HSTP II final March 2021.pdf

Health Sector Transformation Plan

II HSTP II

2020/21-2024/25

(2013 EFY - 2017 EFY)

January 2021

CONTENTS

Foreword ....... 3 List of Acronyms ...................... 5 Executive Summary Chapter 1:

Introduction Chapter 2: Country Context ................................................................................................................................... 14 Chapter 3:

Performance of Health Sector Transformation Plan I – Situation Analysis

3.1 Health status and economic gains

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

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

3.1.3 Economic

gain

3.2 The status of health system performance

................................................................................................ 22 3.2.1 Progress towards universal health coverage.............................................................................................. 22 3.2.2 Healthy lifestyle and practices......................................................................................................................... 22 3.2.3

Demand for health services.............................................................................................................................. 22 3.2.4 Health security, health system resilience, and lessons from the COVID-19 pandemic ................. 22 3.2.5

Health system responsiveness

3.3 Service Delivery

........................................................................................................................................... 24 3.3.1

Service delivery platforms of the health sector

24 3.3.2 Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health (RMNCAYH)

.................... 25 3.3.3 Prevention and control of major diseases.................................................................................................... 26 3.3.4 Health promotion

3.4 The state of equity in the Ethiopian health system

................................................................................. 29 3.4.1 Geographic disparities in health...................................................................................................................... 29 3.4.2 Gender disparities in health

3.4.3 Socioeconomic

disparities

3.5 Health system inputs

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

Workforce

31 3.5.2 Medical products and supplies

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

3.5.4 Health financing

................................................................................................................................................... 33 3.5.5

Health information

.............................................................................................................................................. 34 3.5.6

Community engagement

3.6 Leadership, governance and multi-sectoral

collaboration....................................................................... 35 3.6.1 Leadership and governance.............................................................................................................................. 35 3.6.2

Multi-sectoral collaboration

3.7 SWOT Analysis

............................................................................................................................................ 36 3.8 Stakeholder Analysis 37 3.9 Summary of Lessons from HSTP-I implementation

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Chapter 4: Health Sector Transformation Plan II: Objectives, Targets, and Strategic Directions...................... 40 4.1. Vision

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

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

.............. 41 4.4.

Objectives

........................ 41 4.5.

Targets

......................... 44 4.6. Strategic Directions

4.7. Priorities /Transformation Agendas of

HSTP-II

Chapter 5: Costing and

Financing.......................................................................................................................... 69 5.1 Costing

............. 70 5.2 Financial space and costing analysis

............................................................................................................................... 79 5.3. Financial Gap analysis

86 5.4. The Financing Gap: Business as Usual

................................................................................................................... 87 5.5. Financing the Gap

.......................................................................................................................................................... 88 5.6.

Other Financing the Gap Options

Chapter 6: Implementation Arrangement

......................................................................................................... 91 6.1. Integration initiatives

................................................................................................................................................... 92 6.2.

HSTP-II governance

...................................................................................................................................................... 93 6.3.

Planning and budgeting

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

96 6.5. Optimizing monitoring and review systems

......................................................................................................... 97 6.6. Multi-sectoral collaboration

...................................................................................................................................... 98 6.7. Public-private partnership .......................................................................................................................................... 98 6.8.

Fostering innovation through health technology assessment and adaptation

6.9. Health diplomacy, Communication and visible leadership

............................................................................... 99 6.10. Risks and Mitigation

Chapter 7: Monitoring and Evaluation Plan

....................................................................................................... 101 7.1. Monitoring and Evaluation

Framework ............................................................................................................... 102 7.2. Indicators

102 7.3. Index measurement in HSTP-II

.............................................................................................................................. 103 7.4. Transforming

Data into Information and Action: The Data Cycle ................................................................ 104 7.5.

Evaluation

105 7.6. Dissemination and communication

...................................................................................................................... 105 7.7. Coordination, Policy and Institutional Environment for Monitoring and Evaluation

Annex 1: Indicators and Targets of HSTP-II

....................................................................................................... 108 ANNEX 2: Equity indicators and targets ............................................................................................................ 113 Annex 3: References

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FOREWORD

Ethiopia has implemented the first Health Sector Transformation Plan (HSTP-I) from 2015/16 to

2019/20, during which significant achievements were registered in improving the health of our population and increasing access to and utilization of health services.

Health outcome indicators have shown improvement, with a remarkable reduction in morbidity and mortality from major communicable diseases such as HIV, tuberculosis and malaria. Maternal and child health has also improved that resulted in saving the lives of millions of women and children.

Despite significant improvements, however, mortality and morbidity from communicable diseases and maternal and child health conditions are still high. The prevalence of non-communicable diseases (NCDs) and injuries are on the rise creating a triple burden of diseases for the health system. There is a high disparity in service utilization and health outcomes

H.E.Dr. Lia Tadesse Minister of health, Federal Democratic Republic of Ethiopia among people in different geographical areas and socio-economic groups. The quality of health care is still sub-optimal. The health system is also challenged by emerging pandemics such as COVID-19.

