Health Sector Strategy
The main objective of the health service in the future is to give a comprehensive and integrated primary health care in health institutions at the community level. The approach will be to emphasise the preventive and promotive aspects of health care without neglecting essential curative service. The focus shall be on communicative diseases, common nutritional disorders, and on environmental health and hygiene. Maternal and child care, immunisation, reproductive health, treatment and control of basic infectious diseases like upper respiratory tract infections and tuberculosis, control of epidemic diseases like malaria and the control of sexually-transmitted diseases, including AIDS, will receive special attention. Information, education and communication about health and nutrition shall be strengthened. Human and material resources will be developed, deployed and managed in line with these objectives.
Major components of the health care strategy
Strengthening the preventive and promotive health service
Curative and rehabilitative care
Drugs and medical supplies
Health information, documentation and processing
Organisation and management of the health delivery system
Human resource development and management
Research and development
Financing the healthcare delivery system.
The Ethiopian health care delivery system has historically been unable to respond quantitatively or qualitatively to the health needs of the people. It was highly centralised. Its services were delivered in a fragmented way with a reliance on vertical programs and there was little collaboration between public and private sectors. Consequently, the Ethiopian Transitional and Federal Governments have initiated political, economic and social changes resulting in the formulation of the 1993 Health Policy and Strategy. The Federal Government and the regional authorities seek to reorganise health services into a more cost-effective and efficient system, better able to contribute to the overall socio-economic development effort of the country.
The Government plans to realise its health development objective through a twenty-year health development implementation strategy, with a series of five-year investment programs, of which the first Health Sector Development Program (HSDP) covers the period 1997/98-2001/02. The HSDP proposes a sector-wide approach to achieve the government's objectives.
HSDP has eight components:
1. service delivery and quality of care
2. health facility rehabilitation and expansion
3. human resource development
4. strengthening pharmaceutical services
5. information, education and communication
6. strengthening health sector management and management information systems
7. monitoring and evaluation
8. health care financing.
The Health Sector Development Program, like the National Health Policy, is the result of a critical examination of the nature, magnitude and root causes of the prevailing health problems of the country and awareness of newly emerging health problems. Founded on a commitment to democracy and to decentralisation, it accords appropriate emphasis to the needs of the less privileged rural population which constitute the overwhelming majority of the population and it proposes realistic goals and the means for attaining them. The government thereby accords health a prominent place in its order of priorities and commits itself to the attainment of these goals, utilising all accessible internal and external resources.
Health status indicators
A combination of rapid population growth, poor economic performance and low educational levels has constrained Ethiopia's socio-economic development and impacted on health status in particular.
Vital indicators: The 'crude' death rate is estimated by different sources to be 14.8 per 1,000 population, about double that of Kenya and second only to Uganda in Eastern Africa. Life expectancy at birth (LEB) of males and females is 49.7 years and 52.4 years respectively. The infant mortality rate (IMR) is estimated at 105 per 1,000 live births while the child mortality rate (CMR) is 172 deaths per 1,000. The maternal mortality rate (MMR) is estimated at 500-700 per 100,000.
Burden of disease: The total burden of disease, as measured by premature death from all causes, is approximately 350 deaths per year (D/Ys) lost per 1,000 population. Ethiopia's burden of disease is significantly higher than in neighbouring Kenya (estimated at 170 D/Ys lost per 1,000 population) and in East Africa as a whole (which has a burden of disease of 280 D/Ys lost per 1,000 population).
Ethiopia's burden of disease is dominated by pre-natal and maternal conditions and by acute respiratory infection (ARI), followed by malaria, nutritional deficiency, diarrhoea and AIDS. Indeed, the top ten causes of mortality account for 74 percent of all deaths and 81 percent of D/Ys lost. Diseases that affect children under the age of 5 years (ARI, diarrhoea, nutritional deficiencies and measles) account for 33 percent of deaths. Although largely preventable, childhood and maternal illnesses and communicable diseases are the major causes of death in Ethiopia
Health Service Coverage and Utilisation
Health service coverage The overall level of health service coverage is estimated to be approximately 45 percent. The actual coverage estimates for the individual programs are very low.
The major reasons for the poor coverage of health services in Ethiopia are the limited physical access of the population to health facilities and staff, as illustrated by the facility to population ratio. Currently, health facilities for a population of some 58 million people comprise 89 hospitals, 191 health centres, 1, 1 75 health posts and 2,515 health stations. The available health care facilities are also unevenly distributed across regions.
Health service utilisation Total outpatient utilisation of government health facilities in Ethiopia suggests that, on average, there are about 0.25 visits per person per year. A household survey on health care utilisation found that only 10 percent of persons reporting illness actually obtained treatment for their conditions from any health facility, government or private. Utilisation by the rural population (9.5 percent), as compared to 14 percent in urban areas, is lower than the national average. The findings further show that the three most important determinants of whether treatment is sought are:
the cost of treatment
the distance from, or the absence of, the health care facility
the quality of the facility
the educational status of the patients, or the mothers in the case of children.
Health services quality
Health services quality has been compromised by inadequate and poorly maintained infrastructure and equipment, scarcity of trained health personnel, and the unavailability of drugs and pharmaceutical supplies.
An estimated 20,000 health care workers provide services in Ethiopia, the vast majority through the public sector. Not only are the ratios of health personnel to population substantially less than the average for Sub-Saharan Africa, but the situation is worsened by the fact that a considerable number of staff, (one-third of doctors and one-sixth of nurses), work in Addis Ababa where about 4 percent of the country's population live. Recent efforts to relocate centrally located staff to the regions have started the process of reversing this imbalance.
