Camera Ready MTR HSTP 2008 - 2012 EFY.pdf

COMPREHENSIVE REPORT

MID-TERM REVIEW

VOLUME I

BY THE INDEPENDENT REVIEW TEAM

DECEMBER 2018

ETHIOPIA’S HEALTH SECTOR

TRANSFORMATION PLAN

(HSTP) (2015/16-2019/20 GC

OR 2008 – 2012 EFY)

FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA

MINISTRY OF HEALTH

FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA

MINISTRY OF HEALTH

COMPREHENSIVE REPORT

MID-TERM REVIEW

VOLUME I

BY THE INDEPENDENT REVIEW TEAM

DECEMBER 2018

ETHIOPIA’S HEALTH SECTOR TRANSFORMATION PLAN

(HSTP) (2015/16-2019/20 GC OR 2008 – 2012 EFY)

COMPREHENSIVE REPORT

VOLUME I

CONTENTS

ABBREVIATIONS AND ACRONYMS V

PREFACE VII

ACKNOWLEDGEMENTS IX

EXECUTIVE SUMMARY X

1 INTRODUCTION 1

1.1 Background

1.2 Objective and Deliverables of the HSTP MTR

1.3 Overall Methodology

1.4 Sampling of Regions, Zones and Woredas

1.5 Organization of the HSTP MTR team

1.6 Limitations

2 IMPLEMENTATION OF TRANSFORMATION AGENDAS 8

2.1 Transformation in Equity and Quality

2.2 Information Revolution

2.3 Woreda Transformation

2.4 Caring Respectful and compassionate health workforce

3 Performance of STRATEGIC OBJECTIVES OF THE HSTP 29

3.1 Improve Health Status

3.2 Enhance Community Ownership, Participation and Engagement

3.3 Improve Efficiency and Effectiveness

3.4 Improve (equitable) access to Quality Health Services

3.5 Improve Health Emergency Risk Management

3.6 Improve Good Governance

3.7 Improve Regulatory Systems

3.8 Improve Supply Chain and Logistic Management

3.9 Improve Resource Mobilization

3.10 Improve Research and Evidence for Decision-Making and Enhancing Policy and Procedures . . 70

3.11 Improve Development & Management of HRH

3.12 Improve Health Infrastructure and enhancing using of Technology and innovations

4 ANNEXES 85

Annex 1 Moving towards universal health coverage in Ethiopia: Areas for focus 85 Annex 2: Review of the implementation of Woreda transformation 101 Annex 3: Review of the implementation of Information revolution 111 Annex 4: MTR Team members 125 Annex 5 List of documents consulted 127

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ABBREVIATIONS AND ACRONYMS

AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care ART Anti-Retroviral Therapy BCC Behavioural Change Communication BPR Business Process Reengineering CDC Communicable Disease Control CSOs Civil Society Organizations DHS Demographic and Health Survey DRS Developing Regional States 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 EPHI Ethiopian Public Health Institute EPI Expanded Program on Immunization EQA External Quality Assurance ESPA+ Ethiopian Service Provision Assessment Plus FDRE Federal Democratic Republic of Ethiopia FMHACA Food,Medicine and HealthCare Administration and Control Authority GDP Gross Domestic Product GOE Government of Ethiopia GTP Growth and Transformation Plan HDA Health Development Army HCT HIV Counselling and Testing HEP Health Extension Programme HEWs Health Extension Workers HIS Health Information System HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome HMIS Health Information Management System HR H Human Resource for Health 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 & response IEC Information Education Communication IFMIS Integrated Financial Management System IHP International Health Partnership

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IMR Infant Mortality Rate L/IPFS/MIS Logistic/Integrated Pharmaceuticals Fund &Supply/ Management Information

System IRT Integrated Refresher Training ISS Integrated Supportive Supervision JCCC Joint Core Coordinating Committee JSC Joint Steering Committee M&E Monitoring and Evaluation MCH Maternal and Child Health M/SDG Millennium/ s u s t a i n a b l e Development Goal MIS Malaria Indicator Survey MMR Maternal Mortality Ratio MOFEC Ministry of Finance and Economic Cooperation MOH Ministry of Health NCD Non-Communicable Disease NHA National Health Accounts NMR Neonatal Mortality Rate NTD Neglected Tropical Disease OOP Out of Pocket 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 RDF Revolving Drug Fund 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 SDG PF SDG Performance Fund SLMTA Strengthening Laboratory Management Towards Accreditation SNNPR Southern Nations & Nationalities and Peoples Region SO Strategic Objective SRH Sexual and Reproductive U5MR Under Five Children Mortality Rate UHC Universal Health Coverage UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United USAID United States Agency for International Development VCT Voluntary Counselling and Testing VERA Vital Events Registration Agency WBP Woreda Based Plan WoHO Woreda Health Office

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PREFACE

ETHIOPIA HEALTH SECTOR TRANSFORMATION PLAN

MID-TERM REVIEW OF HSTP

30THAPRIL TO 30THJune 2018

Programme: Ethiopian Health Sector Transformation Plan

Executing Agencies: Federal Ministry of Health and Regional Health Bureaus

Evaluation: Mid-Term Review HSTP 2015/16 till 2019/20 (EFY 2008-2012).

