Report No. 28963-ET Ethiopia A Country Status Report on Health and Poverty (In Two Volumes) Volume II: Main Report July 2005 Africa Region Human Development Ministry of Health Ethiopia The World Bank Document of the World Bank HICES HouseholdIncome, Consumption and TGE Transitional Government o f Expenditure Survey Ethiopia HP HealthPost TT Tetanus Toxoid HSEP Health Services ExtensionPackage USMR Under-five Mortality Rate HSCSR Health Sector Country Status Report UNESCO UnitedNations Educational, Scientific and Cultural Organization HIV HumanImmunodeficiency Virus UNFPA UnitedNationFundfor Population Activities HS Health Station W B World Bank IEC Information, Education and WBCAS The World Bank Country Communication Assistance Strategy IMR Infant Mortality Rate WDR World Development Report IUD Intrauterine Device WH Weight for Height L D C Least Development Countries WHO World Health Organization MBB Marginal Budgeting for Bottlenecks WMS Welfare Monitory Survey M C H Maternal and Child Health MDG MillenniumDevelopment Goals MEDAC Ministry of Economic Development and Co-operation Table of Contents ACKNOWLEDGMENTS ..................................................................................... XI 1. INTRODUCTION .......................................................................................... 1 Purpose o f the Health Sector Country Status Report ................................................................................ 4 2. HEALTHOUTCOMES ............................................................................... 12 Child Mortality ............................................................................................................................................ 12 ChildMalnutrition ...................................................................................................................................... 21 MaternalMortality Rates (MMR)and MDGTargets ............................................................................. 24 Maternal Malnutrition ................................................................................................................................ 26 Fertility ......................................................................................................................................................... 26 HIV/AIDS .................................................................................................................................................... 29 Tuberculosis ................................................................................................................................................. 30 3. HOUSEHOLDAND COMMUNITY FACTORSAFFECTING HEALTH: KNOWLEDGE. ATTITUDE AND PRACTICES ................................................. 32 Child Survival .............................................................................................................................................. 32 Child Malnutrition ...................................................................................................................................... 37 Breastfeeding ............................................................................................................................................... 39 Supplementary Foods ................................................................................................................................. 39 Iodized Salt .................................................................................................................................................. 40 Use of BedNets ............................................................................................................................................ 42 Use of Oral Rehydration Solution (ORS) .................................................................................................. 42 Immunization ............................................................................................................................................... 43 Use of Vitamin A Supplementation ........................................................................................................... 46 Antenatal Care and Delivery Care ............................................................................................................ 46 Women's Nutritional Status ....................................................................................................................... 52 Female Circumcision (FC) .......................................................................................................................... 53 Family planning ........................................................................................................................................... 54 Knowledge of HIV/AIDS ............................................................................................................................ 59 Knowledge o f Sexually Transmitted Illnesses (STIs) ............................................................................... 60 Household Utilization of Services .............................................................................................................. 68 Reasons for Choosing a Health Facility ..................................................................................................... 70 4. HOUSEHOLDHEALTHEXPENDITURESINETHIOPIA ........................ 75 Household expenditures on health compared to food and other expenditures ...................................... 75 Expenditures on Last Consultation ........................................................................................................... 78 Expenditures on transportation for last consultation .............................................................................. 79 5. HEALTHSERVICEDELIVERYSYSTEM ................................................. 82 Policy and Institutional Framework .......................................................................................................... 82 Policy and ProgramReforms 86 Health Sector Development Program(HSDP) ......................................................................................... ..................................................................................................................... 86 Performance ofthe HSDP I(1997-2002) ................................................................................................. 87 HSDP I1and I11........................................................................................................................................ 