for community engament and ownership: model kebele graduation; certificate of competency evaluation of households based on HEP standards; self-reliance movements; health literacy and health systems literacy of the public; rollout and expansion of the Health Development Army; roll out the second generation health extension programme

• Initiatives to improve efficiency and effectiveness: financial management; transparency and accountability development program; regular financial and performance audits; efficiency gain;

efficient facility revenue utilization; implementation of SHI and CBHI

• Initiatives to make positive contribution to the socio-economic development and accelerate progress towards health outcomes –promoting health in all policies and strategies; strengthening multi-sectoral coordination and regional and global partnership;

• Initiatives to enhance good governance: enhancing leadership capacity; establishing public health leadership incubation center; accountability and transparency; community representation at health facility governing boards and regular town hall meetings and public conferences;

• Initiatives to improve regulatory systems, supply chain and logistics management, research and evidence for decision making, use of technology and innovation, development and management of human resource for health and health infrastructure

Having all the strategic objectives and strategic initiatives for the coming five years, HSTP has also identified four transformation agendas that will help the sector to be transformed:

1. Transformation in equity and quality of health care – This is central to HSTP. The substantial inequalities still existing in health outcomes based on differences in economic status, education, place of residence and gender need to be addressed. During implementation of the HSTP, efforts will be doubled up to ensure equity in health care, which has the following important elements;

• Equal access to essential health services,

• Equal utilization of equal need, and

• Equal quality of care for all

Therefore, the success of HSTP will mainly be measured by the quality of health service and how equitable the health outcomes are. A detailed roadmap with innovative strategies will be developed to ensure that every Ethiopian is reached with essential, quality services. The possibility of establishing a centre or institute for health equity will also be explored.

2. Information revolution – this is reforming the methods and practice of collecting, analyzing, presenting and disseminating information. It is a radical shift from traditional way of data utilization to a systematic information management. It includes advancing the data collection, aggregation, reporting and analysis practice; promoting the culture of information use at place of generation; harnessing ICT; improving data visibility and access; and strengthening verification and feedback systems.

3. Woreda transformation – Woreda health offices need to be transformed into high-performing entities that translate the national aspirations into a reality. Therefore, woreda transformation aims at narrowing the gap between the high and low performing woredas. It has three components: Model Kebeles, financial protection through CBHI and high performing PHCUs.

4. The Caring, Respectful and Compassionate health workforce – this is multi-pronged approach and is a that calls for a mechanism to persistently remind health professionals the values, hopes, and aspirations that brought them into healthcare. It’s a movement that requires champions who identify themselves with their profession and take pride by helping people. It also requires a culture change and a change in attitude, manner, and approach of health care delivery.

The overall costing for HSTP implementation is prepared in two scenarios: base and high case scenario with a total cost of 15.6 billion USD and 22 billion USD, respectively. The targets of HSTP are related to the base case scenario and the resource gap under this scenario is estimated to be 21%.

In general, the ultimate purpose with this plan is to improve the health status of the peoples of Ethiopia in an equitable manner. The HSTP is cascaded to all levels and will be translated into annual operational plans using the Woreda-based health sector annual plan. Its implementation will be consistently monitored using the agreed monitoring framework in a coordinated manner.

Chapter 1 Introduction

Chapter 1: Introduction

The Ethiopian health sector successfully concluded 20 years of the National Health Sector Development Programme (HSDP) divided into four series of five-year HSDPs I to IV commencing in 1997. HSDP IV, which has been part of the first Growth and Transformation Plan (GTP), was the final phase of HSDP which ended in June 2015.

The Health Sector Transformation Plan (HSTP) is the next five-year national health sector strategic plan, which covers EFY 2008-2012 (July 2015 – June 2020). It has been prepared by conducting in-depth situational assessment and performance evaluation of HSDPs; considering the global situation and the country’s global commitment; and most importantly, the goals of the national long-term vision and Growth and Transformation Plan (GTP).

The development of the Health Sector Transformation Plan is guided by a roadmap prepared jointly with all relevant stakeholders under the leadership of the Ministry of Health and Regional Health Bureaus.

The roadmap clearly stipulated the major steps of the development process, planning approach and methodology and communication strategy. It also clearly indicated the roles and responsibilities of all actors giving due emphasis for the involvement of all relevant stakeholders, including the private sector to ensure commitment by all for the implementation of the strategic plan by having a shared vision.

