HSTP-II_July_2020_Version 4_.docx.pdf

Federal Democratic Republic of Ethiopia

Ministry of Health

Health Sector Transformation Plan II

2020/21-2024/25

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July 21, 2020

Contents

List of Acronyms 5

Foreword by the Minister 10

Executive Summary 11

Chapter 1: Introduction 16

Chapter 2: Country Context 18

Chapter 3: Performance of Health Sector Transformation Plan I – Situation Analysis 22

3.1. State of Health and Wellbeing in Ethiopia 22

3.1.1. The state of healthy life 22

3.1.2. Major causes of morbidity and mortality 23

3.1.3. Risk factors driving morbidity and mortality 25

3.2. The status of priority health programs and related problems 25

3.2.1. Performance of major Health programs 25

3.2.2. Financial Risk Protection 33

3.2.3. Status of health security in Ethiopia: Public Health Emergency Management 34

3.2.4. Social Determinants of heath: Status of Nutrition and WASH programs 34

3.2.5. Health System Responsiveness 36

3.3. Health system investments 37

3.3.1. Investment in Health workforce 37

3.3.2: Investment in health infrastructure 38

3.3.3: Investment in health products 39

3.3.4. The status of health service delivery 41

3.3.5 Health Information System (HIS) and Research and Development (RD) 43

3.3.6. Health financing system 46

3.3.7. Health system leadership and governance 47

3. 4. The state of equity in the health sector 49

3.4.1. Geographic disparities in health 49

3.4.2. Gender disparities in health 50

3.4.3. Socio-economic disparities 51

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3.5. Summary of the performance of selected HSTP I indicators 52

3.6. Status of Transformation Agenda 53

3.6.1. Woreda Transformation 53

3.6.2. Information Revolution 54

3.6.3. Compassionate, Respectful and Caring Health workforce 54

3.6.4. Transformation in Quality & Equity of Health Services 55

SWOT Analysis 56

Stakeholder Analysis 58

Chapter 4: Health Sector Transformation Plan II: Objectives, Targets and Strategic Directions 60

4.1. Vision 60

4.2. Mission: 60

4.3. Values 60

4.4. Objectives 60

4.5. Targets 65

4.6. Strategic Directions 72

4.7. Transformation Agenda 103

Chapter 5: Costing and Financing 114

5.1 Costing 114

5.2 Financial space and costing analysis 125

5.3. Gap analysis 132

Chapter 6: Implementation Arrangement 134

6.1. Integration efforts 135

6.2. HSTP II governance 136

6.3. Planning and budgeting 137

6.4. Health service delivery arrangements 138

6.5. Optimizing monitoring and review systems 140

6.6. Inter-sectoral collaboration 141

6.7. Public private partnership 142

6.8. Fostering innovation through health technology assessment and adaptation 142

6.9. Risks and Mitigation 143

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Chapter 7: Monitoring and Evaluation Plan 145

7.1. Monitoring and Evaluation Framework 145

7.2. Indicators 147

7.3. Index measurement in HSTP II 147

7.4. Transforming data into information and information into action: the data cycle 151

7.4.1. Data sources 151

7.4.2. Data quality 153

7.4.3. Reporting 154

7.4.4. Use of information for action 154

7.5. Performance review 155

7.6. Evaluation 156

7.7. Dissemination and communication 156

7.8. Coordination, Policy and Institutional Environment for Monitoring and Evaluation 156

Annex 1: Indicators and Targets of HSTP II 158

Annex 2: List of Surveys to be conducted in HSTP II period 168

Annex 3: Ethiopia’s Health System Framework 169

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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 Four visits 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

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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 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

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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 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

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NCDI Non-Communicable Diseases and Injuries NCoD National Classification of Disease NGO Nongovernmental 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 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

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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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Foreword by the Minister

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Executive Summary This is the second Health Sector Transformation Plan (HSTP-II) covering the period between 2013-2017 Ethiopian fiscal years (July 2020 – June 2025). HSTP-II is developed as the first part of a ten-year health sector plan. The preparation of HSTP-II is based on an in-depth situational analysis and performance evaluation of HSTP-I and considering the country’s commitment at global level and aligned with its overall macro-economic development framework.