88 The Public System.................................................................................................................................... 89 Organization o fHealth Services Delivery................................................................................................ SDPRP...................................................................................................................................................... 88 89 The NGO Sector....................................................................................................................................... 92 93 Traditional Healers ................................................................................................................................... The Private Sector .................................................................................................................................... 95 Access to Health Services ........................................................................................................................ 96 Geographical Access ................................................................................................................................ 97 Human Resources ...................................................................................................................................... 100 Regional Distribution ............................................................................................................................. 103 Gender .................................................................................................................................................... 105 Staffing Norms ....................................................................................................................................... 106 Salaries. Incentives and StaffRetention ................................................................................................. 111 Availability of MaterialResources ........................................................................................................... 118 Availability o fBeds................................................................................................................................ 118 Essential Drugs and Common Medicines ................................................................................................ 120 Policy Background ................................................................................................................................. 120 Drug outlets ............................................................................................................................................ Sourcing ................................................................................................................................................. 121 122 DrugAvailability.................................................................................................................................... 124 Personnel ................................................................................................................................................ 125 Special Phannacies................................................................................................................................. 126 Availability of Equipment ........................................................................................................................ 127 Condition o fHealth Facility Buildings .................................................................................................. 129 ... -111- Availability o f Transport for Healthcare Personnel................................................................................ 129 Utilization o f Health Services................................................................................................................. 130 Reasons for Visits................................................................................................................................... 131 Qualityof Health Services ........................................................................................................................ 132 Technical Quality ................................................................................................................................... 132 Consumer/ Client Satisfaction ................................................................................................................ 133 Community Participation (Social Accountability) ................................................................................. 135 6. PUBLICHEALTHEXPENDITURES ........................................................ 137 Public Spending on Health Services............................................................................................... Health Sector Funding: Public and Private Sector Contributions.................................................. Health Spending and Curative Care ....................................................................................................... 143 Public expenditures inEthiopia.............................................................................................. Public Spending on Healthcare............................................................................................... Allocation o f Public Expenditures.......................................................................................................... Capital and Recurrent Expenditures on Health....................................................................... 155 Public Expenditures and Hospital Programs .......................................................................................... 158 Regional expenditures vary widely ........................................................................................................ 161 163 Actual Capital Spending and the HSDP ................................................................................................. Tigray's Success: Expenditures to Results ............................................................................................. 164 Donor Funding: ...................................................................................................................................... 165 166 Public Spending and the Poor................................................................................................................. Cost Recovery Revenues........................................................................................................................ 