1. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University’s School of Public Health HSS Training for USAID DLIs Nejmudin Bilal Health Systems 2020 Abt Associates (August 28, 2011) Health Systems Strengthening Efforts: The Case of Ethiopia

2. Objective To see a country case on HSS efforts to make it responsive to the needs: Ethiopia

3. General Background Population: 80 million Population growth rate: 2.7% /year Rural population:84% Geographic size: over 1.1 million Km. Sq. GDP $220/capita U5 mortality: 123/1000 MMR 470/100,000

4. High burden of disease of preventable causes Centralized Low level of financing, leakage poorly motivated health workers Biased towards curative care Poor access and quality of health care Decentralization Facility Governance and HCF Reform Health Extension Programme Challenges and HSS interventions: Before and After

5. 1. Decentralization of Health System 4 tier health system organization Prioritized primary health care MOH –policy direction and resource mobilization Regional Health Bureaus, District Health Offices---managing service delivery Community participates and strengthens CHS

6. Decentralization of Health…. Decentralization set the stage for the results I share in the next two reforms

7. 2. Governance and Health Care Financing Reform-Five Components 1. Health facility governing boards 2. HFs user fee revenue retention and utilization. 3. Systematizing the fee waiver system and exemption scheme 4. Outsourcing of non-clinical services. 5. Establishment of private Clinics/wings in public hospitals

8. Facility governing boards play critical management role Ensure proper implementation of the reforms Review and approve plans Approves budget and follow up on utilization Ensure that the activities of the hospital are carried out with transparency and accountability

9. Improved responsiveness to local needs Increased accountability to public funds Improved resource mobilization Increased role of local community ---good governance Created sense of ownership by management 86 hospitals and 1,600 HCs have established facility governing boards

10. Governance and Health Care Financing Reform-Five Components 1. Health facility governing boards 2. HFs user fee revenue retention and utilization. 3. Systematizing the fee waiver system and exemption scheme 4. Outsourcing of non-clinical services. 5. Establishment of private Clinics/wings in public hospitals

11. Revenue retention led to improved quality of care Foundation for all health care financing reform agenda Facilities' ownership to control leakage Generates additional resource Invested strictly on quality improvement

12. Safe water Supply for health facility: Wolaita Sodo HC Before the reform After the reform

13. Uninterrupted supply of medicine

14. New Microscope: improving diagnostic capacity of health institutions

15. Modern Dental equipment: Arba Minch Hospital

16. Beautiful Environment motivates staff and encourages patients to use health institution: Awassa HC

17. New Generator: ensuring safe storage of medicine and uninterrupted functioning of diagnostic equipment Shashemene Hospital

18. Health Care Financing and Governance Reform 1. Establishment and operation of governing boards. 2. HFs user fee revenue retention and utilization. 3. Systematizing the fee waiver system and exemption scheme 4. Outsourcing of non-clinical services. 5. Establishment of private Clinics/wings in public hospitals

19. Fee waiver is a key to financial risk protection for the poor  Screening by Village Committees  Criteria for poverty certificate  Waiver system reform is step for health insurance-SHI and CBHI

20. 2 Health Care Financing and Governance Reform 1. Establishment and operation of governing boards 2. HFs user fee revenue retention and utilization. 3. Systematizing the fee waiver system and exemption scheme 4..Outsourcing of non-clinical services. 5. Establishment of private Clinics/wings in public hospitals

21. Non-clinical services are outsourced Outsourcing enabled health facilities to: Focus on core competencies Tapping into external expertise Improved Quality Reduce and control operating costs. Overview of outsourced gardening: Mizan Teferi Hospital /SNNPR/:.

22. Health Care Financing and Governance Reform 1. Establishment and operation of governing boards 2. HFs user fee revenue retention and utilization. 3. Systematizing the fee waiver system and exemption scheme 4..Outsourcing of non-clinical services. 5. Establishment of private Clinics/wings

23. Private wings motivated staff and provided treatment options for patients Established in public facilities Higher payments than the normal fee Amount of time in private wing is limited Staff and health institution share the revenue

24. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University’s School of Public Health 3. The Health Extension Programme (HEP)

25. HEP is an evidence based intervention  Limited knowledge of optimal care practices at the family level  Limited physical access to health services in rural communities Due to  Poor utilization = 30%  Children < 6 months, exclusively breastfed: 32%  Children with diarrhea given ORT: 37%  Delivery attended: 6%  Children with fever/cough brought to a health facility: 17%  Low immunization coverage

26. HEP tackles the major causes of ill-health in Ethiopia 2 HEWs/village On 16 packages of health interventions in 4 major areas Disease prevention and control (Malaria, HIV/AIDS, TB etc) Family Health (FP, ANC, DS, PNC) Hygiene and Environmental health services (personal and env hygienic, rodent control..) Information Education Communication Salaried employees House to house (75%)

27. Why are they all female?

28. Support structure for HEWs---strengthening the system 1 HP/village- equipped 1 supervisor/10 HEWs Community based HMIS 1 HC/5 HPs for technical and logistic support Village council-leadership

29. Health Outcomes Associated with Health Systems Strengthening

30. Maternal Health service coverage

31. Child Health service coverage

32. Results Achieved… (HIV/AIDS & Malaria) Malaria

33. Increasing Expenditure in Health

34. Partnership with USAID’s in HSS Health Financing and Governance Reform Supported the training and deployment of HEWs and Health Officers Supply Chain Management System Design and scaling up of HMIS and DHS

35. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University’s School of Public Health Thank you