Period reviewed: July 2015 - December 2017 (EFY July 2008- Dec 2010)

Date submission: 30th June 2018

Members of the Joint Core Coordinating Committee(JCCC)):

Biruk Abate Halallo (FMOH/PPD, chair), Ortiz Llobel, Jose Antonio (AECID), Marco Gerritsen (Netherlands), Helina Worku (USAID), JS-Tewari (DFID), Luwam Gari (DFID), Richard Arden (DFID), Berhanu Lakew (DFID), Selome Dereje (DFID), Amanuel Kidane (Ireland), l. Pecoraro (Italian Cooperation), Million Admassie (Italian Cooperation), Habtamu ADANE (EU Tito Rwamushaija (GAVI), Shalini Bahuguna (UNICEF), , Sofonias Getachew (WHO), Awoke Tasew (UNFPA), Roman Tesfaye (World Bank), Berhane Meskel.

Core Members of the 2013 MTR Review Team with their funding agencies

The independent team of this MTR was composed of 7 international and 6 national consultants, supported by 3 resource persons from WHO and UNICEF. They were selected by the JCCC on the basis of their professional expertise and participated in their individual capacity. Bill and Melinda Gates Foundation, DFID, UNICEF, UNFPA, USAID and World Bank funded the involvement of these consultants. As an independent review team, the opinions and suggestions in this report are solely the responsibility of the authors and do not in any way commit or imply the agreement of the FMOH or any of the other stakeholders operating in the Ethiopian health sector.

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CONSULTANTS EMAILS MOBILES FUNDING

Abebe Alebachew abebe.alebachew2008@gmail.com +251-911 517 122 World Bank

Jarl Chabot j.chabot@chabotconsult.nl +251-902-462 790 UNICEF

Donna Espeut donna_espeut@yahoo.com +251-901 003 539 Gates Foundation

Wilbert Bannenberg wjb@wxs.nl +251-904 625 118 DFID / HEART

Sundeep Sahay sundeeps@ifi.uio.no Gates Foundation

Rob Fielding robcfielding@gmail.com +251-901 001 715 Gates Foundation

Kate Tulenko ktulenko@corvushealth.com +1 202 460 9919 USAID/Pathfinder

Humphrey Karamagi karamagih@gmail.com WHO

Mekdim Enkossa mkdmea2009@gmail.com WHO

Atakilt Berhe aberhe@unicef.org +251-911-364 216 UNICEF

Yasmin Yusuf Yasmin.yi@gmail.com +251-911-633 106 UNFPA

Binyam Kebede binyamkk19@gmail.com +251-911 224 470 World Bank

Workie Mitiku workie_mitiku@yahoo.com +251-911 212 467 World Bank

Asrade Abate asrade@hotmail.com +251-911 377 096 World Bank

Tsion Assefa tsionassefa21@yahoo.com +251-917 765 907 World Bank

Yibeltal Kiflie Yibeltal@gmail.com +251-921 022 210 World Bank

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ACKNOWLEDGEMENTS

The evaluation team would like to thank his Excellency Dr Amir Aman, Federal Minister for Health, for his guidance of the team to be open, candid, honest but constructive which inspired all the team members to dig-deeper to find out what worked well and not worked well. We would like also to thank Dr Kebede Worku, State Minster for Health, and all the directorates of the FMOH for their openness and constructive engagement during the debriefing session as well as afterwards.

The leadership and coordinating role of the MTR support team was paramount and without which the process would have not been successful, as it was the case now.

In this regard, we would like to the thank Dr Meseret Zelalem, Kahsu Beukeretsion, Dr Wakgari Deressa, and Tsedeke Matheos for their commitment and full support during the entire process.

We would like also to thank the MTR teams that were part of this process from government, development and implementing partners as well as the team leaders of all the regional teams for their commitment and generating the necessary evidence at all levels of the system, without which the quality of the MTR report would not have taken this shape.

We would like to thank the various funding agencies (The Gates Foundation (through AIHA), UNICEF, UNFPA, DFID, USAID and World Bank and in particular Dr Helina Worku from USAID for her special support not only in mobilizing MTR members from USAID’s implementing partners both at the federal and regional levels, but also ensuring that the MTR team also be supported through availability of transport in the regions.

Finally, we would like to acknowledge and thank all the stakeholders at the federal, regional, woreda and facility levels that were unusually open and constructive when they provide their views and recommendations for the MTR team.

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EXECUTIVE SUMMARY

The objective of this HSTP Mid-term review was to assess the level of performance of the HSTP’s four transformation agendas and fifteen strategic objectives against the expected results and document best practices and gaps and challenges of implementation. Sector experts from government and partners supported a team of independent consultants recruited to undertake this review. The team used document review, key informant interview and site visits to collect evidences and views. The main conclusion and recommendation of this review is presented below.

Overall Findings:

The four HSTP transformation agendas remain priority agendas at all levels of the health system.

Efforts are being made to translate some of the strategic interventions into action. These efforts remain fragmented and driven by different directorates. In terms of realising the HSTP targets at mid-term, most of the strategic objective targets were either not met or data were not available. Some of the HSTP Midterm targets for some of the service delivery, regulation and CBHI strategies were met while the most of the other strategic objective targets are either not realized as per the midterm targets or information isn’t available to know their status of implementation.