As critically reviewed using its monitoring and evaluation framework, the implementation of HSTP-I has registered significant results & achievements despite going through various challenges such as conflicts leading to internal displacement of people & the COVID-19 pandemic at the last year of the plan period adding to the straining of the already over-burdened health system.

Encouraging improvements in life expectancy at birth are among the achievements recorded in HSTP-I period, even though pre-mature death and suboptimal quality of life still constitute major development challenges. The reduction in maternal mortality is also notable, as it went down from 676 deaths per 100,000 in 2011 to 401 in 2017. Under-5 mortality and infant mortality per 1000 live births has also reduced from 123 and 77 in 2005 to 59 and 47 in 2019, respectively.

Neonatal mortality, however, has not shown a significant reduction over the years. Though there was a reduction from 39 deaths per 1000 live births in 2005 to 29 in 2016, it went up to 33 deaths per 1,000 live births in 2019.

Dramatic decline has occurred in morbidity and mortality from common communicable diseases including malaria, HIV, TB and vaccine preventable diseases. With such decline, however, the contribution of non-communicable diseases has substantially risen. The burden of Neglected Tropical Diseases (NTDs) is also going down, even though the magnitude of population they affect is still considerable.

In terms of disease risk factors, a relatively high level of reduction has been observed in unsafe sex behaviour, while risks from WASH and dietary factors, alcohol use, and blood glucose level showed a lower rate of reduction. Reductions have also been seen in the prevalence of stunting, underweight, as well as wasting – from 51% to 37%, from 33% to 21%, and from 12% to 7% respectively between 2005 and 2017.

The performance of major health programs has substantially improved as shown in the increased utilization of health services. Accordingly in 2019, 41% of married Ethiopian women were using contraception compared to just 27% in 2011 and 35% in 2016, even though there is still considerable (22%) unmet need. ANC1 coverage has also improved from 62%% in 2016 to 74%

Page | 11 in 2019, though it is only 43% of pregnant women had four or more visits. Skilled delivery has increased from 18% in 2016 to 50% in 2019, and mean availability of tracer items for BEmOC was more than 85% for hospitals, 74% for HCs and 55% for higher clinics. Access to safe abortion services and post-abortion care has also been expanded. In terms of child health, the proportion of children receiving three doses of pentavalent vaccine and all basic vaccines reached 61% and 43%, respectively in 2019.

Prevention and control of major disease burdens also seems to be impressive. The country is on track for achieving one of the three targets of the Global End TB strategy by meeting its milestone of reducing incidence by 21% from the 2015 estimate (as compared to a 20% target).

TB case notification has been improving, with a detection rate of 69%; TB treatment success and cure rates also reached 95% and 84%, respectively in 2019. There was also progress towards achieving the second and third 90s of the three 90 HIV targets of 2020 in that 80% of known HIV infected individuals were on ART with 89% viral supersession. Furthermore, 74% of eligible mothers in 2019 have received ART, and PMTCT service is available in 84% of public health facilities. Similarly, malaria control is on track for a 40% reduction in incidence and mortality by 2020. Between 2015 and 2019, malaria deaths have dropped from 3.6 to 0.3 per 100,000 populations at risk and malaria case incidence has dropped from 5.2 million in 2015 to less than one million in 2019. About 25% of health facilities in the country have integrated mental health service into their general services.

To address the risk of financial barriers in accessing essential health services, the government has implemented several strategies. These strategies include provision of high impact interventions free of charge through an exemptions program; subsidization of more than 80% of the cost of care in government health facilities; implementation of CBHI schemes; and full subsidization of the very poor through fee waivers both for health services and for CBHI premiums. A revised health care financing strategy was developed within the framework of the goal of achieving universal health coverage (UHC).