The second health sector transformation plan (HSTP II) is the sector’s five years strategic plan from 2020/21-24/25. It aims at improving the health of our population through the realization of accelerating progress towards Universal Health Coverage (UHC), protecting people from emergencies, creating Woreda transformation and making the health system responsive to people’s needs and expectations. To measure progress towards these objectives, HSTP-II has set ambitious but realistic targets that are aligned with national and international targets such as the Sustainable Development Goals (SDGs). The plan has identified 14 key strategic directions that define the major strategic areas and initiatives of the strategic period.

The plan aspires to achieve UHC through expanding access to service and improving the provision of quality and equitable comprehensive health services at all levels. We will expand health services based on the recently revised Essential Health Services Package (EHSP), through which different services and high impact interventions will be made available for each respective level of care. Reproductive, Maternal, Newborn, Child, Adolescent and Youth health will continue to be the major focus areas. We will continue to strengthen the prevention and control of major communicable diseases such as HIV, Tuberculosis and Malaria. As NCDs and mental health problems are becoming public health concerns, we will give a special focus on the prevention and control of NCDs and mental health problems, mainly through integrating these services with the primary health care system. The health extension program (HEP) will be revitalized based on the newly revised HEP roadmap and we will implementnew health post arrangement, comprehensive health posts, where more essential health services will be expanded to make services more accessible to the population.

To protect the population from emergencies, we will focus on strengthening our public health emergency management system and work towards building a resilient health system. The plan also focuses on strengthening health investment areas such as medicines, information health workforce, health infrastructure, digital health and

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innovations in health. The plan also emphasizes on strengthening multi-sectoral collaborative approach through which we can tackle the social determinants of health. Engaging the private sector in health is also identified as a major strategic area.

We have identified five priority areas/transformation agendas, which will be the top priority issues of the sector. It includes Quality and Equity of health Services, Information Revolution, Motivated, Competent and Compassionate Health workforce (MCC), Health Financing and Leadership.

The first priority area, i.e, quality and equity aspires to improve the provision of quality and equitable services to the population. A national quality and equity strategy will be developed and implemented. Equity and quality will be mainstreamed in all our health programs and regular measurement and improvement will be done. The information revolution will continue to be the priority in HSTP-II. Availability and use of quality data are key for informed evidence based decision-making in the sector. The sector will focus on improving the production and use of quality of data, with a special focus on improving the routine health management information system (HMIS). As a key priority area, the sector will focus on creating a motivated, competent and compassionate health workforce, which will be one of the key inputs to provide quality and responsive health service. To accelerate progress towards UHC by protecting our people from financial hardship, health financing will be one of the priority areas. The sector will work towards sustainable health financing by implementing different health financing interventions such as insurance schemes, rigorous resource mobilization and different innovative financing mechanisms. The fifth priority area is leadership, which will play a pivotal role in policy and strategy development, creating and strengthening transparency and accountability in the health system, promote coordination and inter-sectoral collaboration and overall guidance of the health system.

The HSTP-II builds on the successes and challenges of the first HSTP. I believe Ethiopia will continue the already started successes, reverse the challenges that hinder the health system and transform the health system in improving the health status of the population as outlined in the plan.

The objectives of the plan can be successful through the dedication of health workers, the continued political commitment, collaboration and concerted effort of all stakeholders. I hope that our collaborative efforts with the community, CSOs, development partners, donors, academia, associations and other stakeholders will continue to transform the health sector and achieve the ambitious targets set in the plan. Looking forward to working with you all towards the successful implementation of HSTP-II.

Lia Tadesse Minister of health, Federal Democratic Republic of Ethiopia

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LIST OF ACRONYMS

AHRI Armauer Hansen Research Institute

AIDS Acquired Immunodeficiency Syndrome

ALOS Average Length of Stay

AMR Ant-Microbial Resistance

ANC Antenatal care

ANC4 Antenatal care fourth visit

APR Annual performance report

APTS Auditable Pharmaceutical Transaction and Service

ARM Annual Review Meeting

ART Antiretroviral Therapy

ARV Antiretroviral

BEmOC Basic Emergency Obstetric Care

CASH Clean and Safe Health Facilities

CBHI Community Based Health Insurance

CEmOC Comprehensive Emergency Obstetric Care

COC Certificate of Competence

COVID-19 Corona Virus Disease-19

CPD Continued Professional Development

CPR Contraceptive Prevalence Rate

CRC Compassionate Respectful and Caring

CRVS Civil Registration and Vital Statistics

CSA Central Statistical Agency

CSC Community Scorecard

CSO Civil Society Organization

DALYs Disability Adjusted Life Years

DHIS2 District Health Information System

DMAT Disaster Management Assistant Team

DPCD Disease Prevention and Control Directorate

DQA Data Quality Assessment

DR TB Drug resistance Tuberculosis

ECD Early Childhood Development eCHIS Electronic Community Health Information System