Conclusions

The health sector was operating in a difficult context during the period under review. Political and social unrest, as well as frequent and protracted disease outbreaks and disasters shifted attentions and actions of stakeholders and decision makers, as well as redirected available resources address these challenges. Within the health sector, frequent turnover of leadership and management at the federal and woreda levels influenced consistency of actions. The success in achieving the HSTP targets and the lessons learnt should therefore be viewed in this environment.

In spite of this difficult environment, there is evidence that the sector has laid the groundwork for implementation of the transformation agendas as was envisioned in the HSTP. The momentum from the HSDPIV particularly in improving system capacity for delivery of essential services was maintained.

Common understanding of the transformation needed is observed at all levels. However, the capacity of knowing ‘how’ to translate these transformation agendas into action and their measurement remains a challenge. The different elements of the transformation agenda are being guided and led with different directorates in separate teams, losing the benefit of combined and coordinated operationalization. As a result, all the transformation agenda targets are not met as planned during this midterm.

This is mainly due to the fact that the essential health services package was not revised to provide a comprehensive approach for improving quality of care.

The sector envisioned transformation in four areas – quality and equity; information; woreda management and person-centred quality of care provision. Multiple initiatives have been initiated across these four transformation areas. There is evidence of transformation in the focus of access and equity improvement, with increased attention to hard to reach populations – urban poor, and pastoralist communities particularly. However, as described in the body of the report, there are persistent disparities between rural and urban areas, and between the poorest and richest quintiles.

There is also variation among the group Developing Regional States (DRS)--Afar, Benishangul- Gumuz (B-G), Gambella and Somali—suggesting that those regions should not always be regarded as a monolithic “low-performing” group. For example, according to the 2016 Ethiopia Demographic and Health Survey, Gambella’s rate of skilled birth attendance (SBA) exceeds the national average;

Benishangul-Gumuz’s rate of Penta-3 vaccination coverage also exceeds the national average. In

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contrast, Afar and Somali have levels of key health indicators that are generally below the national average and far lower than the rates of other states in the DRS group. There are emerging promising practices within regions to tackle barriers (e.g., factors that impede equitable access to high-impact services such as SBA and family planning [FP]), as well as optimize quality of care, both from the client and service delivery perspectives.

The introduction of the DHIS-2 and other information management initiatives is a critical reform to improve availability and use of data and statistics. Woreda transformation, with the 2nd generation health extension program and the model Woreda / family concepts are to be applauded as unique reforms. The introduction of the compassionate and respectful care initiative should, when fully in place, impact positively on the quality of care of Ethiopians are currently receiving, and so improve overall health outcomes.

There is evidence of expansion of health information capacity, further improvement in the production of health workforce, infrastructure, and the EFMHACA shift towards a -food and drug authority (FDA), all of which should facilitate improvement in the availability of inputs needed for service delivery. However, a lot of these efforts are focused on availability, with limited attention to ensuring functionality and readiness. Health workforce improvements are focused on specific staff cadres, with some cadres missing and the quality of production questionable. Health infrastructure improvements are not being made in a manner aligned to functions – with gaps in readiness and designs noted. In addition, interlinkages are not well thought through, with instances of equipment made available but not being used – left in boxes. Commodity supply remains a major challenge, with high reports of stock-outs and poor stock management of essential products.

In addition to these specific gaps, investments are not being fully coordinated or informed by expected services as it isn’t guided by an up to date essential package and investment norms. Finally, investments are made were being compromised by poor readiness. Low availability of power and safe water sources in health facilities limits their functionality as well as the reduce the value-for-money achieved from infrastructure investments made. Low capacity for comprehensive medicines management, particularly for essential medicines as compared to donor funded programs compounds health commodity gaps. The absence of a sector wide and operational approach to improve health worker skills, particularly management skills further reduce effectiveness of available health workforce, a situation compounded by the lack of clarity on the future of health worker regulation and oversight. Health information still suffers from multiple platforms, with limited interoperability.

The weak data use culture compounds the problem of data use. In terms of governance, the different levels of governance structures created during HSDP II and III do still exist but there is coordination fatigue by both government and DPs which undermines the gains made around harmonization and alignment. There is still lack of endorsed overarching health policy/Act to guides the sector towards

UHC 2030.

There was positive movement of sector financing moving towards domestic financing. Although the share of health in domestic financing remains at 7.7%, the government was able to fund more than what is projected in the HSTP resource projection framework. Domestic financing was increasing in absolute amounts and as share of total sector financing (share of domestic funding increasing from 50% to 64% and share of external financing declining from 50 to 36%). There is good progress in expanding prepayment mechanisms for non-formal sector (CBHI) to more than 39% of woredas although enrolment rates in these woredas remain only 44% and nationally 15%. Despite such progress, the adequacy and sustainability of domestic financing is a major challenge as: (i) the per capita health spending is much lower than internationally recommended level to lead to UHC; and

(ii) most of the commodities for exempted services (services provided free of charge to all) still donor dependent. The mobilization of DPs resources through FMOH preferred funding channel- SDG PF- is sustained with relatively similar magnitudes. However, Adopting CBHI design features to different

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contexts (urban and pastoralist), as well as starting SHI for the formal sector is still a challenge that the FMOH and its partners should immediately address. Finally, there is evidence that the amount of resources being mobilized from the external sources is on the decline – in absolute, and in relative terms, which highlights the issue of sustainable sector financing as a big issue in the coming years.