168 Woreda Decentralization: Preliminary Experiences and Issues ............................................................. 169 7. SPENDINGMORE . SPENDINGBETTER.THE COST AND POTENTIAL IMPACT OF ALTERNATIVE SERVICE DELIVERYOPTIONS FOR HIGH IMPACT INTERVENTIONSINETHIOPIA .................................................... 171 Applying the MBB Tool inEthiopia:Processand Methodology .......................................................... 171 Step 1:Identify HighImpact Interventions that Need to be Strengthened inthe Ethiopian Health Services Delivery System....................................................................................................................... 172 Step 2: Identifying Country-Specific Service Delivery Strategies ........................................................ 173 Preventive maternal & neonatal care: ..................................................................................................... Step 3: Identifying Bottlenecks Hampering Effective Coverage Using HighImpact Interventions ......176 176 177 The Reduction o f Bottlenecks: H o w M u c his Enough? ......................................................................... Step 4: Setting the Frontiers o fHealth Service Coverage ...................................................................... 180 Density vs. Quality of Health Care Provision ........................................................................................ 182 Step 5: Variances in Impact and Cost o f Addressing Different Bottlenecks .......................................... 183 The OptimumCombination o f Access and Bottleneck Reduction......................................................... 184 Evaluatingof PotentialReturns from Alternative Service DeliveryArrangements ........................... 186 Simulating PolicyOptions: Costs and Benefits of ExpandingTreatment ............................................ 195 HumanResource Implications o f the Chosen Policy Options................................................................ 199 Reachingthe HealthMDGs in Ethiopia .................................................................................................. 200 Conclusion .................................................................................................................................................. 211 8. BUILDINGONEXISTINGSTRENGTHSAND ADDRESSING POLICY ISSUESFOR IMPROVEDHEALTH OUTCOMES ......................................... 214 -iv- 9. BIBLIOGRAPHY ...................................................................................... 221 10. ANNEXES .............................................................................................. 225 List o f Tables Table 1-1: Population andFertility Trends inEthiopia..................................................... 3 Table 1-2: Health. Population and Select Economic Indicators o f Ethiopia and Other sub- 9 Table 1-4: Socio-Economic & Demographic Indicators o f Ethiopiaby Region.............10 Table 1-3: Summary o f H" Indicators for Ethiopiaby Wealth Quintiles..................... Saharan African Countries (2000) ...................................................................................... 11 Table 2-1: Trends inIMR o f Selected Countries insub-Saharan Africa. 1960-2000 .... 14 Table 2-2: Morbidity by Age Reportedinthe Two Months prior to the Survey.............16 Table 2-3: Overall Morbidity duringthe Two Months prior to the Survey by Region andIncome Quintile.......................................................................................................... 17 Table 2-4: Top Ten Causes for OutpatientVisits. Inpatient Admissions and Deathin Ethiopia............................................................................................................................. 18 Table 2-5: ARI and DiarrheaIncidence (2000) ............................................................... 19 Table 2-6: Diarrhea Incidence amongChildren Under 5 Years Old............................... 20 Table 2-7: Malnutritioninsub-Saharan Africa................................................................ 24 Table 2-9: TFR andASFR by Residence and Wealth ..................................................... Table 2-8: Maternal Mortality inEthiopia and Other Countries insub-Saharan Africa .22 27 28 Table 2-11: The BurdenofHIV/AIDS inAfrican Countries .......................................... Table 2-10: TFR andASFR by region............................................................................. 30 Table 2-12: TB Incidence Ratio....................................................................................... 31 Table 3-1: Results o fWeibull Hazard Ratios for InfantMortality andUnderFive Mortality ........................................................................................................................... 35 Table -3-2: Adjusted Odds Ratios for Prevalence o f Malnutrition.................................. 38 Table 3-3: BreastfeedingPractices insub-Saharan Africa ............................................... 39 Table 3-4: Adjusted Odds for Additional VitaminA Supplementation andUse o f Iodized Table 3-5: Ethiopia: Percentage o f HouseholdsPossessing BedNets, 2000 ..................41 Salts................................................................................................................................... 42 Table 3-6 : Bivariate Analysis: Vaccination by Background Characteristics among Children 12-23 Months Old (percentage that received specific vaccines by the time o f the survey)......................................................................................................................... 45 Table 3-7: Bivariate Analysis: Percentage Distributionof Women with a Live Birthin the FiveYears Preceding the Survey that received at least One Dose o f Tetanus Toxoid Injection, ANC by a Trained Professional and Delivery Assistance by a Medically TrainedPerson.................................................................................................................. 49 Table 3-8: AdjustedOdds Ratios for Maternal Health Services...................................... 51 52 Table 3-10: Prevalence ofFemale Circumcision............................................................. Table 3-9: Nutritional Status o f Women inEthiopia (2000) ........................................... 53 Table 3-11: Needfor FamilyPlanning (FP) for Currently Married Women inEthiopia (2000) ................................................................................................................................ 