EDHS Ethiopia Demographic and Health Survey

EFDA Ethiopia Food and Drug Authority

EFY Ethiopian Fiscal Year

EHAQ Ethiopian Hospitals Alliance for Quality

EHIA Ethiopia Health Insurance Agency

EHRIG Ethiopian Hospital Reform Implementation Guideline

EHSP Essential Health Services Package

EHSTG Ethiopian Hospital Services Transformation Guideline

EmONC Emergency Obstetric and Neonatal Care

ENBC Essential new-born care

EOC Emergency Operations Center

EPAQ Ethiopian Primary Health Care Alliance for quality

EPHI Ethiopian Public Health Institute

EPHIA Ethiopia Population Based HIV Impact Assessment

EPI Expanded Program on Immunization

EPSA Ethiopia Pharmaceutical Supply Agency

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EPTB extra pulmonary tuberculosis

ETB Ethiopian Birr

FMOH Federal Ministry of Health

FP family planning

GBD Global Burden of Disease

GBV Gender Based Violence

GDP Gross Domestic Product

GGE General Government Expenditure

GGHE General Government Health Expenditure

GGI Good Governance Index

GII Gender Inequality Index

GMP Growth Monitoring and Promotion

GTP Growth and Transformation Plan

HALE Healthy Life Expectancy

HAPCO HIV/AIDS Prevention and Control Office

HBV Hepatitis B Virus

HCF Healthcare Financing

HCI Human Capital Index

HCMIS Health commodity Management Information System

HCs Health Centers

HCV Hepatitis C Virus

HDI Human Development Index

HDSS Health and Demographic Surveillance System

HEHD Hygiene and Environmental Health Directorate

HEP Health Extension Program

HEPHD Health Extension and Primary Health Directorate

HERQA Higher Education Relevance and Quality Agency

HEW Health Extension Workers

HF Health Facility

HHM Health Harmonization Manual

HiAP Health in All Policies

HIS Health Information System

HIT Health Information Technician

HITD Health Information Technology Directorate

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

HP Health Post

HPV Human Papilloma Virus

HRD Human Resource Directorate

HRH Human Resource for Health

HRIS Human Resources Information System

HSTP Health Sector Transformation System

HSTQ Health Service Transformation in Quality

HTA Health Technology Assessment

ICMNCI Integrated Community Case Management of Newborn & Childhood Illness

ICT Information Communication Technology

ICU Intensive Care Unit

IDP Internally Displaced People

IHR International Health Regulation

IMNCI Integrated Management of Neonatal and Child Illness

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IMR Infant Mortality Rate

INVEA Immigration, Nationality and Vital Event Agency

IR Information Revolution

JCCC Joint Core Coordinating Committee

JCF Joint Consultative Forum

JRM Joint Review Mission

JSC Joint Steering Committee

KM Knowledge Management

KMC Kangaroo Mother Care

KPI Key Performance Indicators

KPP Key and Priority Populations

LAN Local Area Network

LIP Leadership Incubation Program

LLINs Long-Lasting Insecticidal Net

LMIS Logistic Management Information System

LQAS Lot Quality Assurance Sampling

M&E Monitoring and Evaluation

MCC Motivated, Competent and Compassionate

MCH Maternal and Child Health

MCV Measles Containing Vaccine

MDG Millennium Development Goals

MFR Master Facility Registry

MHM Menstrual Hygiene Management

MMR Maternal Mortality Ratio

MNH Maternal & Newborn Health

MOE Ministry of Education

MOH Ministry Of Health

MPDSR Maternal and Perinatal Death Surveillance and Response

MSWT Multi-Sectoral Woreda Transformation

MTCT Maternal to Child Transmission

MTR Mid-Term Reviews

NAPHS National Action Plan for Health Security

NCDI Non-Communicable Diseases and Injuries

NCoD National Classification of Disease

NGO Non-Governmental Organizations

NHA National Health Account

NHDD National Health Data dictionary

NICU Neonatal Intensive Care Unit

NNMR Neonatal Mortality Rate

NNP National Nutrition Programme

NNT Neonatal Tetanus

NTD Neglected Tropical Diseases

ODF Open Defecation Free

OHT OneHealth Tool

OOP Out of Pocket

OPD Out Patient Department

ORS Oral Rehydration Salt

PCD Partnership and Cooperation Directorate

PHC Primary Health Care

PHCU Primary Health Care Unit

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PHEM Public Health Emergency Management