The performance of HSDP has been reviewed critically using its annual performance reviews and relevant reports, including Health Information Management System (HMIS), the Mid-Term Reviews (MTR), the Joint Review Mission reports and different population and facility-based surveys. The review findings showed that the country has made tremendous achievements from implementing high impact interventions mainly through its flagship community focused program known as the Health Extension Programme. The Ministry of Health embarked on an envisioning exercise to develop its next 20-year plan after the HSDP IV mid-term review. The envisioning exercise resulted in a long-term health sector transformation roadmap titled, ’Envisioning Ethiopia’s Path towards Universal Health Coverage through Strengthening Primary Health Care’. The objective of the long-term envisioning exercise was to define a framework for subsequent strategic actions which will enable Ethiopia to achieve the best health outcomes that would be expected of a lower middle income country by 2025 and to achieve at least median health outcomes of an upper middle income country by 2035.

The Health Sector Transformation Plan (HSTP) is therefore the first phase of the ‘Envisioning Ethiopia’s Path towards Universal Health Coverage through Strengthening Primary Health Care’, and part of the second Growth and Transformation Plan (GTP-II) of the country.

A series of consultations were conducted with the private sector, universities, professional associations, other government sectors and development partners including web-based consultations through MoH’s official website. The feedback received from these consultative workshops were carefully documented, reviewed and incorporated accordingly. A Joint Assessment of National Strategies (JANS) was conducted and comments were addressed.

The remainder of this HSTP document is organized as follows: chapter two covers the country context;

chapter three describes the situation analysis that was carried out; chapter four deals with the HSTP strategy; chapter five details the costing and financial gap analysis; chapter six shows implementation arrangement and chapter seven covers the monitoring and evaluation framework.

Chapter 2 Country Context

Chapter 2: Country Context

2.1. Country profile

Ethiopia is the oldest independent and second most populous country in Africa. It has a unique cultural heritage with a diverse population mix of ethnicity and religion. It served as a symbol of African independence throughout the colonial period, and was a founding member of the United Nations and the African base for many international organizations.

2.2. Geography and climate

Ethiopia is located in the North Eastern part of Africa, also known as the Horn of Africa. It borders six countries - Eritrea, Djibouti, Somalia, Kenya, South Sudan and the Sudan. The country occupies an area of 1.1 million square kilometers ranging from 4,620m above sea level at Ras Dashen Mountain to 148m below sea level1 at the Danakil (Dallol) Depression. More than half of the country lies above 1,500 meters.

The predominant climate type is tropical monsoon, with temperate climate on the plateau and hot in the lowlands. There are topographic-induced climatic variations broadly categorized into three:

the “Kolla”, or hot lowlands up to approximately 1,500 meters above sea level, the “Wayna Degas” which range 1,500-2,400 meters above sea level and the “Dega” or cool temperate highlands 2,400 meters above sea level.

2.3. Demographic Profile

Projections from the 2007 population and housing census estimate the total population for the year 2015 to be 90 million (CSA, 2015)2. Ethiopia is the home of a variety of nations, nationalities and peoples with more than 80 different spoken languages. The average size of a household is 4.7.

The pyramidal age structure of the population has remained predominately young with 44.9% under the age of 15 years, and over half (52%) of the population in the age group of 15 and 65 years.

The population in the age group of over 65 years accounts for only 3% of the total population. While the sex ratio between males and females is almost equal, women of reproductive age constitute 23.4% of the population. The average fertility trend has shown significant decline in recent years from the 2000 level of 5.5 births to 4.1 births per woman (EDHS 2014).

2.4. Government and administration

Ethiopia is a federal parliamentary republic, with the Prime Minister serving as head of government.

Executive power is exercised by the government. Federal legislative power is vested in both the government and the two chambers of parliament (Government Communication Affairs Office, 2015)3.

The Ethiopian constitution, introduced in 1995, created a federal government structure composed of nine Regional States: Tigray, Afar, Amhara, Oromia, Somali, Southern Nation Nationalities and Peoples Region (SNNPR), Benishangul-Gumuz, Gambella, and Harari; and two City Administrations council of Dire Dawa and Addis Ababa. The regional states and city administrations are divided

1 http://www.ethiopia.gov.et/web/pages/ethoverview 2 News release of CSA 30th Januray 2015. accessed at http://www.csa.gov.et/images/banners/csa2 3 http://www.gcao.gov.et/web/guest/politics into Woredas (districts) and Kebeles (sub-districts). A Woreda/District is the basic decentralized administrative unit and has an administrative council composed of elected members. Zonal administrations are in place in some populous regions above Woredas as an extended arm of the regional states.