59 Table 3-12 :Adjusted Odds for Knowledge, Attitude and Practices Relating to Family PlanningandKnowledgeofHIV/AIDS Prevention......................................................... 61 -V- Table 3-13: Reported IllnessIinjury duringthe Two Months prior to Survey by Wealth Quintiles inDifferent Regionsof Ethiopia..................................................................... 63 Table 3-14: Reportedillnesdinjury duringthe Two Months prior to Survey inDifferent Age Categories byWealth Quintiles................................................................................. . . 63 Table 3-15: Distributiono f Individuals with a Health Problem that Consulted for Treatement byRegion....................................................................................................... 63 Table 3-16: Distribution o f Individuals with a HealthProblem that Consulted for Treatement by Age and Income Quintile......................................................................... 64 Table 3-17: ARI andDiarrhea Incidence and Care-seeking Behavior inEthiopia (2000) ........................................................................................................................................... 64 Table 3-18: Diarrhea: Household Care-seeking Behavior inEthiopiaby Income Quintile ........................................................................................................................................... 65 Table 3-19 : Adjusted Odds Ratios for Prevalence andCare-seeking/giving for ARI and Diarrhea............................................................................................................................. 67 Table 3-20: Use o fPublic and Private Facilities by Income Quintile ............................. Table 3-21: Reasons for Choosing a Particular HealthFacility byWealth Quintile .......69 70 Table 3-23: Reasons for Women Seeking or Not Seeking Care by Wealth Quintile .....71 Table 3-22: Reasons for Choosing a Health Facility byRegion..................................... 72 Table 3-24: Reasons Mentioned for Use o f Health Facility for Various Services by Wealth Quintile................................................................................................................. 73 Table 3-25: Use o fPublic and Private HealthFacilities for Treatment o f a Sick Child by Wealth Quintile ................................................................................................................. 73 Table 3-26: Use o fPublic andPrivate HealthFacilities for ImmunizationbyWealth Quintile ............................................................................................................................. 73 Table 3-27: Use o fPublic and Private HealthFacilities for MaternalHealth Services by Wealth Quintile ................................................................................................................. 74 Table 4-1: Annual Household ExpendituresonMedical Care andHealthinComparison to other HouseholdExpenditures...................................................................................... 77 Table 4-2: Average Amount Spent (Birr) for Last Consultationby Region andIncome Quintile............................................................................................................................. 78 Table 4-3: Average Amount Spent (Birr)on Last Consultation byType o fFacility and Income Quintile ................................................................................................................ 79 Table 4-4 : Cost o f Transportation for Last Consultation (Birr)...................................... 80 Table 4-5: Source o f Out-of-pocket Expenditure by Income Quintile ............................ 80 Table 5-1: Overall Health Targets and Goals o f the HSDP, PRSP andMDGs...............88 Table 5-2: Distribution of Health Facilities by Ownership andbyRegion, 2002/03*** 91 Table 5-3: Distribution o f PharmaceuticalRetail Outlets ByRegion& Ownership, 1994EC (2001/02) ............................................................................................................. 92 Table 5-4: Sectoral Distribution o fNGOProjects (2001) ............................................... 92 Table 5-5: Distribution o fHospitals By Type and Ownership, 1994EC (2002/03 .........94 Table 5-6: Distribution o f Private Owned Clinics By Type and Region, 1995EC Table 5-7: Potential Health Service Coverage andVisit Per Capita, 2002/03 ................94 (2002/03) ........................................................................................................................... 97 Table 5-8: Average Distances to Hospitals/Health CentersEfealth Clinics (kms) ..........98 Table 5-9: Access to Nearest Hospital/Health CenterEfealth Clinic by Income Quintile ........................................................................................................................................... 98 -vi- Table 5-10: Access to Nearest HospitalMealth CenterMealth Clinic byRegion..........99 Table 5-11: Means o f Transport to Health facilities ...................................................... 100 Table 5-12: Health Personnel: In-service and Graduates 1997/98-2002/03 ..................102 Table 5-13: Health Personnel: Number andPersonnel to PopulationRatio. National Level 1996/97 and2002/03 ............................................................................................ 103 Table 5-14: Population-to-Physician, Nurse, and HealthAssistant RatiosbyRegion, 104 Table 5-15: Current Types o fhealth care providers andtheir training.......................... 2002/03 ........................................................................................................................... 110 Table 5-16: Ethiopian Average Base Salaries (per month) among Selected Health Staff, 1999 and2003 ................................................................................................................. 112 Table 5-17: Range o f Salary-to-GDP per capita Ratios for General Practitioners and Physicians in Six Countries ............................................................................................ 113 Table 5-18: Beds by Facility Type; Total number o fBeds; and Bed-to-1000 Population Ratios byRegion, 2001/02 ............................................................................................. 120 Table 5-19: Ethiopia: Supply ofPharmaceuticals: Value (000 Birr) by Sources 2000/01 ......................................................................................................................................... 