The overall effect of this status is a subdued impact on overall health of Ethiopians arising from the good investments being made. For many of the morbidity and mortality causes, plus risk factors influencing health and wellbeing, evidence of progress is limited or non-existent. Ethiopia is still struggling with a burden on communicable diseases, but witnessing a constantly rising non-communicable disease burden. Outbreak and disasters continue to negatively influence progress being made. Moving into the 2nd half of the HSTP, the health sector needs to focus on succinct actions to accelerate the transformation program interventions, and address specific system strengthening gaps across the different strategic objectives for it to ensure the HSTP is a success.

Recommendations

Overall Recommendations.

There are promising signs that the context in the 2nd half of the HSTP should be more facilitative for attaining the aspirations of the health sector. The new FMOH top management that has come into effect during 2018 has already initiated positive reforms that should facilitate the sector transformation process (e.g., selection of woredas for woreda transformation). The sector transformation introduced innovations need to be perused in greater commitment and vigor along three core areas. First, defining comprehensive essential service package, defined by life cohort, level of care and across all public health functions is a good starting point as it is a spark to lead to a coordinated transformation agenda implementation, which will lead the charge towards attainment of universal health coverage and SDG targets influencing health in the country, and so facilitate attainment of SDG 3 with no one left behind. This should be complemented with a clear target of essential services by level and age cohort guides the expected outcomes from all the transformation agendas – the interventions and areas for focus with quality and equity, health workforce, infrastructure and medicines norms and standards to be adhered to for Woreda transformation, service and quality standards to be attained for compassionate care, and statistics, information and knowledge needs for information and evidence based decision making. The ‘how’ of attaining these is elaborated more in the annex on movement towards universal health coverage. Second, sustainability and financing of the provision of the comprehensive health package needs to be worked out through endorsing the revised HCF strategy and introducing innovative financing in the sector. Third, these two areas should be complemented by developing and operationalizing clear operational strategies, performance measures, leadership and monitoring mechanisms for of each transformation agenda. These should be built around facilitating availability for all Ethiopians of the essential health services needed for health and wellbeing, and coordinated in a harmonized and centralized manner.

In terms of specific system strengthening actions, the health sector should accelerate its efforts on addressing the following key issues:

a) Advocate for and work with higher level government structures to get the revised financing strategy approved by the Council of Ministers; develop and implement innovative financing strategies to increase domestic financing and sustainability;

b) Review the structure and functioning the governance and partnership mechanisms and processes at all levels and develop strategies for their strengthening; and update policy and Act;

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c) Accelerate investments in establishing harmonized digital platforms, and in building the culture of optimizing information quality and use, within defined frameworks of financing and sustainability;

d) By exploring the best practices of other countries, work towards establishing Independent, comprehensive regulators with authority and enforcement capacity for health professionals and premises;

e) While strengthening PFSA to improve its efficiency and effectiveness should continue as apriority, GOE should also consider establishing alternative complementary sources of commodities and supplies as is the case on other countries;

f) To significantly improve quality of health workforce, FMOH should work with FMOE to guide and motivate health science colleges to shift towards competency based pre-service training;

it should also rationalize and strengthen the capacities of ISTs to be the vehicles of enforcing Continued Professional Development (CPD) IST rationalization and CPD enforcement & productivity monitoring;

g) Develop and implement an accelerated investment plan in addressing issues of infrastructure functionality and readiness; and

Engage high level authorities to kick start the operationalization of SHI for the formal sector.

Immediate Priorities and Monitoring MTR recommendations

This MTR provided a number of short and medium-term recommendation to take the HSTP agenda and priorities forward. These recommendations, however, need to be reviewed, owned and stakeholders’ drive their implementation. The Independent MTR team recommends the following to ensure that the recommendations are considered and implemented:

a) Revitalize/Re-ignite the health sector coordination structures and FMOH leadership and guidance (PPD and Resource Mobilization directorates), revive the coordination role of JCCC supported by TWGs to review the relevance and timeliness of the MTR recommendations and to follow-up and guide all directorates and partners to implement agreed actions;

b) Establish a technical working group, under the leadership of the JCCC, to guide the operationalization of the Essential Health Services Package with its service norms and standards with the participation of all stakeholders’ especially specific interest groups who might not have benefited from previous lists;

c) Work towards getting the sustainability and financing of the health sector through getting revised HCF strategy endorsed and implemented;

d) All directorates with the participation of their respective active partners, review the recommendation of the HSTP MTR, prioritize and develop a work plan for each transformation agenda and strategic objective with guidance and agreement of the JCCC and present this to the ARM 2018 for sector’s endorsement

e) All the endorsed work plans should be included in the 2011 EFY work plan and be reviewed a core priority performance measure in the coming months by the top management.

INTRODUCTION

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1. INTRODUCTION

1.1 BACKGROUND

Since 1997, Ethiopia’s health sector has developed and implemented successive, sector-wide plans referred to as Health Sector Development Plans (HSDPs). The latest plan, referred to as the Health Sector Transformation Plan (HSTP) 2015/16-2019/20, reflects a desire on the part of the Government of Ethiopia and its development partners to elevate efforts to bring about broad scale, transformational health improvements in the country. The plan centers of four transformation agendas (TAs): (1) quality and equity, (2) Information Revolution, (3) Woreda Transformation, and (4) a Caring, Respectful and Compassionate (CRC) health workforce.