2.5. Socio-economic situation

Over the last decade (2003/4 -2013/14), Ethiopia’s economy has registered rapid growth with a GDP of 10.9% annual average growth rate. In the last four years of Growth and Transformation Plan (GTP) implementation periods (2010/11 – 20013/14), the economy has also registered robust growth with a GDP of 10.1% annual average growth rate. Agriculture, Industry and Service sectors have 6.6%, 20.0%, and 10.7% annual average growth rates, respectively (MOFED, 2014)4. According to Ethiopia poverty assessment, Ethiopian households have experienced a remarkable reduction in poverty rate from 56% of the population living below $1.25 purchasing power parity (PPP) a day to 29% in 2010 (Rio+20, 2012)5; this figure is expected to be much lower at the end of 2015 (about 22 as set in GTP-I).

The Government of Ethiopia has been implementing a comprehensive economic reform program over the past decade. The Government follows a market–based and agricultural led industrialization economic policy for the development and management of the economy. Currently the country is exerting utmost effort to ensure economic transformation from an agricultural to industrial led economy. There have been a number of policy initiatives and measures taken in these directions which included privatization of state enterprises and liberalization of government regulations. The health sector is playing its part as a means of economic growth while benefiting from the economic growth. Among the important features of the economic reform in Ethiopia is empowering women through the creation of an enabling environment for equal opportunity for women to participate in the economic development of the country which is enshrined in the constitution. The Ethiopian Constitution recognizes the principle of equality of access to economic opportunities, employment and property ownership for women. Following this, the government has formulated a national gender policy, which recognizes equality between the sexes and sets up mechanisms for the improvement of women’s condition, such as the establishment of the Ministry of Women’s Affairs. The main strategies employed to implement the national policy include gender mainstreaming in sector and development programs, advocacy and capacity-building initiatives. The health sector is equally committed to strengthening gender mainstreaming at all levels of the health care system through the development of the Gender Mainstreaming manual and supporting its implementation.

Cognizant of the irreplaceable role of the transport sector in economic growth, the government of Ethiopia has spent up to 40% of its capital budget for road construction. As a result, the length of roads has reached 105,000 km, a six-fold increase compared to 1990 road coverage. About 10,765 rural kebeles are connected with the Universal Rural Road Access Program (URRAP), creating better healthcare access to millions of mothers and children who were deprived of such a right before. Similarly, the rural electrification program is benefiting more than 5,100 rural and urban kebeles, paving way to a better life. Connectivity of citizens through modern communication means is showing a prominent stride evidenced by 32 million mobile phone subscribers and a rise in telecom penetration to 37%, thus making Ethiopia one of the top six countries in Africa.

4 http://www.mofed.gov.et/Amharic/Resources/Documents/ESTIMATES%20OF%20GDP%20AND%20OTHER%20MACROECONOMIC%20 INDICATORS_ETHIOPIA%202006%20(2013_14%20EFY).pdf 5 https://sustainabledevelopment.un.org/content/documents/973ethiopia.pdf

2.6. Educational status

It is a well-established fact that education is a key instrument for socioeconomic development and hence considered as one of the basic human rights. According to several studies, people are observed to have differences in health status, exposure to health risks, access to health services and health seeking behavior because of their differences in educational status. Ethiopia has given due emphasis to improving the educational status of its citizens evidenced by massive expansion of primary, secondary and tertiary level educational institutions. There are 21.2 million children in 30,800 primary and 2,333 secondary schools in the 2013/14 academic year (MOE, 2014). As a result, net primary school enrolment (Grade 1-6) reached 99% in 2014, a five-fold increase from the 1990 rate of 19%.

In 2014, more than 1.7 million youth were attending higher education in 1312 Technical and Vocational Education and Trainings (TVETs) and 33 universities. More than 3.5 million adults benefited from adult education program and W.6 million are currently in adult education programs.

Proportion of girls enrolled in primary and secondary education has exceeded 45% in 2014 as a direct result of the GoE’s policy to empower women through enhancing girls’ education.

Performance of the Health Sector Development Programme (HSDP) – Situational Assessment

Chapter 3

Chapter 3: Performance of the Health Sector Development Programme (HSDP) – Situational Assessment

The general situational assessment of the health sector which mainly focuses on the performance evaluation of the twenty-year Health Sector Development Program (HSDP) was organized using the WHO framework for monitoring and evaluation of health system strengthening –HSS (See M&E framework chapter 7). The assessment report starts with the activities performed to enhance community ownership. It then presents the whole performance organized using the results’ chain beginning with the population’s health status and health systems performance (impact and outcome), followed by the health systems’ capacity performance which includes the outputs, processes and finally the inputs and processes.

