TRANSITIONAL GOVERNMENT OF ETHIOPIA HEALTH SECTOR STRATEGY

Addis Ababa, April, 1995

 

1. INTRODUCTION AND OVERVIEW

Ethiopia has one of the worst health status in the world as could be attested by conventionally accepted health indicators (Table 1). At the center of the problem is the backward socio-economic development resulting in one of the lowest standard of living, poor environmental conditions and low level of social services. This prevailing situation has been aggravated, in recent years, by the high population growth, the two decades of strife and civil war, the repeated natural disasters, the degradation of the environment and the associated low productivity of land.

Table 1: Selected Health Indicators

Infant Mortality Rate (IMR)

110/1000 LB

Child Mortality Rate (CMR)

99/1000 C

Maternal Mortality Rate (MMR)

5.6/1000 LB

Life Expectancy at Birth (LEB)

53.4 yrs

Fertility Rate (FR)

7.5 C/W

Crude Birth Rate (CBR)

46.7/1000

Crude Death Rate (CDR)

17.9/1000

 

 

Infectious and communicable diseases are wide spread and nutritional disorders are quite common. About 75% of the endemic diseases in Ethiopia are communicable and potentially preventable. Major problems amongst these include respiratory infections, diarrhocal diseases, malaria, tuberculosis and sexually transmitted diseases such as syphilis. Malaria at the moment heads the least of killing diseases, quite often occurring in epidemic forms. Tuberculosis is next and recently on the ascendance. In relative terms, AIDS is not yet a major health problem, the trend however is alarming and could be of major consequence unless preventive actions are taken. The prevalence of blindness is estimated to be about 1.5% with trachoma, cataract, glaucoma, measles and vitamin A deficiency being major contributors.

Nutritional disorders are also important causes for morbidity and mortality. Major problems in this area are protein-energy malnutrition and micronutrient deficiencies such as iron, iodine and vitamin A. The average per capita intake of energy is estimated to be 7,33OkJ (1750 Cal) which is about 80% of the daily average requirement. A recent study of the nutritional status showed that amongst children who are under five nearly 5% show wasting, 47% are underweight and 64% are stunted. About 1% of the child population show vitamin A deficiency and 17% of pregnant-and lactating mothers have been found to have anemia.

The health service system has eight specialized vertical programs functioning at various degrees of involvement and effectiveness. These, include, malaria and other vector borne diseases, tuberculosis prevention and control, leprosy control, AIDS and other sexually transmitted disease prevention and control, the expanded program on immunization, control of diarrhoeal diseases, acute respiratory diseases control and prevention and control of micronutrient deficiency diseases. Though the priorities are right the programs lack appropriate direction and management and most often undermining the other services. They are also grossly under funded making their activities a futile exercise with little impact. Health professional training and specialized health research institutions are very few, under funded and overcrowded (Table 2).

 

 

Table 2: Human Resources Training Institutions in Ethiopia (MOH, 1990)

Institution

Certification

Duration of Training

Output

I. Medical Schools (3) Addis Ababa

Gondar

Jimma

MD

12+7

150

II Nursing Schools (7)

Addis Ababa

Assella Gondar

Jimma Mekelle Nekemt Yirgalem

 

Diploma

12+1/2

360-450

III. Paramedical Schools (7)

School of pharmacy (A.A)

Lab. Tech. (Jimma, A.A)

X-ray Tech. (A.A)

Pharmacy Tech. (Jimma)

Sanitarian (Gonder, Jimma)

 

B.Sc.

Diploma

Diploma

Diploma

 

Diploma

 

12+5

12+1/2

12+1/2

12+1/2

 

12+1/2

 

10

90

20

30

 

80

IV. Health Assistant

(AA Aw, B, D, Met,D.T,

B.D. AX, Ai, H, Sh, Y)

Diploma

10+1 1/2yrs

730

Aggravating these states of affairs are, the rapidly growing population and the lack or inadequate infrastructures which contribute to the general well being of the population. The population has been increasing at an average rate of 3% per annum for the last decade and is expected to continue to grow on or slightly above this figure for the coming decade. According to the estimate based on 1984 census, the population of Ethiopia in 1995 is 56.5 million, most of them young and a staggering 70% made up of children (under 15) and women in childbearing age (15-49). The total fertility rate is 7.5% with a wide regional variations. In spite of such a growth rate contraceptive use is only 4% and only 15% of the expectant mothers receive antenatal care out of whom 5% delivered by trained personnel.