121 Table 5-20: Number o f DrugOutlets per Region from 1989 to 1994E C (1996/97 to 2001/02) ExcludingBudget and Special Pharmacies ..................................................... 123 Table 5-21: Distribution o fPharmaceutical Retail Outlets ByRegion & Ownership, 1994EC (2001/02) ........................................................................................................... Table 5-22: MainFindingsby the HSDP IFinal EvaluationinRegions, Feb .2002....123 124 Table 5-23: Average Availability o f the Basket o f 10Indicator Drugs on the Day o f Visit by Type o fProvider .............................................................................................. 125 Table 5-24: Qualifications o f Personnel incharge byProvider and Facility Type, 2001 ......................................................................................................................................... 126 Table 5-26: Distribution o fEquipment inHospitals and Selected Facilities - 1995.....126 Table 5-25: Selected DrugPrescriptionIndicators........................................................ 128 Table 5-27: Percentage Reported ofAvailability o f Selected Equipmentand Transportation byFacility Type-1995 ........................................................................... 128 Table 5-28: Health Institutions ByType And BuildingCondition............................... 129 Table 5-29: Ethiopia: Total OutpatientVisits and Visits per Capita byRegion, 2000/01 to 2002/03 ....................................................................................................................... Table 5-30: Top TenReasonsfor Inpatient andOutpatient Visits (2002/03)* .............130 132 Table 5131: Variation inQuality o f Care for Maternal Health Services* by Wealth Quintile, Region andResidence...................................................................................... 133 Table 5-32: Evaluation o fthe Level o f Quality o f Care inMost Recently Visited Facility ......................................................................................................................................... 133 Table 5-33: Respondents' Perception of Quality by Different Providers...................... 134 Table 5-34: Improvements Suggested by Respondents for the Health Sector...............135 Table 6-1: National HealthAccounts--Evolutiono f Total, Public and Private Spending 1996/1997-1999/2000 ..................................................................................................... 138 Table 6-2: Health Expenditure for Selected Countries inSSA (1990-98); SSA average (1990-98, 2000) ................................................................................................................ 139 Table 6-3: Ethiopia: NationalHealth Accounts Data for 1999/2000 ........................... 142 Table 6-4: Expenditure byMajor Functions (Amount and as % ofTotal Expenditures) ......................................................................................................................................... 143 -vii- Table 6-5: Trends inOverall GovernmentRevenues, Ethiopia, 1980-81to 2001-02... 145 Table 6-6: Trends inTotal GovernmentExpenditure inEthiopia, 1980/81to 2001/02 146 Table 6-7: Public Spendingas a Share of GDP inSelectedAfrican Countries............. 147 Table 6-8: EthiopiaHealthExpendituresinCurrent and Constant Prices and Per Capita Expenditures, EFY 1983, 1988-1994(1990/91, 1995-2002) ......................................... 149 Table 6-9: Share o fPublic Spending on HealthinEthiopia,1990, 1995/2002 According to Budget Monitoring Data (Percent GDP and Percent of Public Spending) ................150 Table 6-10: Recurrent and Capital Health Expenditures (current and constant prices) EFY 1983; 1992-1994(1990/91, 1997-2002) ................................................................. 153 Table 6-11: Evolutiono fRecurrent and Capital expenditures on HealthinEthiopia, 1990/91,1995/2002 (percent o fpublic spending and GDP) .......................................... 154 Table 6-12: Ethiopia: Composition ofRecurrent Expenditures, EFY 1989-1994 (Statistics from 1996/97-2001/02)Birr inThousands .................................................... 155 Table 6-13: Data on Budget andExpenditure for Procurement ofDrugs and Medical Supplies inthe Ethiopia Public Health Sector, EFY 1989-1994 (Statistics from 1997- 2002) ............................................................................................................................... 156 Table 6-14: Ethiopia: Composition o f Capital Expenditures, EFY 1989-1994 (Statistics from 1996-2001), inBirrThousands.............................................................................. 158 Table 6-15: Budget ExecutionRatesbyRegionEFY 1989to 1994 (Statistics from Table 6-16: Budget ExecutionRates: Recurrent and Capital byRegion, 2002/03 .......160 1996/97-2001/02)............................................................................................................ 160 Table 6-17: National Level Recurrent and Capital Budget Execution Rates, 1992-2002 ......................................................................................................................................... 161 Table 6-18: RegionalHealthBudget, Expenditures (inBirr 000) andper Capita Expenditures 2000/01 and 2002/03 ................................................................................ 162 Table 6-19: Relation BetweenAverage per Capita Spending (inBirr)by Region EFY1990-1994 (1997/98 to 2001/02) andsome selected CoverageIndicators at Baseline (EFY 1989, 1996/97) andinEFY 1994(2001/02, endHSDP I) .................................. 164 Table 6-20: Sectoral Distributionof Aid inEthiopia: Average 1997-2001 and Most Recent Year..................................................................................................................... 166 Table 6-21: Proportion ofFree Patientsto Total Patients and Estimated Foregone Revenue byHealthFacility..................................... . . ....................................................... 167 Table 6-22: Use o fHealthFacilities and Services: NationalData per Income Quintile168 Table 7-1: Health interventions includedinthe HSEPStrategy andDeliveredby Population-oriented Outreach Services........................................................................... 174 Table 7-2: Health Interventions iDeliveredby Community HealthPromoters or Family/Community-orientedServices...........................................................,............... 