3.1. Community Ownership – the center of remarkable

achievement

In the last two decades, the government of Ethiopia has been putting tremendous efforts in building pro-poor policies and strategies, to reorient health services towards health promotion, disease prevention, curative services. Throughout these processes, the key concept of community ownership has been emphasized in all HSDPs.

The country’s flagship program, called the Health Extension Programme (HEP), delivers cost-effective basic services to all Ethiopians, mainly women and children. HEP is underpinned by the core principle of community ownership that empowers communities to manage health problems specific to their communities, thus enabling them to produce their own health

The Government believes that the GTP targets can be achieved by organizing citizens voluntarily into functional Development Armies. To this end, the Ministry of Health uses the Health Development Army (HDA) mechanism to organize community and health workers. HDA mobilizes families, mainly women, to scale-up best practices gained from the HEP and ensure wider community participation in facilitating community ownership. HDA implementation started in Ethiopian fiscal year (EFY) 2003, with progress being made in the organization and network formation over the past three years. According to MoH’s annual report, a total of 442,773 HDA groups with 2,289,741 one-to-five networks were formed in EFY 2006. Although, the mechanism of reaching every household and community through the Health Development Army is a relatively recent initiative started during HSDP IV, evidence shows that in areas with advanced HDA networks, the coverage of key health interventions has improved significantly including institutional delivery. However, appropriate organization and capacity building of HDA remains a challenge in some parts of the country.

The concern is that such inequalities in HDA networks may later be reflected in inequalities of access to services and subsequently in health outcomes. In particular, the implementation of the HDA initiative in developing regions (Afar, Benishangul-Gumuz, Gambella and Somali), and urban areas is yet at its infancy. Fine tuning implementation based on evidence, recognition of excellent implementers, tailored training, strengthening the HEP and primary health care unit (PHCU) link and keeping the momentum with the required political commitment, is critical in scaling up and sustaining HDA gains.

3.2. Health Status – Impact and Outcome Analysis

The impact analysis deals with some vital indicators such as mortality, morbidity, life expectancy, as well as inequalities, whenever information is available. It mainly focuses on progress made to date and challenges encountered in achieving the health specific Millennium Development Goals and addressing other prominent health problems.

3.2.1. Overall health outcome: Life Expectancy and Demographic Dividend Due to the reduction of morbidity and mortality mainly in child mortality coupled with improvement in social determinants of health, Ethiopians have begun to live longer as evidenced by the improvement with the estimated average life expectancy at birth to 64 years from that of 45 in 1990. This makes Ethiopia one of the six countries which have made top individual gains since 1990. The healthy life of Ethiopians is estimated to be 55 years, indicative of 9 years being compromised with morbid diseases or health conditions which calls for improvement in the quality of life and extending individuals’ life expectancy.

Life expectancy at 60 years of age has also increased to 18 years in 2012, a three year rise from the 1990 estimate. The probability of dying between 15-60 years of age per 100,000 populations (Adult mortality rate) has decreased by more than 42% in females and 47% in men based on the 1990’s estimate (World Health Statistics Report, 2014).

As a result of Ethiopia’s commitment to reducing infant and child mortality, improving reproductive health and family planning, and the subsequent fertility decline, the country is on the right path to a population age structure that may enable a demographic dividend.

The total dependency rates of Ethiopia were 94.6, 92.9 and 80.6% in 1994, 2007 and 2012 respectively. Breaking this into young and old dependencies, one can observe from the three censuses conducted that the young dependency rates were 88.4, 86.8 and 75% in 1994, 2007 and 2012, respectively, while the old dependency rates were 6.2, 6.1 and 5.6 respectively in the above census years. All the three dependency rates, showed a declining trend from 1994 to 2012. The trend in the size of the working age population of the country showed progressive increase from 51.1% to 55.4% between in 1994 and 2012. It has shown a

0.7 percentage point increase between 1994 and 2007 and a 3.6 percentage point increase between 2007 and 2012. Such an increase calls for appropriate policy of creating adequate job opportunities to benefit from the demographic dividend. Urban unemployment rate is about 17.4% (CSA, 2014). The corresponding rates for males and females were 11.3 percent and 24.1 percent respectively.

3.2.2. Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health

(RMNCAYH)

3.2.2.1. Maternal and child health MDG performance

Reduction of Child Mortality-MDG 4:

According to the 2014 World Health Statistics Report, Ethiopia has achieved MDG 4 target three years earlier by reducing under-five mortality by 67% from the 1990 estimate. The UN Inter Agency Group’s 2013 mortality estimate reported that Ethiopia’s under-five, infant and neonatal mortality rates were 68, 44 and 28 per 1000 live births respectively.