The national per capita consumption of water is estimated to be about 10 liters per day and is one of the lowest in the world. According to a recent survey about 12% of the rural and 70% of the urban population have access to safe water and the national sanitation coverage is only 7%. The health care infrastructure has been crippled by the preceding

decades of civil war, underfunding and neglect. The number of health facilities, the distribution and the quality of service leaves a ?? to be desired. Roughly more than 50% of the health facilities are in urban areas most of them in Addis Ababa (Table 3). Over 30% of the health facilities need either major repair or replacement (Table3)

 

 

Table 3: Distribution of health facilities by region (MOH, 1994)

N

Region

Hospitals

Beds

Health centers

Health Stations

1

Tigray

6

864

12

138

2

Afar

1

60

3

24

 

Amara

10

1 298

39

461

4

Oromia

21

2126

49

801

5

Somali

3

206

4

88

6

Benshangul

2

203

5

55

7

SEPRA

9

827

21

317

8

Gambella

1

100

1

30

9

Harar

3

345

3

11

10

Dire Dawa

2

206

1

25

11

Addis Abeba

14

3 302

15

144

 

Total

72

9 538

153

2094

 

 

 

Table 4:Building Conditions of Health Institutions and Their Needs (MOH, 1989)

Health Institution

Good

Minor Repair

Major repair

Replacement

Not Available

Total

Hospital

22(29%)

17 (19.3%)

37(42%)

6(6.8%)

6(6.8%)

88

Health Center

45(28.7%)

66(42%)

31(19.7%)

7(4.5%)

8(5.1%)

167

Health Station

765(36%)

443(20.8%)

393(18.51%)

211(9.9%)

313(14.7%)

2125

Health education is rudimentary and in many ways lacks a clear objective, focus and a cohesive direction. 'Mere is hardly any environmental monitoring, guidelines for protection and safety and public standards of hygiene. Large industrial or agricultural schemes are neither given proper advice during planning nor regularly monitored after commissioning. As a result there is a great deal of unnecessary pollution to the environment and exposure of the workers and community to communicable diseases such as malaria and schistosomiasis, hazardous chemicals and byproducts.

The health service organization and management is very centralized, undemocratic and unprofessional with very minimal community participation. This has a great deal of undesirable impact on efficiency and resource allocation. Health care is delivered in a purported pyramidal six-tier system (Figure 1) which in practice is more of a reversed pyramid. There is also a dearth of problem in human resource development and utilization in the health sector. Health professionals tend to heavily concentrate in urban areas, particularly in Addis Ababa . There is a relative shortage of front line and middle level professionals resulting in non-ideal ratio between doctors and other professionals. There is also a mismatch between trained professionals and health facilities resulting-g in an extraordinary situation whereby doctors-are underutilized in a country with one of the lowest professionals to population ratio (Table 5). All these factors added to the poor pay and incentive system has created a body of professionals who are mismanaged, disinterested, unsympathetic and unethical.

Table 5: Number of health workers per population (MOH, 1994)

 

 

 

Medical Doctors

2,214

1: 24,841

Nurses

5,000

1:11,000

Health Assistants

13,500

1:4,074

Lab Technicians

900

1:61,111

Pharmacists

650

1:84,615

Druggist

450

1:119,565

Radiographers

311

1:176,848

Sanitarian

687

1:80,058

Total

23 722

1:2 318

 

The health service has always been under funded but in the last decade or so this has been aggravated by the decline of per capita share of public expenditure in health due to the dramatic growth- in population and the reallocation and utilization of resources for the civil war efforts of the previous regime. The sector's share from government expenditure has remained below 5% (under 2% of the GDP) for the last 10 years.

 

In general the major features of health service expenditure in Ethiopia are:

1. Most of the recurrent budget is spent on wages and salaries, making very little money available for running expenses, drugs and medical supplies.

2.There is an imbalance in expenditure between services since most of the money is spent on curative care.

3.1t Is also inequitably allocated with most of it going to health institution in Addis Ababa.

4.There is an ad hoc system of cost recovery in place but it is grossly inefficient and grossly misused. place but it is inefficient and grossly misused.

5.Though the capital expenditure is relatively small, the implementation has been very poor, averaging just over 50% for much of the 1980's.

In summary, the major constraints of the health service are the low number of health care facilities which are ill-equipped, mal-distributed and in a state of disrepair, an ineffective health care delivery system which is top heavy, uncoordinated, inefficient and biased towards the curative service, a very centralized and undemocratic health care delivery system and management, an acute shortage of human and material resources with inefficient utilization of the available and the almost nonexistent involvement and participation of the private sector and the beneficiary communities.