The goals of HSTP are twofold: (1) improve quality and equity of healthcare, coverage and utilization of essential health services; and (2) enhance the implementation capacity of the health sector at all levels of the health system. HSTP targets are in line with the country’s Sustainable Development Goals (SDGs) and support the overall vision of Ethiopia to become a middle-income country by 2035. Guided by four key themes and four overarching transformation agendas (TAs), HSTP’s key principles relate to excellence in health service delivery, excellence in quality improvement (QI) and quality assurance (QA), excellence in leadership and governance, and excellence in health system capacity. The plan also set out targets and strategies for 15 strategic objectives. One of the major processes of these sector plans over the last 20 years has been their midterm evaluation at mid of their implementation period. The HSTP was implemented for more than two and half years and GOE and its partners have initiated this mid-term review of HSTP.

1.2 OBJECTIVE AND DELIVERABLES OF THE HSTP MTR

The main objective of this MTR was to assess the level of performance against the progress towards the expected results of HSTP as well as assessing its relevance in relation to the national development agenda (GTP) and the global commitment (SDGs), and to draw best lessons from the accomplishments and challenges to date. The specific objectives of the MTR were:

a) Reviewing the implementation of HSTP and assess the achievements against targets;

b) Assessing the progress towards the implementation of the four transformation agendas;

c) Assess the health systems strengthening interventions and their effects on improving health impacts;

d) Identifying facilitating factors, barriers and challenges in the implementation of HSTP;

e) Identifying and documenting key lessons learned and experiences gained at all levels of the health sector;

f) Provide recommendations that enable the sector to address the bottlenecks and challenges in the implementation of the HSTP in the remaining period and beyond.

The MTR team was expected to produce the following deliverables:

• An Inception Report

• Regional Reports and debriefing power points

• Draft MTR Report

• Revised final report and PPT to be presented in the ARM

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1.3 OVERALL METHODOLOGY

In keeping with the Terms of Reference (annex 1) of this evaluation, the team used a mixed method approach for data collection and analysis, which is aligned to the deliverables and the need to assess progress against the HSTP outcome and output indicators. Qualitative methods, including structured desk review and key informant interviews, were used to collect information about the successes and challenges of HSTP implementation and some possible ideas on how to accelerate its scale up and removing bottlenecks. Quantitative data will be drawn from secondary sources, including HMIS, epidemiological data (surveillance and research), and financial data. The data collection methods include document review, quantitative data analysis, key informant interviews, direct observation of health facilities. Each of these is described below.

Figure 1: Four steps of this evaluation

• An pr

• Tr of

• C -f

• R b p

• P in nalysis of secon ogramme data iangulated ana qualitativie dat ompilation of d feedback + final evision of the fi ased on the com rovided resentation of t n the 2018 ARM dary + lysiss ta draft report lisation nal report mments the findings

Step Report + f up

Step Analys follow

S 3 sis

Step 1 Inception

Phase

Step 2 Dat Collection

Phase

• N w co m

• sy na an

JC

• Des

• Dev

• Sam and

• Sta

• Log n ta ational, regiona woreda level visi ollection using methods ythsis of regiona ational prelimin nd feedback to CCC and stakeh sk review velopment of to mpling of Regio d woredas keholder comm gistical arrangem al and t and data mixed al and naryfindings o to regions, holders ools ns, zones munication ments

Sources of information

Comprehensive desk review –the desk review assessed a broad range of policy, strategy and planning documents related to the HSTP and its linkages to the broader growth and transformation plan landscape. The team reviewed the HSTP and its transformation agenda roadmaps, the 2016 and 2017 annual review reports, other assessments and studies carried out in each thematic area by government and its partners. The document review included program level strategies, innovations and performance assessments and review in the last two and half years. This review was also supported by analysing relevant survey findings and literatures including the HMIS data and database (for example to see list of registered health facilities) at different levels, EDHS as well as SARA assessment (see annex 7 for document review).

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Semi-structured interviews with key stakeholders– a broad range of stakeholders (different FMOH directorates, regional, zonal, woreda and facility management teams, development and implementing partners both at the federal and regional levels, other sectors-BOFEDs, WOFEDs, Women affairs, MOLSA, etc.,) were interviewed at different levels. Different semi-structured interview guides (questionnaires)was developed tailored to specific sub-groups (see annex 9) for federal, regional, zonal, woreda and health facility questionnaires). The interviews provided the MTR team with detailed information on results, strengths, gaps and challenges in the implementation of the HSTP at all levels. Key informants were identified from various organizations and institutions at the different administrative levels in consultation with federal and regional level MTR coordinators (see Annex 6: for people interviewed).

Analysis methods

The gathered information and data were analyzed, triangulated and crosschecked for validity of findings. The MTR team developed different analysis tools to ensure a rigorous and systematic analysis of quantitative and qualitative information. The core outcome and output targets outlined for each of the 15 SO and 4 TA’s of the HSTP were used to provide benchmarks for the quantitative analysis for the MTR performance. The main source of data for the achievements of these SO was the national data routinely generated by PPD and survey results like EDHS. This was crosschecked whenever possible with other survey data (SARA and other surveys). In addition, the quality and reliability of this routine information was reviewed on the ground as part of this process. Furthermore, the more qualitative information coming from the interviews at the various levels was used to verify the validity of the quantitative information. If no information is available, NA was included, but the indicator will not be removed. The team used three approaches to analyze data during the evaluation. First, they explored and undertook different aspects of quantitative analysis (trend, percentages, shares, etc.) and compared achievements and targets. Second, the team undertook a rolling analysis of the qualitative data generated from national, regional and woreda level interviews and the sample visits.