Among the measures that have been in place to address the social determinants of health through multi-sectoral engagement with local and international stakeholders include nutrition and WASH programs. Multi-sectoral collaborative efforts & interventions have been implemented to improve the status of food security and nutrition in the country, including a multi-sectoral and high-level government commitment platform - the “Seqota” Declaration to end child under-nutrition by 2030. With regard to hygiene and environmental health, major strategic initiatives were implemented, such as: urban sanitation; scale up of community led and school led total sanitation and hygiene; sanitation marketing and building adaptation and resilience to climate change in the health sector

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The delivery of health services continued to be structured into a three-tier system - primary, secondary and tertiary level health care. The primary health care infrastructure has made huge expansion in terms of potential coverage reaching more than 90% in 2019. Similarly, outpatient attendance rate also reached 0.9 per capita per year. Being the main platform for delivery within the primary care level, the HEP has continued to significantly contribute to improvements in health indicators. At the second and third tier levels, pre-hospital and hospital clinical care has been strengthened through the implementation of strategic initiatives and reforms.

Regarding policies and guidelines, the revision of the 1993 health policy is being finalized. The essential health services package was also revised and approved with emphasis on services availability, accessibility, acceptability as well as affordability. The performance of HSTP-I was regularly monitored and periodically evaluated using its monitoring and evaluation framework.

Health information was generated through the various components of the M&E framework.

Appropriate legal and regulatory system was in place demonstrating the commitment of the government for the implementation of HSTP-I through effective leadership and governance of the health system. In addition, stakeholders’ engagement and partnership with the health sector for the implementation was facilitated through platforms that include the Joint Steering Committee (JSC) meetings with RHBs, the Executive Committee Meetings with agencies; and the regular meetings of the Joint Consultative Forum (JCF) and the Joint Core Coordinating Committee (JCCC).

In HSTP I, the health sector identified and implemented four transformation agenda. During this period, the agenda reached the attention of all actors and were closely monitored by the leadership at all levels. These transformation agenda played pivotal role in mobilizing resources, gearing and catalysing the health sector efforts which resulted in tremendous achievements.

HSTP-II was developed building upon the successes and challenges as well as making an in-depth situational analysis and performance evaluation of HSTP-I, and in consideration of the country’s commitment to global situations. It is also aligned with the country’s overall macro-economic development framework through a consultation with the National Plan and Development Commission and by employing Strategic Planning and Management (SPM) tool.

Led by the health sector, the plan development process was participatory with the inclusion of representatives from various health sector stakeholders. The process has also been iterative through the development and release of a series of versions of the plan for comments and inputs by partners, health bureaus, professional and civil services organizations, as well as members of the academia.

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The overall objective of HSTP II is to improve the health status of the population through realization of - accelerating progress towards Universal Health Coverage; protecting people from health emergencies; contributing towards transformation of households; and improving health system responsiveness.

The plan has set targets to measure its objectives and target setting was done using OneHealth tool and by considering baseline, national and international standards and anticipated resources.

HSTP-II sets ambitious targets to reduce MMR per 100,000 live births, U-5 and neonatal mortalities per 1000 live births to 277, 43 and 35 respectively. In terms of service uptake some of the targets but not limited to increasing skilled delivery attendance to 76%, ANC 4 coverage to 81%, Pentavalent three coverage to 98%, TB detection rate to 88%, ART coverage to 90% and the list of all indicators with the corresponding targets is presented in the “Targets” section.

To achieve the targets, a list of 14 strategic directions are identified and each is described along with their major activities:

▪ 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;

▪ Ensure integration of health in all policies and strategies; and

▪ Enhance private engagement in the heath sector

HSTP-II has also identified five transformation agenda with their respective interventions that will help the sector to transform and result in better health for all. The transformation agenda identified within HSTP-II include:

1. Transformation in equity and quality of health service delivery – which refers to ensuring delivery of quality health services and creating a high performing primary health care units, engaging the community in service delivery and consistently improving the outcome of clinical care.

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2. Information revolution – which refers to the phenomenal advancement on the methods and practice of collecting, analyzing, presenting, using and disseminating information that can influence decisions;

3. Transformation in Health Workforce:- that aims at ensuring the availability of adequate number and mix of quality health workforce that are Motivated, Competent and compassionate (MCC) to provide quality health service

4. Transformation in health financing – which is about reforming the financing and management structure of the health system so as to mobilize adequate and sustainable health financing and improve efficiency;

5. Transformation in leadership – which deals with enhancing the leadership and governance system at all levels of the health system to drive attainment of the national strategic objectives through improving aligning and harmonizing efforts, creating enabling environment to translate the plan to results and enhancing effective utilization of resources

The overall costing for HSTP-II implementation is computed using OneHealth Tool (OHT), a tool that is built on the WHO’s six health system building blocks framework. Accordingly, USD

24.5 billion and USD 29.9 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 USD 19.8 billion, USD 22.2 billion and USD 23.4 billion for low, medium and high case scenarios respectively.