PLHIV People Living with HIV

PMT Performance Monitoring Team

PMTCT Prevention of Mother to Child Transmission of HIV

PNC Postnatal Care

PPP Public-Private Partnership

QI Quality Improvement

QUALY Quality-Adjusted Life-Year

RDQA Routine Data Quality Assessment

RDT Rapid Diagnostic Test

RED Reach Every District

RHBs Regional Health Bureau

RHD Rheumatic Heart Disease

RIS Regulatory Information System

RMNCAYH Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health

RMNCH Reproductive, Maternal, Neonatal and Child Health

RRT Rapid Response Team

SALTS Saving Life Through Safe Surgery

SARA Service Availability and Readiness Assessment

SDGs Sustainable Development Goals

SHI Social Health Insurance

SPA Service Provision Assessment

SPM Strategic Planning and Management

SRH Sexual and Reproductive Health

STH Soil Transmitted Helminthiasis

STI Sexually Transmitted Infections

SUD Substance Use Disorders

SWOT Strengths, Weaknesses, Opportunities and Threats

TB Tuberculosis

TF Total Fertility

TFC Treatment Follow up Centers

TFR Total Fertility Rate

THE Total Health Expenditure

TICs Treatment Initiating Centers

TVET Technical Vocational Educational Training

U5MR Under 5 Mortality Rate

UHC Universal Health Coverage

USD United States Dollar

VLBW Very Low Birth Weight

VMMC Voluntary Medical Male Circumcision

VPN Virtual Private Network

VSD Very Sever Disease

WASH Water, Sanitation and Hygiene

WBHSP Woreda Based Health Sector Plan

WDG Women Development Group

WHO World Health Organization

WoHo Woreda Health Office

ZHD Zonal Health Department

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EXECUTIVE SUMMARY

This is the second Health Sector Transformation Plan (HSTP-II) covering the period between Ethiopian fiscal years 2013 and 2017 (July 2020–June 2025). HSTP-II was developed as the first part of a 10-year health sector plan. It was prepared based on an in-depth situational analysis and performance evaluation of HSTP-I; it takes into consideration the country’s global commitments and aligns with its overall macro-economic development framework.

HSTP-I (July 2015–June 2020) achieved significant achievements despite ongoing challenges, such as internal conflicts leading to population displacement and the COVID-19 pandemic.

The HSTP-I period was marked by encouraging improvements in life expectancy at birth. This included notable reductions in maternal mortality (decreased 676 deaths per 100,000 live births in 2011 to 401 in 2017). In addition, under-5 mortality and infant mortality per 1000 live births decreased from 123 and 77 in 2005 to 59 and 47, respectively, in 2019. However, over the years, there have been no significant reductions in neonatal mortality (33 deaths per 1,000 live births in 2019).

Morbidity and mortality from common communicable diseases, including malaria, HIV, tuberculosis (TB), and vaccine preventable diseases, declined dramatically during HSTP-I. However, the same period witnessed a substantial rise in the prevalence of non-communicable diseases. Although the burden of neglected tropical diseases (NTDs) is decreasing, the proportion of people affected remains considerable.

In terms of disease risk factors, there has been a relatively high level of reduction in unsafe sex behaviour.

The prevalence of stunting, underweight, and wasting have also diminished from 51% to 37%, from 33% to 21%, and from 12% to 7% respectively, between 2005 and 2019.However, risks from water, sanitation, and hygiene (WASH) and dietary factors, alcohol use, and high blood glucose level showed a lower rate of reduction.

The performance of major health programs has improved, as seen by an increase in the utilization of certain health services. For instance, in 2019, 41% of married Ethiopian women were using contraception compared to just 27% in 2011 and 35% in 2016 (the unmet need remains considerably high at 22%). Antenatal care visit 1 (ANC1) coverage also improved from 62% in 2016 to 74% in 2019, although only 43% of pregnant women had four or more visits. Skilled birth delivery has increased from 28% in 2016 to 50% in 2019. The mean availability of tracer items for basic emergency obstetrical care (BEMOC) stands at more than 85% for hospitals, 74% for health centers (HCs) and 55% for higher-level clinics. Access to safe abortion services and post-abortion care has also expanded. In terms of child health, in 2019, the proportion of children receiving three doses of pentavalent vaccine and all basic vaccines reached 61% and 43%, respectively.

There has also been impressive progress in prevention and control of major communicable diseases.

Ethiopia is on track to achieve one of the three targets of the Global End TB Strategy; TB incidence has declined by 21% from the

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2015 estimate (as compared to a targeted decline of 20%). TB case notification has been improving, with a detection rate of 71% in 2019/20. TB treatment success and cure rates also reached 95% and 80%, respectively in 2019/20. There has also been progress towards achieving two of the 90-90-90 targets for HIV: 90% of people who know their status were on ART, with 91% achieving viral supersession.

Furthermore, in 2019/20, 91% of eligible mothers received services for antiretroviral therapy and prevention of mother-to-child transmission were available in 84% of public health facilities. Malaria control initiatives have been on track. Between 2015 and 2019, malaria deaths dropped from 3.6 to 0.3 per 100,000 among populations at risk. Malaria case incidence has dropped from 5.2 million in 2015 to under 1.6 million in 2019/20.

Several interventions have been implemented to enhance financial risk protection in accessing essential health services. These include provision of high-impact interventions free of charge through an exemption program; subsidization of more than 80% of the cost of care in public health facilities; implementation of community-based health insurance (CBHI) schemes; and full subsidization of the very poor through fee waivers for both health services and CBHI premiums. A revised health care financing strategy was developed within the framework of achieving the goal of universal health coverage.