At the end of each day of fieldwork the team members met to review the field notes and developed an ongoing tally of key findings. The team then discussed new findings and trends that may have emerged during the day and place them in to a findings, conclusions and recommendations PPT template developed by the MTR team for this purpose.

1.4 SAMPLING OF REGIONS, ZONES AND WOREDAS

The MTR teams visited all regions. In the three bigger regions (Amhara, Oromia, SNNP) two zones (one well performing and another less well performing) were selected. Again, within these zones, one well performing woreda and one less performing woreda were selected. The team also visited well performing and less performing facilities and communities within each woreda. In the other regions, while all other sampling frame remained the same, there were no visits to specific zones. In each region, two woredas were visited. The selection of the zones, woredas and health facilities was carried out by the regional teams in consultation with and guided by the achievements in the HMIS data. The regional visits followed the division of roles as outlined in Table 1. The core team members that visit the regions was worked out during the first week with the support of FMOH and JCCC

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Table 1: Proposed distribution of sample regions for six Teams

Region Woredas Hospitals HCs HPs

Tigray Raya-Azebo

Enda Mokoni

Ayder

Mehoni

Kukufto

Kara

Meswaiti

Shimta

Tseadameda

Koban

Simeret

Hizba T/ Haimanot

Afar Afambo

Asayita

Asayita

Dupti

Afambo

Berega

Logia

Semera

Dubti

Private Clinic

Mego

Adegera

Berega

Amhara

Dejen

Shebel Berenta

Farta

Estie

Felege Hiwot

Debremarkos

Debretabor

Daejen

Shebel Berenta

Maken Eyesius

Gambi Private

Deremo

Leway

Estie

Buno

Dejen

Yetnora

Mergech

Ye’edwiha

Kanat

Amche

Dangolt

Selamuko

Dejen

Zemtn

Yetnora

Ye’edwiha

Oromia

Wonchi

Illu

Guliso

Babo

Tulu Bolo

Gimbi

Chitu

Darian

Tajo

Asgori

Gudeto Babo

Guliso

Meti

Kurfo Butery

Dugeda Mida

Logo

Somali Babile

Awbere

Jigjiga University, Meles Zenawi Memorial

Karamara

Ermias Internal

Dandama Elbahay

Awbere LaFey-isa

Biko Bodhley

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Benishangul Gumuz

Menge WoHO

Sherkole WoHO Assosa General Hospital

Menge HC

Undulu HC

Sherkole HC

Sugul Etnin HC

Abenare HP

Fudndu HP

Kashaf HP

Obeyubeshie HP

SNNP

West Azernet

Sankura

Alatyon Private

Alem Gebiaya

Mugo

Regedina

West Mugo

Jata

Adasha

Gambella Gambella Zuria

Abobo

Gambella

Private m/cllinc

Abol

Bonga

Mender 8

Ukuna

Opagne

Jawe

Mender 8 and 13

Terchero

Harari Sofi

Jenella

Jugol general Hospital

Harar General Hospital (Private)

Sofi

Jenella Jenella UHEP

Diredawa Jaldessa Biyo Awale DilChora General Hospital

Jaldessa

Biyo Awale

Mud -Anon

Adado

Addis Ababa Gulele Sub City Hallelujah Private

Ras Desta

Maichew

Guto Meda

Woreda 6

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1.5 ORGANIZATION OF THE HSTP MTR TEAM

The MTR team was composed of two major groups of experts. The first group was made up of independent subject matter experts who were recruited and financed by different agencies as national and international consultants for the MTR. The second group experts (about 67 in number) were drawn from FMOH and its agencies, development and implementing partners, NGOs and private sector. The national and international consultants developed the HSTP MTR tools and trained all MTR team members. MTR team members were allocated to regions for fieldwork, with attention paid to the mix of thematic skills and experience when assembling the regional field teams. Overall, six regional teams were established and deployed to collect and analyse information (see annex 5: MTR team members by region). With the exception of the Amhara and Oromia teams, each field team reviewed the HSTP performance of two regions.

MTR fieldwork took place from 13–26 May 2018 and entailed a combination of key informant interviews (KIIs) and site visits. For each region, fieldwork culminated in the development and presentation of regional MTR findings, conclusions and recommendations to the Regional Health Bureau. Teams also prepared region-specific MTR reports (Volume II for all Regional MTR reports).

Upon completion of regional fieldwork, the independent consultant team embarked on national consolidation of findings. These findings were presented to the FMOH Management Team with all directorates, as well as to the JCCC and the HPN. These three forums provided very constructive and useful comments that are reflected in this MTR report. This report will be further improved as per forthcoming comments given by JCCC in the coming month.

1.6 LIMITATIONS

The duration of the review period was short, with limited time to complete both federal and regional-level interviews. This limitation was exacerbated by limited availability of some regional and federal-level stakeholders during the data collection process, and most stakeholders from development partners and FMOH directorates did not respond to the harmonization and alignment questionnaire on time. Also, although more than 70 members of the MTR were mobilized from government and development partners, they, too, were not available throughout the entire fieldwork phase, which affected the thematic balance of the regional teams. Lastly, the MTR team fully exploited available data sources; however, it should be noted that available data paint an incomplete picture in terms of HSTP progress.