The plan will be cascaded to all levels 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

Ethiopia has accomplished the second growth and transformation plan (GTP-II) that spanned from June 2015 – June 2020. During this period, though the country registered different positive results and achievements, the country has gone through conflicts that results in short lived massive internal displacement of people that created additional burden to the health system in addressing the health care needs of these people. The COVID-19 pandemic happened in the fifth year of the strategic period and has posed big challenges to the health system and impacted the socioeconomic progresses the country has envisioned. Despites all the tides, the country has achieved tremendous progress in terms of transforming the socio-economic 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 reviewed critically using its annual performance reviews and ad hoc assessments, including Health Information Management System (HMIS), the Mid-Term Reviews (MTR), the Joint Review Mission reports and different population and facility-based surveys.

The review findings showed that the country has successfully realized the goals of the plan overcoming all the challenges it has faced during the strategic period. The country has made tremendous achievements from implementing high impact interventions mainly through its flagship community focused program known as the Health Extension Program. The health sector has been successful in stirring momentum in the health sector through the implementation of the four transformation agendas. The four transformation agendas namely Woreda Transformation, Information Revolution, Transformation in Quality & Equity and Compassionate, Respectful and Caring health workers engendered momentum with the health sector to transform critical barriers

Page | 16 of the health system. The health sector has also rigorously advocated the need for multi-sectoral collaboration to address social determinants of health and thereby to realize socio-economic development in the country. Nonetheless, the COVID-19 pandemic that occurred at the fifth year of the strategic period has to some extent caused certain setbacks in health gains and has somewhat swayed implementation of some of the programs.

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). In this strategic period, the sector envisions to build on successes and consolidate the gains of HSTP-I. As such, the preparation of HSTP II was informed by in-depth situational analysis of the performance of the health sector during HSTP-I. The nation’s long-term socio-economic strategic directions and priorities, the global situation and country’s commitments to sustainable development goals, and the dynamics of social determinants of health were taken into consideration during the development of the plan.

The development of HSTP II perused a participatory process spearheaded by the ministry of health and regional health bureaus. The health sector first identified the long-term strategic goals of the nation through a consultation with the National Plan and Development Commission. The sector has employed Strategic Planning and Management (SPM) tool for the preparation of HSTP II with consultation and support from the national Plan and Development Commission. A series of consultations were conducted with the private sector, universities, professional associations, other government sectors and development partners. The consultations were instrumental to develop a comprehensive plan and ensure commitment of and a shared vision among all stakeholders. The feedback received from these consultative workshops and reviews of the draft plan were carefully documented, reviewed and incorporated accordingly.

The objectives and strategic directions were developed based on the situational analysis of the HSTP-I and baselines and targets were set based on the recent survey findings and in consultations with experts from the programs. The costing and target setting was developed using one health tool—a software 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 HSTP II document is organized into seven chapters: Chapter one is introduction, chapter two covers the country context; chapter three describes the situation analysis; chapter four deals with HSTP II objectives, targets and strategic directions; chapter five details the costing and financial gap analysis; chapter six describes the implementation arrangement and chapter seven covers the monitoring and evaluation plan.

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Chapter 2: Country Context

Geography and climate

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 square kilometers and the water bodies occupy 7,444

sq. km. Ethiopia is a country with rich geographical diversity. It consists of rugged mountains, flat-topped plateaus, deep gorges and river valleys. Its erosion, volcanic eruptions and tectonic movements over the ages have contributed to the nation’s diverse topography. More than half of the geographic area of the country lies above 1,500 m. 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 next to Nigeria and ranks 12th in the world. The country’s population grew from about 18 million in 1950 to 40 million in 1984, and from 54 million in 1994 to 74 million in 2007.