 

 

 

II THE OBJECTIVES OF THE NEW 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 emphasize on the preventive and promotive aspect of health care without neglecting essential curative services. The focus shall be on communicable diseases, common nutritional disorders and on environmental health and hygiene. Maternal and child care, immunization, reproductive health, treatment and control of basic infectious diseases like upper respiratory tract infection and tuberculosis, control of -epidemic diseases like malaria and the control of sexually transmitted diseases particularly 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.

 

111. MAJOR COMPONENTS OF THE HEALTH SECTOR STRATEGY

1. STRENGTHENING THE PREVENTIVE AND PROMOTIVE HEALTH SERVICE

More than 80% of the common diseases are infectious and communicable and some of them occurring in epidemic forms. This is mainly due to the poor standard of housing, the lack of potable water and inappropriate disposal of waste. Most of the epidemic diseases occur in populated and conducive areas such as irrigated agricultural schemes indicating that they are potentially preventable and would be cost effective to spend the limited resources on preventive and promotive actions. Thus, the long term health service strategy is to as much as possible concentrate on prevention of common infectious and communicable diseases and the control of major epidemic outbreaks. Such goals will be achieved on the main by enhancing information, education and communication about health and well being and through provision- of basic immunizations and promotion of environmental and personal hygiene.

1.1 Community Health Service

A basic health service at the grass-root level will facilitate the implementation of the above strategy by making the health care delivery more accessible, affordable, cost-effective, efficient and sustainable. Primary health care units with standard facilities and staffing serving a manageable population and equitably distributed throughout the country shall be established. []

 

 

 

1.3 Environmental and Occupational Health and Safety

Agricultural schemes and industries will be expected to have a strong health prevention and promotion programs. Starting from inception appropriate environmental health advice have to be sought and incorporated in the project. Guidelines, standards, regulations and legislation will be prepared in order to assist the community, planners, builders, agricultural schemes and industries on safe disposal of waste, minimizing environmental pollution and incorporating appropriate health and safety standards in housing and work premises.

2. CURATIVE AND REHABILITATIVE CARE

Essential curative service will continue as this is part and parcel of a comprehensive health service to the community and vital in assisting the preventive and control efforts. Specialized curative care will not be expanded in the short to medium term and public -support will only be in the form sustaining the already existing services. In as much as possible rehabilitative care will be encouraged within the family home setting and those specialized institutions in public hands will be gradually phased out or transferred to private concerns.

 

3. DRUGS AND MEDICAL SUPPLIES

The major problem in the country with respect to drugs and medical supplies is the fact that they are in short supply at health institutions and private vendors most of the time. Lately, they are becoming more and more inaccessible and unaffordable to vast majority, of the population. This is mainly because drugs and medical supplies are imported and systems of procurement and distribution are not well organized. As drugs become in short supply and inaccessible, the visible symbol of quality care disappears and public confidence in the overall health service is eroded. 'Mus, provision of a good quality primary care cannot be envisaged without a regular and adequate supply of drugs.

In the short term, basic drugs will have to be made available at all health care units and essential drugs provided in a sustainable manner. Preparing a list of essential drugs and medical supplies for all levels of the health service will be given priority attention. Overhauling the system of procurement, distribution, storage and utilization of drugs and medical supplies will then follow. In the medium and long term, production capability of basic drugs, medical supplies and vaccines need to be built and quality control mechanisms instituted. An appropriate drug administration and regulation and public awareness in the use and misuse- of drugs shall be an essential component of a good health service.

The private sector will be encouraged to participate in procurement, distribution and production of drugs and supplies. The government will also create a conducive environment for mobilization of resources and assistance by NGO and international donors.

 

4. HEALTH INFORMATION, DOCUMENTATION AND

PROCESSING

There is a great need for information documentation and processing in the country. Vital statistics, demographic and health data are non-existent or poorly recorded. As a result it is very difficult to plan and make informed decisions. Basic information need to be gathered at the primary health care units and information documented, partially processed and utilized locally and transferred for central documentation and processing. The information must be available for all who need it and a system will be developed for rapid and effective dissemination and utilization at all levels of the decision making process. This will greatly facilitate the efficient delivery of health care, resource allocations, monitoring and evaluation.