To address the social and environmental determinants of health, the Government of Ethiopia has taken steps to strengthen engagement with key local and international sectors and stakeholders, for example in the nutrition and WASH programs. There have been multi-sectoral collaborative activities and interventions to improve the status of food security and nutrition, including the high-level government commitment platform, -the “Seqota” Declaration to end child under-nutrition by 2030. The government implemented major strategic initiatives to improve hygiene and environmental health, such as- urban sanitation, scale up of community-led and school-led total sanitation and hygiene, sanitation marketing, and actions to build adaptation and resilience to climate change into the health sector.

The three-tier health system—primary, secondary and tertiary—continues to be the backbone of health service delivery. The primary health care infrastructure has expand enormously, with potential coverage reaching more than 90% in 2019. The Health Extension Program continues to make significant contributions towards improved health indicators in the country. In the second- and third-tier facilities, implementation of strategic initiatives and reforms has strengthened pre-hospital and hospital clinical care. Overall, outpatient attendance rate increased from 0.27 to 0.9 per capita per year between 2000 and 2019.

In 2019, the Essential Health Service Package (EHSP) was revised and endorsed with emphasis on service availability, accessibility, acceptability, and affordability. The 1993 Health Policy has undergone revision and is currently being finalized. Based on the HSTP-I M&E (monitoring and evaluation) framework, the health information system was strengthened to generate data to the monitor the performance and various components of the plan.

An effective leadership and governance system further strengthened the legal and regulatory framework for the implementation of HSTP-I. In addition, stakeholder engagement and partnership with the health sector was strengthened through such platforms as the Joint Steering Committee meetings with Regional Health

Bureaus, the Executive Committee Meetings with agencies; and the regular meetings of the Joint Consultative Forum and the Joint Core Coordinating Committee.

Four transformation agendas were implemented during HSTP-I: 1) Woreda Transformation, 2) Information Revolution, 3) Transformation in Quality & Equity, and 4) Compassionate, Respectful, and Caring Health Workers. Leadership at all levels prioritized and closely monitored these agendas; and the agendas were successful in mobilizing resources and strengthening health sector’s efforts to achieve the positive results described above.

HSTP-II aims to build on the successes of the HSTP-I period, incorporating the lessons from its implementation. HSTP-II is aligned with the country’s overall macro-economic development framework. The plan was developed in a consultation with the National Plan and Development Commission by employing Strategic Planning and Management tool, and using an inclusive and active participatory process led by the health sector. The process included iterative gathering of feedback during which different versions of the Plan were shared with a wide range of stakeholders, including government sectors and agencies, regional health bureaus, academia, professional associations, the private sector, civil service organizations, and development partners.

The overall objective of HSTP-II is to improve the health status of the population –by accelerating progress towards universal health coverage, protecting populations during health emergencies, transforming woredas, and improving the health system’s responsiveness.

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HSTP-II has targets to measure its objectives and performance that are developed by considering baseline, national and international standards and anticipated resources. For instance, HSTP-II has set ambitious targets to reduce the maternal mortality rate to 279 per 100,000 live births and to reduce under-5 and neonatal mortalities to 44 and 21 per 1,000 live births, respectively. In terms of service uptake, targets include increasing skilled delivery attendance to 76%, coverage of ANC 4 to 81%, and coverage of pentavalent (3), TB detection rate and ART coverage to 90%, 81%, and 95%, respectively. The list of all indicators with the corresponding targets appears in the “Targets” section.

The Government of Ethiopia developed 14 strategic directions, along with their major activities, to achieve the targets laid out in HTSP-II:

▪ Enhance provision of equitable and quality comprehensive health service

▪ Improve health emergency and disaster risk management

▪ Ensure community engagement and ownership

▪ Improve access to pharmaceuticals and medical devices and their rational and proper use ▪ Improve regulatory systems

▪ Improve human resource development and management

▪ Enhance informed decision-making and innovations

▪ Improve health financing

▪ Strengthen governance and leadership

▪ Improve health infrastructure

▪ Enhance digital health technology

▪ Improve traditional medicine

▪ Enhance health in all policies and strategies

▪ Enhance private engagement in the heath sector

Five priority issues were identified as part of the transformation agenda for HSTP-II. Key interventions will be implemented to address these priority issues to transform the health system and to achieve health for all. The transformation agenda are:

1. Quality and Equity: Ensuring equity in delivery of quality health services by creating high-performing primary health care units, ensuring active engagement of the community in service delivery, and continually improving clinical care outcomes.

2. Information revolution: Significantly improving methods and practices for collecting, analyzing, presenting, using, and disseminating information that can influence decisions.

3. Motivated, competent, and compassionate health workforce:- Ensuring equitable distribution and availability of an adequate number and skill mix of health workers who are motivated, competent, and compassionate to provide quality health services.

4. Health financing: Reforming public financial management and health financing to improve efficiency and accountability, while pursuing the agenda of sustainable domestic resource mobilization for health. 5.

Leadership: Enhancing leadership and governance mechanisms at all levels of the health system to drive attainment of the national strategic objectives through activities to ensure alignment and harmonization, thereby creating an enabling environment for the translation of plans into results.