IMPLEMENTATION OF

TRANSFORMATION AGENDAS

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2.IMPLEMENTATION OF

TRANSFORMATION AGENDAS

2.1 TRANSFORMATION IN EQUITY AND QUALITY

EQUITY AND QUALITY TRANSOFRMATION is the first transformation agenda of HSTP and aims at ensuring: (1) equal entitlement to available services for everyone based on health care needs and ease of access in each geographical area; (2) removal of barriers to access, including lack of income to pay for health services and opportunity costs (e.g., transportation costs), language and cultural barriers, inconvenient working hours of health facilities and physical access; (3) proactive and planned interventions to redress differences in the rates of utilization by different segments of the population; (4) that providers strive to deliver services for all sections of the community with the same high standard of professional care; (5) the seamless flow of information within the health system about best practices to improve quality of health care and achieve high levels of patient and community satisfaction; (6) a patient-centered health care delivery system; (7) pragmatic regulations and standards, strengthening set standards and monitoring adherence to them through regular inspection and accreditation at different levels to facilitate higher compliance with evidence, with special emphasis on laboratory quality assurance (QA) and accreditation to ensure quality of diagnostic services.

Major targets and their achievements

The HSTP’s five-year vision is to: (1) raise the performance of the Developing Regional States (DRS) of Afar, Benishangul-Gumuz (B-G), Gambella and Somali, and other “lower-performing” areas; (2) create a detailed roadmap centered on innovative strategies to extend equitable health care access to all Ethiopians; and (3) explore the establishment of a center or institute for health equity. In this regard, the HSTP includes 14 core equity indicators to track progress (see Table 2 and annex 2)), although the indicators were not analyzed and presented in either of the two HSTP Annual Performance Reports to date. The Federal Ministry of Health (FMOH) has, however, produced a report on the State of Inequality in the Health Sector based on Ethiopia Demographic and Health Survey (EDHS) survey data from 2000 to 2014, as well as EFY 2008 health management information system (HMIS) data.

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Table 2. Current Status of HSTP Equity Indicators (DATA SOURCES: HMIS EFYs 2008 and 2010, 2016 EDHS)

HSTP EQUITY INDICATOR HSTP

TARGET

BEST AVAILABLE

ESTIMATE DATA SOURCE

= Approaching HSTP target = Improvement over base-line but below target

= No progress/ wrong trend

= No data available to assess progress

1. Ratio of deliveries assisted by SBAs between pas-toralist and non- pastoralist woredas

1.0

0.556

(Non-pastoralist rate 1.8x higher) EFY 2008 HMIS (State of

Inequality)

2. Ratio of deliveries assisted by Skilled Birth Atten-dants between rural and urban woredas

1.0

0.625

(Urban rate 1.6x higher)

3. Difference of SBA: lowest & highest quintiles 0 percent-age points

59 percentage points (Difference increased since 2000)

2016 EDHS

4. Ratio of Penta 3 coverage b/n median of woredas below half of national median & national median

1.0

5. Difference of Penta 3 coverage between bottom and top wealth quintiles of rural woredas

0 percent-age points

6. Difference of OPD attendance between lowest and highest quintiles

0 percent-age points

7. Ratio of OPD attendance between Females and Males

1.0 1.08 for new OPD EFY 2010 (6-mo.) HMIS

8. Ratio of OPD attendance between rural and ur-ban

1.0

9. Ratio of OPD attendance between Pastoralist and Non-pastoralist

1.0

10. Difference of stunting between lowest and high-est quintiles

0 percent-age points

19 percentage points 2016 EDHS

11. Ratio of currently on ART between pediatrics (<15) and adults (>15) .051 EFY 2010 (6-mos.) HMIS

12. Ratio of Tuberculosis Case Detection between Pediatrics (<15) and Adult (>15)

1.0

Magnitude of inequal-ity has increased since 2000 (State of Inequali-ty, pages 48-9) EFY 2008 HMIS (State of

Inequality in the Health Sector)13. Ratio of facility utilities (e.g., water, electricity, sanitation, ICT): pastoralist vs. non-pastoralist areas

1.0

6 out of 10 urban/ agrarian HFs have electricity vs. 4 out of 10 HFs in pastoralist areas

14. Availability of essential drugs by rural and urban facilities

No differ-ence

Efforts are made to finance the coverage of the poor (fee waivers for non CBHI woredas/indigent CBHI members in CBHI Woredas) through government financing by regions and woredas, which is presented in Resource mobilization section of this report.

The analysis for the EFY 2008 State of Inequality did not include data from the latest EDHS (2016).

Table 3 further explores differentials according to three indicators (skilled birth attendance (SBA) coverage, coverage for the third dose of Pentavalent vaccine (Penta 3) and stunting prevalence) using

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2016 EDHS data. As seen in the table, there are persistent disparities between rural and urban areas, and between the poorest and richest quintiles. There is also variation among DRS, suggesting that those regions should not always be regarded as a monolithic “low-performing” group.