From 1990 to 2000, the average Annual Reduction Rate (ARR) of U5MR was at 2%, which accelerated to 5% since 2000. Notwithstanding the achievement observed in the reduction of under-five mortality rates, about 190,000 children are still dying each year.

Moreover, the reduction in mortality in neonatal age groups (48%) is not as impressive as that of childhood mortality.

The major causes of under-five mortality, based on the 2014 WHO/CHERG estimates for Ethiopia, are acute respiratory infection (ARI) (18%), diarrhea (9%), premature births (11%), sepsis (9%), birth asphyxia (14%), meningitis (6%), injury (6%), measles (3%) and others (21%). Malnutrition underlies nearly 50% of under-five deaths. Prematurity (37%), infection (28%), and asphyxia (24%) are the most common causes of death in neonates.

Neonatal conditions which used to account for a quarter of under-five deaths in 2004 have recently increased to 43% while deaths due to malaria, measles, HIV, diarrhea and pneumonia have declined (The Lancet, 2012). Moreover, there is wide geographic and socio-economic variation in under-five mortality rates. According to the EDHS 2011, it ranges from as low as 53/1000 live births in Addis Ababa to as high as 169/1000 live births in Benishangul-Gumuz region. Additionally, there is a strong association of newborn and child mortalities with wealth, maternal educational status, residence, maternal fertility characteristics and access to safe water and sanitation.

Improve Maternal Health –MDG 5:

According to UN estimates, Ethiopia has so far reduced maternal mortality by 69% from the 1990s estimate with annual reduction rate of 5% or more. According to the latest UN estimate, the proportion of mothers dying per 100,000 live births has declined from 1400 in 1990 to 420 in 2013.. However, EDHS 2005 and 2011 reported maternal mortality rate of 673 and 676 per 100,000 live births respectively, indicating no change between the two surveys. Another report from Lancet (2014) estimated that maternal mortality was 497 in 2013. Significant variation in estimating maternal mortality is observed in different studies, calling for more robust and locally generated information. However, a reduction was observed in maternal mortality in all the studies with different magnitude of reduction.

Hemorrhage, hypertension in pregnancy, abortion and sepsis are the leading causes of maternal deaths, which can only be averted through skilled institutional care.

3.2.2.2. Child health services

The achievements in child health are mostly attributable to large scale implementation of promotive, preventive and curative primary health care interventions alongside a positive trend of socioeconomic changes. These include: IMNCI/ICCM 6(currently being provided in more than 2500 health centers and 12,000 health posts); prevention and management of malaria (with 65% of under 5 children sleeping under insecticide treated nets (ITN) with indoor residual spray (IRS) reaching 47% of houses in endemic areas in 2011); community based nutrition programs and establishment of Neonatal Intensive Care Units. Notwithstanding current improvements, coverage of some other essential interventions such as proper case management of acute respiratory illness (ARI) and diarrhea have been low. In the 2011 EDHS, only 27% of children under age of five with symptoms of ARI sought counseling from a health care facility or provider. Similarly, one-fourth of children with fever and 32% with diarrhea sought care from a health care facility or provider.

The dramatic increase in immunization coverage has also significantly decreased fatalities associated with vaccine preventable diseases. Currently, Ethiopia is providing 10 antigens targeting major killer diseases during childhood. Four new vaccines (PCV 10, Rota and Penta) were introduced since 2007 in addition to the already existing six traditional antigens. The introduction of these new vaccines coupled with ICCM programs and expansion of the Health Extension Programme is expected to further lower childhood morbidity and mortality due to pneumonia and diarrhea. The recent HMIS report of EFY 2006 showed that the coverage of Pentavalent 3, PCV3 and Measles vaccines coverage have reached 91.1%, 85.7% and 86.5% respectively. Fully immunized children under one year of age also reached 82.9% in EFY 2006. Though the coverage is improving, the program is challenged with dropouts, shortage of supplies, vaccine stock out and cold chain breakages.

Availing newborn corners at health centers, establishing neonatal intensive care units in hospitals and more recently, the expansion of community based newborn care by health extension workers (HEWs) is ongoing and expected to contribute to a decrease in neonatal mortality. However, there is still a gap in availing quality health services for newborns in many facilities. Neonatal ICUs are also ill equipped and have yet to expand.

The limited competency of midwives, doctors and anaesthetists in the provision of emergency obstetrics and new born care (EmONC) services, lack of a separate newborn corner, absence of a neonatal…