The overall costing for HSTP-II implementation was computed using OneHealth Tool (OHT), a tool based on the WHO’s six health system building blocks framework. Accordingly, U.S. dollars $21.88 billion and $ 27.55 billion at base and high-case scenario respectively is required for the five years to be covered in the plan, while the available financial resources during that period are projected at $18.7 billion, $19.7 billion, and $21.9 billion for low-, medium-, and high-case scenarios, respectively.

HSTP-II will be cascaded to all levels of the health system, and will be translated into annual operational plans using the woreda-based health sector annual plan. Its implementation will be regularly monitored using the agreed monitoring framework in a coordinated manner.

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Chapter 1

INTRODUCTION

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Ethiopia has accomplished the second growth and transformation plan (GTP-II, June 2015 – June 2020), marked by several positive results and achievements. However, this period was also marred by internal conflicts, resulting in large displacement of populations and creating additional burden to the health system.

In addition, the COVID-19 pandemic posed a clear threat to ongoing reforms and relatively strong economic growth, with wide-ranging, serious impacts across the country. Nevertheless, the country has still managed to achieve impressive progress in transforming the socioeconomic status of its people.

The first Health Sector Transformation Plan (HSTP-I) was the health chapter of the GTP-II and the first phase of the “Envisioning Ethiopia’s Path towards Universal Health Coverage through Strengthening Primary Health Care by 2035.” The performance of HSTP-I has been critically reviewed through annual performance reviews and ad hoc assessments, including routine Health Information Management System (HMIS) assessments, mid-term reviews, Joint Review Mission reports, and various population- and facility-based surveys.

These reviews show that Ethiopia has achieved the goals of the GTP despite the challenges mentioned above. These achievements were made possible due to the implementation of high-impact interventions, primarily through flagship community-based programs such as the Health Extension Program (HEP).

Through the implementation of the four Transformation Agendas (1. Woreda Transformation, 2. Information Revolution, 3. Transformation in Quality & Equity, and 4. Compassionate, Respectful, and Caring Health Workers), the health sector has developed momentum to address critical health system bottlenecks. The health sector has also ardently advocated for multi-sectoral collaboration to address the social determinants of health. However, the COVID-19 pandemic caused an important setback and threatened to unwind these gains and achievements.

The second Health Sector Transformation Plan (HSTP-II) is the next five-year national health sector strategic plan, which covers the period between 2013–2017 Ethiopian fiscal years (July 2020–June 2025). During this strategic period, the sector envisions building on the successes and consolidating the gains of HSTP-I to build a resilient, sustainable, high-quality, equity-based health system. Thus, the preparation of HSTP-II was informed by in-depth situational analysis of the performance of the health sector during HSTP-I. The plan also took into account the nation’s long-term socioeconomic strategic directions and priorities, the global situation and country’s commitments to sustainable development goals, and the dynamics of social determinants of health.

The Ministry of Health (MOH) and Regional Health Bureaus (RHBs) used an active participatory process to develop the HSTP-II. The health sector first identified the nation’s long-term strategic goals in consultation with the National Plan and Development Commission, using the Strategic Planning and Management tool. A series of consultations were held with the private sector, academia, professional associations, other government sectors and development partners. These consultations were instrumental in developing a comprehensive plan and ensuring commitment and shared vision among all stakeholders, and the resulting feedback was incorporated in the plan.

HSTP-II’s objectives and strategic directions were developed based on the situational analysis of the HSTP-I;

and the baseline and targets were developed using data from recent surveys and in consultation with program experts. Costing and target setting was developed using a OneHealth tool designed to inform national strategic health planning in low- and middle-income countries by linking strategic objectives and targets of health programs to the required investments in health systems.

The six chapters that follow give a comprehensive overview of HSTP-II. Chapter 2 covers the country context; Chapter 3 describes the situation analysis; Chapter 4 outlines the objectives, targets, and strategic directions of HSTP-II; Chapter 5 details the costing and financial gap analysis; Chapter 6 describes the implementation arrangement; and Chapter 7 covers the monitoring and evaluation (M&E) plan.

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Chapter 2

COUNTRY CONTEXT

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Geography Ethiopia is located in the North-Eastern part of Africa, also known as the Horn of Africa. It is bordered by Sudan and South Sudan on the west, Eritrea and Djibouti on the northeast, Somalia on the East and Southeast, and Kenya on the south. Ethiopia lies between the Equator and Tropic of Cancer, between the 30oN and 150oN Latitude and 330o E and 480o E longitude.

The country occupies an area of 1.1 million km2 and water bodies occupy 7,444 km2. Ethiopia is a country with rich geographical diversity that includes rugged mountains, flat-topped plateaus, deep gorges, and river valleys. Over the ages, erosion, volcanic eruptions and tectonic movements have contributed to the nation’s diverse topography. More than half of the geographic area of the country lies 1,500 m above sea level. The highest altitude is at Ras Dashen (4,620 m above sea level) and the lowest altitude is at Danakil (Dallol) Depression (148 m below sea level).