Health system financing 1
The health sector is financed through a variety of sources in Ethiopia. These include:
general government revenue
donor aid/external assistance and foreign loans
user fees (for services and drugs)
various types of health insurance
Government financing The increased share of government financing is the result of a sustained effort to increase the share of health sector expenditure in the total national budget:
Between 1989 and 1996, health expenditures rose from 2.8 percent to 6.2 percent of the total budget.
Between 1991 and 1996, the Government health budget has increased from about 1 percent of GDP to about 2.7 percent of GDP.
During this period, the real value of the health budget increased by 35 percent. Despite this effort, 1996 health expenditures were about US$1.20 per capita, which is significantly lower than the Sub-Saharan African average health expenditure of US$ 10 per capita.
Since 1992 there have been several major changes in the structure of the government budget to the health sector.
First, the proportion of salaries in the recurrent budget has declined to 53 percent in 1996 as a large share of the recent increases in health spending has gone to drugs and other non-salary items.
Second, there has been a reallocation of resources away from facilities in Addis Ababa and to primary care facilities. Since 1994, capital expenditure on health centres and health stations has risen from 17 to 40 percent of the capital budget.
Third, support for public health services has increased with (in 1994) more than half of total regional recurrent expenditures focused on Primary Health Care-related services.
Fourth, control over health expenditure has shifted
to the regions, which have, since 1994, controlled between 83 and 88 percent of the health
expenditure and which in 1996 controlled 83 percent of the recurrent budget and 95 percent
of the capital budget.
Individual private payments Studies have confirmed that households in Ethiopia make substantial direct payments to private practitioners, traditional healers, private pharmacies and others in the health sector. Households also make payments to government facilities in the form of user charges, which have been collected by the Ministry of Health since 1950. Since the introduction of the fees, major changes and/or revisions have occasionally been attempted, but unsuccessfully.
Health system financing 2
The Government is firmly enforcing a ceiling of 5 billion Birr for implementation of the first phase of HSDP, and expects to finance this amount through a combination of its own revenues, proceeds from user fees and external resources including assistance and credit. Substantial addition resources for the health sector are also anticipated from local financing through the Health Care Financing Strategy. Among the options under consideration are the Health Care Financing Strategy and the encouragement of private sector/NGO participation in health service provision.
Since 1992, the Government has taken steps not only to increase the overall share of budget for health, but also to reallocate resources away from urban hospital-based curative services toward more preventive care, with an emphasis on the rural population. Despite such measures, the sector suffers from chronic under-funding. Assuming increased demand - from increased access to quality care, increased incomes and willingness to pay for health services, and improvements in the educational status of the population - the health sector will need to find ways to finance both an increase in volume and in quality of service.
The Ministry of Health has drafted a Health Care and Financing Strategy that is currently under review by the Council of Ministers' Office. The document proposes strategies for both improving government health sector efficiency and generating additional and new sources of revenue.
Involving the Private Sector The government has sought to increase the involvement of the private sector (both for profit and non-profit) in the delivery of health services. Today, practically all drug vendors and drug stores are privately owned, as are more than 70 percent of pharmacies. The role of private health clinics and medical services is growing in importance, particularly in urban areas. There are also just under 200 NGO health clinics and 8 NGO hospitals operating throughout the country, particularly in rural areas. Government recognition of the complementarity of the public and private (particularly NGO) sectors is growing, and it will propose improved regulation in a number of areas, including: hospital autonomy, pharmaceutical distribution and licensing.
Health and related policies
The National Health Policy comprises nine components for achieving its overall policy objectives. These include:
improving PHC service access to the population
the technical quality of PHC service provision
health systems management
the financial sustainability of the health sector
encouraging private sector investment in the health sector
directing attention to the pharmaceutical sector
developing an IEC implementation strategy to extend Public Health Care messages to the periphery
investing in expanding the supply and productivity of health personnel
strengthening the local capacity for evaluation, research and development for Ethiopia's health sector.
Strategies to improve health care utilisation and access
The Ministry of Health is concerned about the current extremely low utilisation rates of public health services. It has, therefore, through out the preparation of HSDP, emphasised supply of services by designing a package which both responds to the identified burden of disease and can be delivered by primary health care units located within reasonable distance of the population served. Furthermore, it must be cost-effective.
The Ministry of Health also recognises that increased utilisation rates require the mobilisation of community leaders and communities to promote the quality of health services and the importance of utilising them. In addition to its traditional role of changing the health behaviour of the community, HSDP will publicise the available services to gain the confidence of the population.
Reorganisation of health services The Ministry of Health has decided to reorganise the existing six tiers of the health care delivery system into four, consisting of:
1. Primary Health Care Units, incorporating the former health centres, health posts and health stations. These comprise a health centre and an average of 5 satellite health posts and providing comprehensive and integrated primary care services, as well as minor surgery and life-saving emergency operations;
2. District Hospitals incorporating the former rural hospitals, providing comprehensive out-patient and in-patient services (with a minimum of 50 beds) with some serving as training centres for front-line health workers.
3. Regional Hospitals or Zonal Hospitals which provide specialist services in the four basic specialities as well as clinical training for nurses, health officers and paramedics; and
4. Specialised Hospitals which provide sub-specialist care as well as clinical training for health officers, generalises and specialist doctors.
Health service quality Quality improvement is assured through better training and staffing of health care facilities, adequate and sustained provision of drugs and medical supplies, adequate budgetary allocation and improved management.