5. ORGANIZATION AND MANAGEMENT OF THE

HEALTH DELIVERY SYSTEM

-The existing health service is highly centralized, bureaucratic and non-participatory in its management -and service delivery. The health care delivery is organized in a six tiered pyramidal system which functions more like a system in one plane. There are also a few specialized services and vertical programs such as the EPI. Private and community participation in the health care delivery is minimal and there is hardly any intersectoral collaboration.

The present six tiered system will be organized in a more practical and functional manner serving realistic population sizes. The management will be decentralized and localized with the appropriate linkage. Each health unit shall democratize its internal management with active popular participation of the staff and continuity. All health institutions shall incorporate in their health care service, preventive and promotive aspects of health, education on health and nutrition, promotion of personal hygiene and environmental health and safety, appropriate for their level. The present vertical programs will be gradually phased out as their n-design will be attended to in an integrated fashion. The existing institutions will have to be restructured so as to come in line with the new system.

Each unit will be provided with at list a minimum standard of facilities and staffing and will have a continuous supply of basic drugs and medical supplies. Voluntary participation of the community in mass immunization and control campaigns, health education, neighborhood environmental care and the care and maintenance of their local health facilities will be encouraged. Intersectoral collaboration shall be intensified in the provision of potable water, safe disposal of waste, environmental hygiene, disaster management, care of groups with special needs and at schools.

6. HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

'Me manpower in the health service is small in number, underutilized in some cases and does not have the appropriate level and mix of skills. It has an uneven distribution and is top heavy. An appropriate system of supervision and monitoring is also lacking. Performance and standards have been falling for the last two decades or so for a number of reasons, particularly due to lack of appropriate career structure and incentive schemes. The administrative staff lacks professional competence and motivation at the level required for a social service such as health. Management at all levels of the health care delivery system appears to be headed by health professionals who neither have the training or the motivation.

Thus, the major strategy in this area is to increase the number, to bring about an appropriate mix of skill, to rationalize the ratio of deployment, to raise standards and to establish a career structure with an acceptable pay and incentive system. The focus in the short term should be on training and upgrading of front-line, lower and middle level health workers who will be destined to work in primary health care. In-service training continued education programs, an effective supervision and monitoring system shall be instituted in order to continuously upgrade the skills and improve on their performance and motivation. High level professional training will continue and shall be coordinated with the needs of the health service and a realistic assessment of requirements for such skills and the economic reality of the country. Health personnel management has to improve at all levels and decentralized with effective control at the district level.

7. RESEARCH AND DEVELOPMENT

Research and development in health care, treatment and delivery systems is essential but can be very expensive and unaffordable if it is unrealistic and not appropriately guided. Of necessity, research done in Ethiopia need to focus on priority health problems of the country and as much as possible address the needs in management and control of communicable diseases. It has to also identify peculiarities in the Ethiopian situation of common diseases encountered. Assessment of different health care delivery systems and finding better management and control methods will have important impact on the disease situation and contribute in minimizing cost. Capacity building in health research will enhance self-reliance and is important for the future direction of the health service.

 

8. FINANCING THE HEALTH CARE DELIVERY SYSTEM

The major reasons for the present poor state of health service are underfunding, inefficient utilization and inequitable distribution. This can only be improved by increased public expenditure on health, private participation in health care delivery and rationalizing allocation of budget and its utilization.

The main thrust of government activity in the sector shall be to allocate a realistic and sustainable budget and to create an enabling environment for community and private participation in the health care delivery as well as for efficient and effective utilization of limited resources. Redirecting the finance from tertiary to primary health care not only will make it more effective and equitable but also less costly. Government finance will mainly be geared in the short term to rehabilitation and upgrading of existing health institution. Some new institution need to be built in neglected areas to redress some of the acute imbalance and to avoid bottlenecks in the new system of health care delivery. In the medium term, the share of government finance going to primary health care will increase and there will be a gradual expansion of primary health care units. In the long term, emphasis will be directed to expansion and strengthening existing institution: and providing specialized services in selected areas.

The existing cost sharing mechanisms for hospital services shall be unproved and made more effective. Other cost sharing mechanisms such as user fees, revolving funds, insurance systems, etc. will also be instituted and gradually developed and diversified. An enabling environment will also be created for the community to mobilize finance for local health care, services and to contribute in kind to the building and maintenance of facilities. The private sector and non-government organization will be encouraged to invest in health care delivery and to participate in government and community efforts to strengthen and diversify health services. Enabling environment for the full participation, coordination and fund mobilization by NGO's, bilateral and multilateral agencies will-be instituted.