Demographic Profile With a population of about 101 million in 2020, Ethiopia is the second most populous country of Africa and ranks 12th in the world. Ethiopia is the home to various ethnicities, with more than 80 different spoken languages. The country is characterized by rapid population growth (2.6%), young age structure, and a high dependency ratio, with a high rural-urban differential. Ethiopia has a high total fertility rate of 4.6 births per woman (2.3 in urban areas and 5.2 in rural areas) and a corresponding crude birth rate of 32 per 1000 in 2016. The average household size is 4.6. By 2024, the population is projected to reach 109.5 million (Central Statistics Agency, Juy 2013) and will reach 122.3 million by 2030 (See Figure 1 below).

Children under age 15 years and individuals in the age group of 15-65 years account for 47% and 49% of the population, respectively. Only 4% of the population is above the age of 65 years. The sex ratio between males and females is almost equal, and women of reproductive age constitute about 23% of the population.

Nearly 80% of the population lives in rural areas mainly depend on subsistence agriculture (Central Statistics Agency, Juy 2013).

population by age and sex (percent)

2020 2029

80 MALE

FEMALE MALE FEMALE

75-79 75-79

70-74 70-74

65-69 65-69

60-64 60-64

54-59

54-59

50-54 50-54

45-49 45-49

40-44 40-44

35-39 35-39

30-34 30-34

25-29 25-29

20-24 20-24

15-19 15-19

10-14 10-14

5-9 5-9

0-4 0-4

6 4 2 0 2 4 6

6 4 2 0 2 4 6

Figure 1. Ethiopian population by age and sex (percent)

Demographic shift/dividend Ethiopia’s population age structure has the potential to yield demographic dividends since the majority of the population is young. However, harnessing this dividend will depend on the country’s ability to scale up human capital investments and address existing inequalities. With enhanced efforts to reduce health and education inequalities between urban and rural areas and among regional states, Ethiopia can benefit from accelerated economic growth and improve citizens’ quality of life. Strategic investments in health, education, economic policy, and governance will be crucial to achieve substantial gains from the demographic dividend.

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Socioeconomic situation Ethiopia is engaged in rapid, comprehensive development activities to transition from poverty to sustainable, reliable growth and prosperity. Since 1991, the country has implemented several macroeconomic policies, including a market-based and agriculture-led industrialization. The government has introduced initiatives to ensure successful transformation from an agrarian to industry-led economy. The country has registered commendable achievements on Millennium Development Goals (MDGs) mainly in reducing poverty head count, achieving universal primary education, narrowing gender disparities in primary education, reducing child and neonatal mortality, and combating HIV, TB, and malaria.

Ethiopia is a low-income country with a gross domestic product (GDP) per capita (current US$) of $772 in 2018, up from about $340 in 2010. It is one of the fastest-growing economies in Africa, experiencing an average annual growth of about 10% between 2004 and 2014. The main contributors to the economic growth are agriculture, industry, and service sectors. According to Ethiopia’s poverty assessment report, household poverty rate has diminished remarkably, by around 20%, between 2011 and 2016 (World Bank 2019). However, despite its significant economic growth, the country remains one of the world’s poorest.

Women’s empowerment has been an important feature of Ethiopia’s economic reform. The Ethiopian Constitution recognizes the principle of equality of access to economic opportunities, employment, and property ownership for women. According to a report by the Central Statistical Agency (CSA), the national income inequality coefficient increased from 0.298 in 2010/11 to 0.328 in 2015/16.

Between 2000 and 2017, Ethiopia’s Human Development Index value increased from 0.283 to 0.463, an increase of 63.5%. However, it remains below the average of 0.504. According to the 2019 World Bank report, Ethiopia’s Human Capital Index is 0.38, making Ethiopia 135th of 157 countries (The World Bank, 2019).

The road coverage has increased by six-folds compared to 1990, with total road length reaching 105,000 kms. Under the Universal Rural Road Access Program, about 10,765 rural kebeles are now connected, creating better access to health care for millions of mothers and children. Connectivity via modern communication devices has improved tremendously, with 32 million mobile phone subscribers, which expands opportunities for digital health.

Humanitarian impact and needs

Ethiopia is prone to natural and manmade shocks and stresses. The country experiences cyclical hazards that affect households, infrastructure, and system resilience. The periodic occurrence of regular outbreaks such as measles, yellow fever, and cholera poses a challenge to the health system, and the global COVID-19 pandemic has further tested the health system’s resilience. In 2020, an estimated 8.4 million needed humanitarian assistance (UNOCHA, 2020). Of these, women and children are disproportionately affected. For the health sector specifically, 5.9 million people are estimated to have humanitarian needs, including 1.2 million women and girls needing family planning and maternal health services. Among internally displaced people (IDPs), unmet need for health services for pre-existing and new disease conditions, physical and mental trauma, and sexual and gender-based violence (GBV) remains high. IDPs put additional pressure on local health systems, straining the health care work force and stocks of medicines and other essential supplies.