175 Table 7-3: Healthinterventions includedinthe Clinical Individual-oriented Service Delivery Strategy............................................................................................................ 176 Table 7-4: Trade-offs between Reducing Gaps inDemand, Continuity and Quality and IncreasingAccess............................................................................................................ 184 Table 7-5: Increase inHealth Service Coverage for each Bottleneck Removal Option 185 Table 7-6: EstimatedImpactandcost o f Service Delivery Arrangements for Three Modes: HSEP, Community Promoters & Clinical Care................................................. 191 Table 7-7: Cost-effectivenessAnalysis o fthe Service Delivery Packages- I............... 194 Table 7-8: EstimatedImpact and Costs for Different Policy Options........................... 197 -viii- Table 7-9: Additional HR Implications o fExpandingHealth Service Coverage........... 199 Table 7-10: HealthServices ExpansionStrategies inEthiopia ..................................... 203 Table 7-11: Key Investmentand Recurrent Costs for Each Step o f the Health Services Expansion Strategy ......................................................................................................... 204 Table 7-12: Scaling-up Coverage o f Health Services inEthiopia: Resource Implications. Costs. and Potential Benefits .......................................................................................... 206 Table 7-13: Costs o f Scaling-up Health Services inEthiopia: Incremental Cost per capita 2005-2015 Neededto Reachthe MDGs............................................................... 209 . Table A 1: Poverty. Development. and Per Capita Revenue Indices by Region..........225 Table A 2: Distribution o fHealthWorkers and % ofFemale Staff across Regions (2002/03) ......................................................................................................................... 226 Table A 3 StaffingNorms by Types o f HealthcareInstitutions ................................... 227 List o f Boxes Box 5-1: Salaries. Benefits. Overalljob satisfaction: What do Health Workers Say? .. 115 Box 5-2: Exampleo fLocal Community Ownership o f a Health Center (HC) .............136 Box 6-1: Examples o fEarlyExperiences with Block Grants........................................ 170 Box 7-1: Density versus Quality InHealth Care Provision: current evidence from Ethiopia........................................................................................................................... 182 Box 7-2: Five Steps o f Health Services Expansion inEthiopia .................................... 202 List o f Figures Figure 1.1: HNPPRSP Framework: Determinants ofHealthRelatedPoverty Outcomes ............................................................................................................................................. 6 Figure2-1: Ethiopia andthe Global Trends inInfantMortality andUnder-Five Mortality ........................................................................................................................................... 13 Figure 2-2: IMR andPoorRich Inequalities inVarious Countries................................. 13 Figure2-3: Trends inU5MR inEthiopia Compared to Other Regions ofthe World .....14 Figure2-4: Achieving MDGfor Child Survival.............................................................. 15 Figure 2-5: Regional Variation inIMR and U 5 M R inEthiopia...................................... 16 Figure 2-6: ARI inChildren Under Five duringthe Two Week Period prior to Survey Sorted by Income quintiles ............................................................................................... 19 Figure 2-7: Diarrhea in Children under Five duringthe Two Week Period prior to Survey Figure 2-8: Moderate to Severe Underweight Rates Sortedby Income Quintiles ..........20 Sorted by Income quintiles ............................................................................................... 23 Figure2-9: RegionalDifferences inChildMalnutritionRates inEthiopia..................... 23 Figure2-10: EstimatedMMRfor Selected Countries inSSA and the World. 1995......25 Figure 2-11: Malnutrition Among Mothers o f Children less than3 years old in 17 SSA Countries ........................................................................................................................... 26 Figure2-12: Changes inTFR insub-Saharan African countries includingEthiopia......28 Figure 3-1: IMR and U5MR by Wealth Quintiles inEthiopia ........................................ 33 Figure3-2: ConcentrationCurves for IMR andU5MR inEthiopia 2000....................... 33 Figure3-3: Iodized Salt andVitaminA Supplement Coverage inSSA.......................... 40 -ix- Figure3-4: InternationalComparisonofDPT 3 byWealth Quintiles............................. 43 Figure3-5: A N C inthe Poorest QuintilebyaMedically TrainedPerson (ranked by country) ............................................................................................................................. 47 Figure 3-6: Delivery inthe Poorest QuintileAttended by a Medically Trained Person (ranked by country) ........................................................................................................... 47 Figure 3-7: Average Use o f Modem Contraceptives by Women inthe Richest and Poorest Quintiles............................................................................................................... 56 Figure 3-8: CPR and TFR insub-Saharan African Countries ......................................... 57 Figure 3-9: Various FamilyPlanningIndicatorsby Wealth Quintiles inEthiopia.......... 58 Figure 3-10: Percentage o fthose I11inthe Last Two Months Seeking Care by Gender Illness inthe Last Two Months. and seeking percent ofthose illseeking care by gender62 Figure 3-11: Rate o f I11People Seeking Consultation inthe Last Two Months by Gender and Age ............................................................................................................................. 62 Figure3-12: Poor-to-rich Care-seeking rates for ARI inselected sub-Saharan African Figure 3-13: Use o fPublic or Private Facility for Last Consultationby Region ............64 Countries........................................................................................................................... 68 Figure3-14 HealthFacility Utilization inDifferent Wealth Quintiles............................ 69 Figure 3-15: Distribution o fReasons for Facility Choice ............................................... 