Ethiopia is the home to various ethnicities, with more than 80 different spoken languages. The population is characterized by rapid population growth (2.6%), young age structure and a high dependency ratio with a high rural-urban differential. Ethiopia has the highest total fertility rate

Page | 18 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. According to the 2007 population and housing census, the population of the country is projected at 109.5 million by 2024 (CSA projection). If it follows its current rate of growth, the population will reach 122.3 million by 2030.

The following figure shows the predicted population pyramid of Ethiopia for 2020 and 2029.

Children under age 15 accounted for 47% of the population and the age group of 15 and 65 years accounted for 49%, and individuals aged 65 and older accounted for only 4% of the total population. While the sex ratio between males and females is almost equal, women of reproductive age constitute about 23% of the population. The population is predominantly rural with nearly 80% living in rural areas, mainly based on subsistence agriculture. Source; EDHS 2016 and CSA

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

Demographic shift/dividend

As a result of Ethiopia’s commitment to reducing infant and child mortality, improving reproductive health and family planning, and the subsequent fertility decline, Ethiopia is on track to a population age structure that may enable a demographic dividend. However, harnessing this dividend depends on the country’s ability to scale up investments in human capital by addressing disparities among different equity dimensions. Different reports show that some regional states are not making sufficient progress in the key factors of the demographic dividend requiring intensified effort. With enhanced effort to reduce health and education disparities between urban and rural as well as among regional states, the country can gain a sizable demographic dividend that can fuel the reforms towards improving the quality of life of the people. Effective implementation of supporting policies, strategies and reform agendas are crucial to tap from the

Page | 19 opportunity of demographic dividend; otherwise the flipside of this may be a concern leading to social instability.

Socio-economic situation

Ethiopia is engaged in rapid and comprehensive development activities to transition from poverty to sustainable and reliable growth and prosperity. 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, combating HIV, TB and malaria.

Since 1991, Ethiopia has implemented a number of macroeconomic policies, including a market-based and agriculture led industrialization. Utmost efforts have been exerted by the government to ensure economic transformation from an agricultural to industrial led economy.

Ethiopia is classified by the World Bank as a low-income country with gross domestic product (GDP) per capita (current US$) of US$700 in 2016 (update with latest data), up from about US$340 in 2010. The country has been one of the fastest growing economies in Africa, experiencing rapid economic growth with an average of about 10% annual growth rate between 2004 and 2014. The main contributors to the growth in the GDP include agriculture, industry and service sectors. According to Ethiopia’s poverty assessment report, households have experienced a remarkable reduction in poverty rate from 39% of the population living below US$1.25 purchasing power parity a day in 2004/05 to 29% in 2010. The poverty levels fell by around 20% between 2011 and 2016 (World Bank, 2019). Despite rapid economic growth, the country remains one of the world’s poorest countries. Poverty and income inequality remain persistent challenges to Ethiopia.

The important feature of the economic reform in Ethiopia is empowering women through the creation of an enabling environment for equal opportunity for women to participate in the economic development of the country which is enshrined in the constitution. The Ethiopian Constitution recognizes the principle of equality of access to economic opportunities, employment and property ownership for women. Following this the government established Ministry of Women’s Affairs. According to the CSA report the national income inequality coefficient has increased from 0.298 in 2010/11 to 0.328 in 2015/16.

Ethiopia has increased and progress was made towards the attainment of the MDGs, particularly in hunger, gender parity in primary education, child mortality, HIV, and malaria. Between 2000 and 2017, Ethiopia’s HDI (Human development Index) value increased from 0.283 to 0.463, an

Page | 20 increase of 63.5% still it shows below the average of 0.504. According to the 2019 World Bank report, Ethiopia’s HCI (Human Capital Index) is 0.38, making Ethiopia 135th of 157 countries .1

The length of roads has reached 105,000 km, a six-fold increase compared to 1990 road coverage. About 10,765 rural kebeles are connected with the Universal Rural Road Access Program creating a better healthcare access to millions of mothers and children. Connectivity of citizens through modern communication means are showing a prominent stride evidence by 32 million mobile phone creating better electronic community health information system by supporting health extension workers to share basic healthcare services being implemented at community level.