Table 3. Key Differentials in Three HSTP Indicators, 2016 EDHS

RED TEXT denotes most-disadvantaged subgroup for the indicator

INDICATOR

2016 EDHS ESTMATE

National Rural Urban DRS Wealth Quintile Sex

Afar* B-G Gam-bella Somali* Lowest Highest Female Male

SBA 27.7% 21.2% 80.1% 16.4% 28.6% 46.9% 20.0% 11.0% 70.3% -- --

Penta-3a 53.2% 49.7% 79.5% 20.1% 76.2% 54.8% 36.3% 36.4% 76.3% 53.3% 52.9%

Stunting 38.4% 39.9% 25.4% 41.1% 42.7% 23.5% 27.4% 44.6% 25.6% 35.3% 41.3%

*Also regions with high concentrations of Pastoralists

Another key component of equity is financial risk protection. During the first half of HSTP implementation, financial equity issues have been addressed primarily through two initiatives: the community-based health insurance scheme (CBHI) and fee waiver system for the very poor. CBHI has been initiated in 375 woredas, representing 39% of all woredas in the country (the end-of-HSTP target is 80% of all woredas). Of the 375 woredas currently covered by CBHI, 289 woredas have commenced health service provision to CBHI enrolees. The utilization of services by CBHI enrolees increased from

2.1 million in 2008 EFY to 5.6 million in 2009 EFY, and 2.2 million during first six months of 2010 EFY.

The fee waiver system for the poorest of the poor is operational in both CBHI woredas and non-CBHI woredas. Regional and woreda governments financed the coverage of 7.7% of eligible households through fee waiver/indigent financing. There is also some effort to link fee waiver beneficiaries with social protection schemes such as the Productive Safety Net Program (PSNP) in some localities, thus enable the poor to benefit from other forms of social assistance.

With respect to quality transformation, the HSTP does not have a standard set of Quality Improvement (QI) or Quality Assurance (QA) indicators. However, findings from the 2016 Service Availability and Readiness Assessment (SARA) suggest that basic aspects of service quality must still be addressed to achieve quality transformation. For example, according to the SARA, only 30% of health facilities (HFs) had improved water sources, with a huge disparity between urban and rural HFs (76% and 20%, respectively). Also, while 100% of referral hospitals had improved water sources, only 53% of health centers (HCs) and 17% of health posts (HPs) had improved water sources1. Although there has not been a repeat SARA since 2016, regional field visits during the HSTP MTR confirm that poor availability of basic amenities such as water and electricity are systemic gaps across most regions and levels of care.

In summary, best-available data suggest that progress to date is not yet on par with the aspiration of equity and quality transformation. However, due to the time lag in data (e.g., 2016 was the last year in which EDHS and SARA data were generated), it is not possible to accurately assess the extent to which there have been improvements since the start of HSTP.

Although there is limited current evidence on improved quality and equity outcomes, there have been efforts at all levels to establish clear strategies and, introduced or strengthened systems to support transformation since the start of HSTP. Overarching strategies and plans (e.g., as National Health Care Quality Strategy, 2016–2020; National Health Equity Strategy; Equitable Health Services Plan of Action, 2016–2020)) were developed and are being implemented. The FMOH’s Health System Special Support Directorate is working to provide health system strengthening (HSS) in the DRS. A Health

1 Ethiopian Public Health Institute (EPHI). 2017. Service Availability and Readiness Assessment 2016, Table 2.1.1 Ibid.

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Service Quality Directorate as well as a National Health Care Quality Committee have established to guide and lead efforts to improve quality. Standards and guidelines (e.g., revised Ethiopian Hospital Reform Implementation Guidelines (EHRIG), Ethiopian Health Sector Transformation in Quality Guidelines) and tools (e.g., health care service improvement guidelines, audit tools) were developed/ revised. Special initiatives and mechanisms to address certain aspects of quality of care (e.g., national rollout of Saving Lives through Safe Surgery (SaLTS), with assessment of hospital readiness, trainings of hospital staff, procurement of Operation Theatre Equipment and other activities); Maternal and Newborn Health Quality of Care Network (MNH QoC Network) established using the Ethiopian Health Institute Alliance for Quality (EHIAQ) as a platform; Improving Nursing Services Initiative) have gained momentum. Other envisioned mechanisms (e.g., center for health equity), were not, however, established. Nonetheless, the above tools, activities and structures introduced since the start of HSTP are yielding promising practices (Boxes 1 and 2). Below are other by-products of investments and inputs under HSTP:

• Targeted Technical Assistance: For example, in EFY 2009, a total of 59 technical experts were deployed to DRS and seven “low-performing” zones to fill skills gaps in those locations2.

• Sub-national Capacity-building: Over 2,700 frontline workers and managers from all hospitals were trained on QI and national hospital standard guidelines.

• Identification of “high-performing/best-performing” hospitals and HCs.

• Increased availability of state-of-the-art medical equipment to support clinical care (e.g., GeneXpert® and CD4 equipment)

• Financing models to promote equity (e.g., fee waivers to reduce financial access barriers) and quality (e.g., revenue retention).

• Improved service integration (e.g., provision of TB services within integrated management of newborn and childhood illnesses (IMNCI) clinics; cervical cancer screening and family planning (FP) services within HIV clinics).

Gaps and Challenges

The intervention of equity and quality are limited in scale (e.g., initiatives and promising practices) to bring significant influence health outcomes.