Position of the health sector in the country context Population health is both the means and outcome of development. A healthy population is an engine for economic growth. Investment in health can reduce poverty and catalyse wider cycle of economic growth.

Investment in health is also an outcome, as good economic status of a nation allocates more resource to keeping their people healthy. The latter depends on the country’s policies and strategies for safeguarding health.

The Ethiopian health sector, alongside other sectors, is playing its part as a means of economic growth. The contribution of the sector towards national socioeconomic development is critical, as equitable human development well-being relies on the health status and well-being of individuals and communities. Investing in health is an investment in current and future generations, and towards sustainable development. Health is also a measure of inclusive growth that should be commensurate with economic development. Otherwise, economic growth without equitable social development may not be sustainable. The health sector should therefore be viewed as a conduit to development, and as a means to ensuring social justice and sustainable economic development.

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Chapter 3

PERFORMANCE OF HEALTH SECTOR

TRANSFORMATION PLAN I – SITUATION

ANALYSIS

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This section provides a comprehensive overview of the progress made in achieving the Ethiopian health sector’s goals and objectives. The section also presents some of the key lessons from the implementation of HSTP-I, including strengths, weaknesses, opportunities, and threats (SWOT) and stakeholder analysis of the Ethiopian health system. The Ethiopian health system framework (Figure 2), adapted from the WHO African region framework, is used to analyze and structure the situation analysis.

Vision: To see a healthy, productive and prosperous society

Mission: To promote the health and wellbeing of the society through providing and regulating a comprehensive package of health services of the highest possible quality in an equitable manner y c n

Improved Health Status Economic Gain t c a p m

I e i c i f f

E e t a i s t d l e u s m e r e R t n

I

Universal Health Coverage Woreda Transformation

Health System Responsiveness Protect People from Health Emergencies s e s s e c o r

P y t i l a

Quality Service Delivery Health Promotion, Disease Prevention, Curative, Polliatuve

& Rehabilitative Services u

Q y t i u q

E g n h i t c l a n e a n

H i

F l s s a e t i c l i c p d u p e d u o

M r S

P e c h r t o l f a k e r o

H

W y t i n u m m o

C e r u t h c t l u r a t e s

H a r f n

I n o i h t t a l a m e r o H f n

I s t u p n

Is e l p i c n i r

P

Governance, Multisectoral Collaboration

Figure 2. Ethiopia’s health system framework (adapted from the WHO African regional framework)

Overall, while HSTP-I was successful on some fronts, the performance on certain domains in the health system framework, as measured by key performance indicators from its M&E framework, was in general sub-optimal. Table 1 summarizes the baseline, targets, and achievements of HSTP-I on key performance indicators. Details on specific topics are presented in subsequent sub-sections.

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Table 1. Summary of performance for HSTP-I key performance indicators

Domain Indicator 2015 baseline HSTP-I Target Achievement

Life expectancy at birth (in years) 64 69 65.5

Maternal morality ratio 420 199 401

Under five mortality (per 1,000 live births) 64 30 59

Infant mortality (per 1,000 live births) 44 20 47

Neonatal morality (per 1,000 live births) 28 10 33

Health status

Status of Priority Health Programs

Health Security

Health System Investments Stunting (under five years old) 40 26 37 Wasting

(under five years old) 9 4.9 7 HIV incidence rate

(per 1,000) 0.03 0.25 0.16 TB incidence rate (per

100,000) 224 156 151 TB mortality rate (per

100,000) 32 17 22 Malaria death rate (per

100,000) 0.6 0.32 Contraceptive prevalence rate

42 55% 41% Unmet need for FP 24 10% 22%

ANC (at least four visits) 95% 43% Skilled birth attendance 90% 50% Postnatal care coverage

95% 34% Still birth rate (per 1000 live births) 18

10 15 CS rate as proportion of births 2.2 8 4 ART to prevent MTCT of HIV 59% 95% 91% Three doses of pentavalent immunization 98% 61%

Exclusive breast feeding at six months 72% 59%

ART coverage – Adult >=15 years 82% 90%

75.8% TB case detection rate 61% 87% 71% TB treatment success rate 92% 95% 95% Proportion of women screened for cervical Ca 0.6% 20% 5%

% of HHs with safe water source 35% 28% OPD attendance per capita 0.48 2 0.9 Average length of stay 4.3 5 days 4.5 days Health emergency risk management

Proportion of emergency affected people provided rehabilitation 36% 95% 84% Proportion of epidemics controlled NA 85% 80% Health workers per 1,000 population 0.84 1.6 1.74 Proportion of Woredas with CBHI 15% 80% 70%

OOP as a proportion of THE 33.7% 15% 31% % of HCs with BEmONC 56% 100% 74% % of hospitals with CEmONC 83% 100% 85% Essential medicines availability at PHC 90% 100% 48% Report completeness 72% 90% 89%

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3.1 HEALTH STATUS AND

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

3.1.2 Major causes of mortality and morbidity

Ethiopia is currently facing triple burden…