Humanitarian impact and needs

Ethiopian’s national context cannot be analysed without recognizing Ethiopia’s risk profile to natural and manmade shocks and stresses. Ethiopia experiences cyclical hazards that affect households, infrastructure, and systems resilience. Like many countries in the world, the global COVID-19 pandemic has also tested Ethiopia’s health system resilience. Moreover, the occurrence of epidemics such as measles, yellow fever and cholera has also posed a challenge to the health system. In 2020, an estimated 8.4 million are in need of humanitarian assistance .2

Many of these people have not recovered from previous shocks and have decreased coping mechanisms to deal with future crisis. Women and children are disproportionately affected by humanitarian crisis, reflecting Ethiopia’s existing gender gaps and the unequal socio-economic burdens. There is a disparate effect of protracted food insecurity on women and girls, who are most negatively affected by macro- and micronutrient deficiencies, especially during their reproductive years. For the health sector specifically, 5.9 million people are estimated to have humanitarian needs, of which 1.2 million people are women and girls needing family planning and maternal health services. Internally Displaced People are more vulnerable and require additional health services for pre-existing and new disease conditions, physical and mental trauma, and sexual and gender-based violence. IDPs put additional pressure on local health systems, straining healthcare workers, stocks of medicines and other essential supplies. People affected by drought and food insecurity are at higher risk of malnutrition.

Position of the health sector in the country context

Health of people is both means and product of development. It is a means as healthy people are more productive physically and mentally driving the economy a nation. It is a product as good

2 Humanitarian Needs Overview 2020

1 World Development Report, 2019. World Bank Group

Page | 21 economic status of a nation allocates more resource to health to keep their people healthy. The later depends on the country’s policy and strategy towards the health sector.

The Ethiopian health sector, alongside other sectors, is playing its part as a means of economic growth. The contribution of the sector towards socioeconomic development of the country is critical as equitable human development relay on health status and wellbeing of the society. The country is among the low performing countries in many of holistic development parameters of its people evidenced by low HDI, HCI and GII (described above). Hence, investing in health is investing in the current and future generation towards sustainable development. Health is also a measure of inclusive growth that should commensurate with the economic development.

Otherwise, economic growth without equitable social development may not be sustainable.

Therefore, health sectors need to be positioned as a product of development in terms of ensuring social justice and enabler of the economic development.

Chapter 3: Performance of Health Sector Transformation Plan I – Situation

Analysis

This situation analysis of the health sector considers three components, namely content analysis, SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis, and stakeholder analysis, as described below.

Content Analysis

The HSTP-I situation analysis provides a comprehensive scrutiny of health services and systems in Ethiopia from the context of achieving Ethiopia’s health sector goals and global goals such as

Page | 22 the SDGs. The results of the analysis are organized and presented based on “Ethiopia’s Health System Framework” and based on adoption of the WHO African region framework for situation analysis. The framework includes domains related to state of health and well-being (impact level), state of health and health-related services and performance of the health system (outcome and output levels), and state of investments in the health system (input and process levels).

3.1. State of Health and Wellbeing in Ethiopia

The state of health and wellbeing of Ethiopians is analysed based on the three dimensions of health status that includes the state of healthy life, the burden of diseases, and risk factors driving ill health and death.

3.1.1. The state of healthy life

Ethiopia achieved remarkable improvement in health indicators during the last decade. Life expectancy at birth increased from 58 years in 2007 to 65.5 years in 2016 with an annual rates of increase ranging from 1.98% in 2007 to 0.7% in 2016. Life expectancy at birth is currently higher for females (67.3 years) compared to that of males (63.7 years) , , . Despite encouraging3 4 5 improvements in life expectancy at birth, pre-mature death and suboptimal quality of life still constitute major development challenges in Ethiopia. Estimates by the World Health Organization indicate that disability from poor health conditions in the country is equivalent to loss of 8.5 years per person resulting in healthy life expectancy at birth of 57.5 years (58.9 for6 females and 56.1 years for males).7

Ethiopia’s health adjusted life expectancy at birth is above the average for low-income countries (54.9 years); however, it is lower than the global average of 63.3 years and that of low middle-income countries is 59 years.

