1. Health System Decentralization the Case of Ethiopia
Kenya National Health Leadership Management and Governance Conference
Nejmudin Kedir Bilal, P. Health Economist, AfDB
January 29, 2013

2. Outline Background How was decentralization conducted?
Why decentralization in Ethiopian health system?
Key health systems aspects of decentralization
Lessons learnt

3. Background
A coalition of rebel forces under the Ethiopian Peoples’ Revolutionary Democratic Front defeated the socialist government of Mengistu Haile Mariam in May 1991
Ethiopia’s first popularly chosen national parliament and regional legislatures were convened in May and June 1995
The current government of Ethiopia was established in August of 1995
Since then the government has promoted a policy of ethnic federalism, devolving significant powers to subnational authorities.

4. The process of Decentralization
Part of broader government decentralization
Phased approach
1996 to Regional States
2002 to Woredas (and Zones)
Not one size fits all approach
Some with strong zones
Some with lessor role for zones
Some with no zones
9 regional state governments, 2 city adminis Zones, More than 850 districts 15,000 Kebeles

5. Health Systems Decentralization was one of the key reforms triggered by multiple challenges
High burden of disease of preventable causes
Poor access and quality of health care
Centralized
Low level of financing
Shortage and poorly motivated health workers
Biased towards curative care
Poor governance of health institutions
Decentralization
Health service
Delivery reform
Health Planning
& HIS reforms
Governance and
Financing Reform
Pharmaceuticals
reform

6. Health System Decentralization
4 tier health system organization
PHCU (health center + 5 health posts) (25,000)
District hospital (250,000)
Zonal hospital (1 million)
Specialized hospital (5 million people)
Health Extension Programme 2003/2004
Specialized Hospital(5 million)
General Hospital (1million)
Rural Hospital ( )
PHC unit=1HC+5 Satellite HP (25 million)

7. Roles of different levels of the health system was defined
MOH –policy direction, setting standards and resource mobilization
RHBs, ZHDs and WorHOs set health priorities, deliver services, and determine budget allocations
WorHOs manage personnel issues, health facility reconstruction, and procurement at PHCU
Regions and woredas get block grants
Potential advantages decentralization
Decisions made locally are based on better information
Faster decisions
Greater accountability

8. Health Human resources management was one of the key decentralized functions
Major universities under MoEducation
Regional collages midlevel and low level health workers
RHBs, ZHDs and WorHOs can hire and fire
WorHOs are charged with HCs and HPs
Challenge: inter regional transfer

9. Health Planning Challenges in early phase of decentralization
Global and national commitments vs decentralized decision
Challenge of getting priorities across
Multiple plan documents
Historical budgeting not relevant to the local contexts

10. The “One plan” initiative
Priorities are set every 5 years and every year
The main Principe is ensuring vertical and horizontal linkage of priorities and targets
Led by government via steering committees at all levels
Combination of top down and bottom up process
Sharing and consulting with stakeholders
Endorsing the strategic and annual plans at joint sector meeting
Joint monitoring on annual basis

11. Centralized and fragmented information system required reform
Data collection
Too much data items 400 at HCs, 500 at WorHo.
Irrelevant
Reporting problems
Incomplete, Untimely
Redundancy, parallel= administrative burden
Data analysis
Not done at point of collection
Uncoordinated initiatives
Poor institutionalization

12. Key principles were set to reform and decentralize health information system
Standardize
Indicators & definitions
Disease list for reporting & case definitions
Client / patient flow & data elements
Recording & Reporting forms
Procedure manual
Information use guidelines
2. Simplify
Reduce data burden
Streamline data management procedures
3. Integrate
Data channel
Client / patient information at facility (integrated folder)
4. Institutionalize

13. Not only collection but use information at all levels
FMOH
Quarterly
Compiled and used
RHB
Monthly
Weekly
Quarterly
WoHO
Monthly
Weekly
Compiled and used/reported HF
Quarterly
Compiled and used/reported
Monthly
Weekly
Service delivery report

14. Health Service challenges: Preventable health problems as major causes of morbidity and mortality (60%-80%)
Only 1% of households had ITNs (<18% insecticide treated)
Only 40% of the population within 10 KM of health institution
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
Due to
Limited knowledge of optimal care practices at the family level
Limited physical access to health services in rural communities
Poor institutionalization of PHC

15. HEP: Innovative approach to deliver Preventive and Promotive Health Services
Hygiene and
Environmental
Sanitation
Disease
Prevention
and Control
HEP
MNCH
Health
Education

16. HEWs assigned back to the village, train and graduate households
HEP: Process & Roles defined for Training, Deployment & Support on Implementation
2 trainees per village recruited by local government and community
MOH and MOE collaborate to provide a 1 year training
Community builds health post as a hub of operation for HEWs
Local government pays salary
HEWs assigned back to the village, train and graduate households
Village council involves the HEWs and provides leadership
Supervisors assigned
1 HC/5 HPs for technical and logistic support
FMOH and DPs provide equipment and supplies
Customized HMIS to track progress

17. Capacity building: Accelerated scaling up of HRH and infrastructure to support HEP

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

19. Key Lessons Part of broader government decentralization
Sequencing decentralization makes it more effective
Continuous and demand based capacity building
Some things are better kept at higher levels
Devolution does not mean no accountability!
Be ware of interrupting ongoing programmes