71 Figure3-16: Proportion o fResponses Citing Quality as Reason for Selecting a Particular Facility .............................................................................................................................. 72 Figure 4-1: Total Health Expenditure as a Percentage o fNon-Food Expenditure by Income Quintiles ............................................................................................................... 76 Figure4-2: Source o fOut-of-pocket Expenditure byRegion ......................................... 81 Figure5-1: Ministryo fHealth: Organizational Structure .............................................. 83 Figure5-2: Structure o fthe Public HealthDelivery System (make figure larger) ..........90 Figure 5-3: Number of HealthFacilities byType from 1996/97 to 2002/03* .................96 101 Figure5-5: Trends inGrowthofHealthProfessionals. 1996/97-2002/03 .................... Figure 5-4: Physiciansper 100.000 Persons vis-A-vis GDP.......................................... 102 Figure5-6: Public Sector Physicians andHealthOfficers per 100.000Populationby Region (EC1989 andEC1994 or 1996/97 and 2001/02) ............................................... 105 Figure 5-7: Distribution o f Public Sector Midwivesby Region (EC1989 andEC1994 or 1996/97 and 2001/02) ..................................................................................................... 105 Figure5-8: Percentage ofFemales inEachHealthWorker Professional Category in Ethiopia. 2002/03 ........................................................................................................... 106 Figure5-9: Plannedand Achieved Training Outputs EY 90-94 (1997/98 to 2001/02) 108 Figure5-10: Health Care Provider Absence Rate.......................................................... 116 Figure5-11: Populationper HospitalBedby GDPper capita....................................... 119 Figure5-12: Populationper HospitalBedinsub-Saharan African Countries...............119 Figure6-1: Per Capita Expenditure on HealthinVarious Countriesvis-a-vis GDP..... 138 Figure6-2: Per capitaPublicandPrivate Expenditures (as apercentage of GDP) on HealthinVarious Countries o f the World...................................................................... 140 Figure6-3: Per capita Public andPrivate Expenditures (as apercentageo f GDP) on HealthinVarious Countries o f the World...................................................................... 141 Figure6-4: Ethiopia Health Spending: Source o fFinancing. 1999/2000...................... 142 Figure 6-5: Breakdown ofPromotive and PrimaryHealth Care Services ..................... 144 -X- Figure6-6: Total Public Expenditures from 1995-2002 (Current and Constant Terms. 1995=100) ....................................................................................................................... 147 Figure6-7: Total Public Health Expenditures (Current and Constant Prices).............. 148 Figure6-8: RealPublic Health andTotal Public Expenditures Indexedto 1995/96 Expenditures ................................................................................................................... 149 Figure 6-9: Public Recurrent and Capital HealthExpenditureTrends (1990/91-2001/02) (Current and Constant Prices) ......................................................................................... 151 Figure 6-10: Functional Breakdown o fMinistry o fHealth andRegional Health Bureau Expenditures ................................................................................................................... 152 Functional/Service Levels. 1999-2000 ........................................................................... Figure6-11: Capital andRecurrent Expenditures Capital Expendituresby 157 Figure 6-12: Ethiopia: Composition o fRegionalRecurrent Expenditures (2000/01) ...163 Figure 7-1: Examples o f IdentifyingBottlenecks and Setting Coverage Frontiers for Immunization. ORT Use and Assisted Delivery Services ............................................. 178 Figure 7-2: Impact o f the Reduction o fBottlenecks on Quality. Continuity and Demand of Services by 50%. 75% and 90% Respectively........................................................... 181 Figure 7-3: Reduction inMortality and Costs Associated with Increased Access without Addressing Bottlenecks .................................................................................................. 182 Figure7-4: Cost andPotential Impact o fRemoving Bottlenecks inQuality. Continuity Figure 7-5: DiminishingRetumson Additional Resources for Health Services...........183 andDemand.................................................................................................................... 186 Figure 7-6: Cost Function Estimate o fthe Health Service Contribution to Reducing 187 Figure 7-7: Cost and Impact o fAll Three Service Delivery Modes.............................. ChildMortality................................................................................................................ 188 Figure 7-8: Cost-effectiveness Analysis o fthe Service DeliveryPackages .I1............194 Figure 7-10: Predictions inAchieving MDGs for Child Survival................................. Figure7-9: Impact and Costs o fAddingBasic Clinical Care at the HP Level.............198 200 Figure 7-11: Projected Cost andAssociated Reduction inChild Mortality Linked to Implementation o f Services Scale-up Strategies: Ethiopia 2006-2015........................... 210 Figure 7-12: Evidence ofthe Impact o f IncrementalInvestments on Strengthening o f HighImpact Interventions(Tanzania EHIP).................................................................. 211 Map: IBRD33405 -xi- ACKNOWLEDGMENTS 1. This Country Status Report (CSR) i s ajoint product o fthe Ministry o fHealth (MOH), NationalOffice o fPopulation, PrimeMinister's Office, andthe World Bank (WB). Itwas undertaken inclose collaboration with the UnitedStatesAgency for International Development (USAID), the World Health Organization (WHO), andthe UnitedNations Children's Fund(UNICEF) with inputs from other HealthNutrition and Population (3")Donors Group HNP members inEthiopia including: Italy (the Italian Cooperation), Norway ( N O W ) , Sweden (SIDA), and Ireland (IrishAid). 2. The Ethiopia MOHteam was headed by Dr.Kebede Taddese (Minister o f Health) and Dr.Girma Azene (Head, Program and PlanningDepartment) and includes staff from the various M O H departments includingHealth Extension, FamilyHealth, Human Resources, Communicable Diseases, Program and Planning, and the USAID-funded Essential Services for Health inEthiopia (ESHE) project, with extensive technical assistance from Ato Netsanet Walelign. The National Office o fPopulation inthe Prime Minister's Office was represented by Ato Sisay Worku. 