7 World Health Statistics, 2019. https://www.who.int/gho/mortality_burden_disease/life_tables/hale_text/en/

5 World Health Statistics, 2019. https://www.who.int/gho/mortality_burden_disease/life_tables/hale_text/en/

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Figure 2. Life Expectancy and Health-adjusted life expectancy at birth compared to global and regional benchmarks (Source:

World Health Statistics 2019)

3.1.2. Major causes of morbidity and mortality

The Ethiopian population is currently dying and suffering from triple burden of communicable diseases, non-communicable diseases and injuries affecting all age groups but with disproportionate burden on children and women of reproductive age group. Analyses of burden of disease in 2017 showed that the major causes of premature mortality are communicable, maternal, neonatal and nutritional diseases with neonatal disorders, diarrheal diseases, and lower respiratory tract infection constituting the top three .8

Ethiopia has documented notable achievements in reducing maternal mortality ratio (MMR), under 5 and infant mortality rates during the last two decades. Maternal Mortality Ratio has decreased from 676 deaths per 100,000 in 2011 (EDHS 2011) to 401 in 2017 (WHO and World Bank). Mortality rates in children has also remarkably decreased over the years. Under-5 mortality rate (U5MR) is reduced from 123 per 1000 live births in 2005 to 59 in 2019. Infant mortality rate (IMR) has also decreased from 77 per 1000 live births to 47 in 2019. Neonatal mortality declined from 39 deaths per 1,000 live births in 2005 to 29 deaths per 1,000 live births in 2016 before increasing to 33 deaths per 1,000 births in 2019 (an overall reduction of 15% over the past 14 years). The risk of mortality during the neonatal period currently contributes 55.9% of the total risk of death during the first five years of life among Ethiopian children.

8 Population Health Metrics 2017 https://vizhub.healthdata.org/gbd-compare/.

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Figure 3. Trends in childhood mortality rates, 2005 – 2019

Morbidity and mortality from common communicable diseases including malaria, HIV, and vaccine preventable diseases has also declined dramatically. Between 2007 and 2017, the relative contribution of communicable diseases, including measles, HIV/AIDS, and lower respiratory tract infections, for premature mortality has shown substantial decline. However, the contribution of NCDs has increased during the last decade with congenital defects and ischemic heart disease ranking 6th and 10th in their contribution for pre-mature mortality in 2017, respectively. NCDs are becoming among top ten killers in Ethiopia with ischemic heart disease and cirrhosis showing increasing trends over a decade by about 6.4% and 17.2%, respectively. In addition to their increasing contribution for pre-mature mortality, NCDs have become major causes of disability among Ethiopians; six of the ten top causes of disability were NCDs in 2017.

The burden of Neglected Tropical Diseases (NTD) is decreasing, even though considerable number of people in Ethiopia are still affected by these diseases. According to GBD 2017, NTDs caused 547,599 DALYs annually, which is 1.4% of the total DALYs, lost from any cause. In addition, NTDs caused 3 deaths per 100,000 population in 2017, which is 0.6% of the total deaths in the country in the same year.

Injuries and accidents are becoming growing concern in Ethiopia. EDHS-2016 showed that 3% of households reported having at least one member who was injured or killed in the 12 months before the survey . According to the WHO’s estimate, road traffic accidents (RTA) had an9 estimated 27 deaths per 100,000 population in 2016.10

10 World Health Organization (WHO). Global status report on road safety 2018. Geneva: WHO; 2018.

9 Ibid. 6.

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3.1.3. Risk factors driving morbidity and mortality

Between 2007 and 2017, a relatively high level of reduction has been observed in unsafe sex behaviour with about 73% reduction while the risk from WaSH, alcohol use, dietary risk, and blood glucose level showed a lower rate of reduction ranging from 16 % to 1%. Occupational risk and high blood pressure showed increasing rates over the past decade .11

Ethiopia has one of the highest rates of malnutrition in Sub-Saharan Africa and faces acute and chronic malnutrition and micronutrient deficiencies. Between 2005 and 2019, the prevalence of stunting decreased from 51% to 37%; underweight declined from 33% to 21%; and wasting decreased from 12% to 7%. Anaemia is prevalent among children and women in the reproductive age group.

The prevalence of anaemia in children aged 6 to 59 months and in women in the reproductive age group were 57% and 24% respectively (EDHS 2016)

Figure 4. Trends in major forms of malnutrition among children, 2005-2019

3.2. The status of priority health programs and related problems

Both the health policy and health sector strategy of Ethiopia have placed substantial emphasis to make essential health services available, accessible, acceptable, and affordable. The essential health services package (EHSP), that was first defined in 2005, included a set of health promotion, disease prevention, curative, and rehabilitative services. The 2019 revision of the package expanded the type and number of interventions resulting in identification of 1,019 interventions for delivery at different levels of the health service delivery system through different healthcare financing mechanisms . The status of priority health and other programs is12 described below.

12 Federal Ministry of Health (FMOH). Essential Health Services Package of Ethiopia 2019. Addis Ababa; FMOH, 2019.

11 Institute of Health Metrics & Evaluation (IHME). Burden of Disease Analyses for Ethiopia- Based on a systematic analysis of the 2017Global Burden of Disease Study. Available at: http://www.healthdata.org/ETHIOPIA

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3.2.1. Performance of major Health programs

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

The 2019 mini EDHS showed that the coverage of maternal and child health services continued to rise leading to expectation of further reduction in maternal, under five and infant mortality rates.

Family Planning

Family planning services are available universally in almost all health facilities in Ethiopia, mainly in public health facilities ranging from 99% in health centres to > 93% in general and referral hospitals. About 82% of private health facilities also provide family planning services .13

In 2019, 41% of married Ethiopian women were using contraception compared to just 29% in 2011 and 36% in 2016. However, there is still unmet need (22% in 2016 – EDHS 2016). There is also significant variation in total fertility rate, desired family size, and contraceptive prevalence between regions and different socioeconomic groups. Efforts are needed to increase both demand for and utilization of contraceptives. Domestic resource mobilization is required to reduce donor reliance – particularly for commodities – as Ethiopia moves towards lower-middle income status.

Maternal, Neonatal and Child Health

Even though ANC1 coverage improved from 28% in 2005 to 74% in 2019 , only 43% of14 pregnant women had four or more visits and only 20% of women started ANC visit timely. The quality of ANC care women receive is suboptimal; only 10.6% of mothers received iron for 90 days and more during their pregnancy. The stagnantly high rate of neonatal mortality also indicates the huge gap in access and quality of healthcare during the perinatal period.

Even though skilled delivery increased from 6% in 2005 to 50% in 2019, only 40% of health facilities were fully functioning EmONC facilities in 2016 . Moreover, only 14% of expected15 deliveries took place in functioning EmONC facilities. The caesarean delivery rate was 4% with large regional disparities, ranging from 25% in Addis Ababa to less than 1% in Afar and Somali.

PNC in the first two days increased from 17% in 2016 to 34% in 2019 . According to SARA16

2018, 75% of hospitals and no HC were providing CEmOC services. Mean availability of tracer items for BEmOC was more than 85% for all the three types of hospitals, 74% for HCs and 55% for higher clinics.

16 Ibid. 7.

15 Ibid. 6.

14 Ibid. 7.

13 Federal Ministry of Health (FMOH). Service availability and readiness assessment (SARA) 2018. Addis Ababa;

EPHI, 2018.

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Access to safe abortion services and post-abortion care has been expanded during the period of HSTP-I. As a result, maternal death due to unsafe abortion decreased from 32% in 2006 to 4% in 2018. The 2016 EDHS revealed that 0.4% of women had obstetric fistula. However, Ethiopia is still one of the countries with high burden of pelvic organ obstetric fistula due to child marriage and early age at first birth, high fertility and high proportion of home delivery .17

Despite the encouraging reduction in under-5 mortality rate, it is still estimated that 189,000 under-five children die from preventable childhood diseases every year with more than half happening during their neonatal period. Pneumonia and diarrhoea remain the major killers of under-five children contributing for 16.4% and 8% of deaths, respectively, followed by injury, measles, and malaria - each contributing to 7.1%, 4.6%, and 0.8% of deaths . Malnutrition18 remains to be a major contributor to child mortality contributing for nearly half of under-5 deaths .19

The progress of Ethiopia in preventing childhood deaths has been less successful in the prevention of neonatal mortality. Neonatal deaths amount to about 95,000 every year. In addition, equivalent numbers of stillbirths occur, representing a “silent epidemic”.