3. Contributions to the CSR from the WB-side were coordinated by Christine Pena and Agnes Soucat. The WB CSR core team is composed o fAnwar Bach-Baouab, Sekhar Bonu, Gebreselassie Okubagzhi and FengZhao. Importantcontributions were madeby Maria EugeniaBonilla-Chacin, KimBeer, Deborah Mikesell, Sarbani Chakraborty, SonNamNguyen, William Savedoff and William James Smith. Caroline Hope and Debbie Tangprovided editorial support. Therese Tshimanga and Southsavy Nakhavanit assisted indocument processing. Invaluable comments and suggestions were received from peer reviewers HaroldAlderman, Mukhesh Chawla, andMichelle Lioy; as well as from other membersofthe country team includingJeni Klugman, Jee-Peng Tan, Karim ElAynaoui andLuc Christiensen. LauraFrigentiandIshac Diwanprovided over-all guidance. This report has beenpresented and benefited from comments and suggestions inthree major fora inEthiopia: (i) The 3" Donors Group meeting on July 7,2004, which was attendedby the Italian Cooperation, SIDA, UNICEF, USAID, IrishAid, WHO; (ii) A workshop organizedbythe EthiopianDevelopment Research Institute (EDRI)onJuly9,2004, attendedbyrepresentatives from the PrimeMinister's Office, MOH, MinistryofFinanceand Economic Development (MOFED), other policy makers, donor agencies and academic institutions such as Addis Ababa University; and (iii) TheHealthSectorDevelopmentProgramAnnualReviewMeetingon September 21,2004, attendedby representatives from MOFED and MOH, regional and woreda HSDP stakeholders and donors. Site visits and discussions were also conducted during the preparation o f this report in Addis, Oromia and SNNPR. 1. INTRODUCTION 1.1 Ethiopiai s locatedinNortheast Africa, commonly referred to as Horno f Africa, andis situated east o f Sudan, north o fKenya, south o f Eritrea, west o f Djibouti, and northeast o f Somalia. Ethiopia i s a country endowed with many resources, a diversified topography, andmanynationalities. A multi-ethnic society, it serves as the home o f about 80 ethnic groups (CSA 1998). 1.2 Ethiopia is a country o f great geographical diversity. Its main topographic features range from Ras Dejene, the highest peak at about 4620m above sea level, downto the Afar depression (Kobar Sink) at about 110mbelow sea level. The Great RiftValley separates the western andnorthernhighlands from the southeastern and eastern highlands. These highlands give way to vast semi-arid lowland areas inthe east, west and especially inthe south o f the country. The country is dividedinto three major ecological zones: Kolla (aridlowlands below 1,000 meters above sea level), Weina Dega (land between 1000meters and 1500 meters above sea level) andthe Dega (highlands between 1500 and 3000 meters above sea level). About 40 percent o f Ethiopia's total landarea is comprisedofhighlands,which are found at elevations above 1500m. The annual rainfall o f the highlandarea ranges between 500" to over 2000 mm. The mean annual temperature inthe highlands is below 20"~.The lowlands o f Ethiopia cover about 60 percent o f the total area o f the country. Rainfallinthe lowland areas is relatively low, often poorly distributed, and highly erratic. It ranges from 300" to 700" annually. Thetemperature inthe lowland areasis consistently greater than 2Ooc. 1.3 Ethiopia is one o f the poorest countries inthe world. The country's per capita gross national income (GNI) o fUS$lOO (US$720 inpurchasing power parity(PPP) terms) in2002 compares poorlywith the sub-Sarahan Africa (SSA) country average per capita GNIo f US$450 (US$1,620 inPPP terms) and is significantly lower than the world average o fUS$5,080 (US$7,570 inPPP terms) (WorldDevelopment Indicators (WDI), 2003)'. Millions o f Ethiopianscontinue to live inabsolute poverty. The poverty headcount declined slowly from 45.5 percent in 1995 to 44.2 percent in2000, with about 28 million Ethiopiansbelow the poverty line (PRSCI PAD 2004, Worku 2004).' More than 50 percent o fEthiopiansremain food insecure, particularly inrural areas. About ten percent o fthe population is chronically food insecure. 1.4 Over the past ten years, Ethiopia has beenprogressively undertaking economic reforms. The country has been operating a free market economy since 1991. The government introducedthe Economic Recovery and Structural Adjustment Program in 1992 to stabilize the macro-economic fi-amework by liberalizing foreign exchange markets. Structural reforms were initially emphasized inthe agricultural sector where ' In terms of GDP per capita (constant 1995 US$), Ethiopia's GDP was only US123 in 2002 compared to the SSA average of US$575 and the world averageof US$5,654 (WDR 2003). Usingthe absolutepoverty line of Birr 1075 in 1995 prices, the Risk and Vulnerability Study (WB 2003) also finds that the national head count poverty rate also declined between 1995 and 2000 although the % decline was much higher (from 61% in 1995 to 48% in 2000). -L- various restrictions and quotas were either liftedor lowered. Legal, institutional and policy reforms were also undertakento promoteprivate sector investment. These economic measures paid positive dividends, reversing years o fpersistent decline inthe per capita gross domestic product (GDP). Real GDP grew on average by 5.8 percent from 1992/93-2001/02, while population growth was about 2.7 percent over the same period. The Ethio-Eritrean border conflict affected GDP growth rates from 1998 to 2000, andin 2003 the economy declined sharply and experienced a negative growth rate as a result o f the drought, which affected 14million people. 1.5 The agricultural sector continues to be a major contributor to the overall Ethiopian economy although its contribution has decreased from 54.4 percent 1982 to 39.9 percent in2002.' Agriculturalproductivitylevels are lowresulting fromthe decline oftraditional farming systems, whichis due to environmental degradation and rapidpopulation growth. The sector is also highlyvulnerable to extemal shocks as droughts have occurred every three years duringthe past decade. The humanresource base for agricultural development i s also largelyilliterate and inadequately equipped with modem skills, inputs and equipment. As a result o f these conditions, within the span o ftwo decades, the services sector has emerged as the most dynamic sector, increasingits sectoral share from 33.2 percent inthe 1980s to 47.6 percent in2002. Within the same period, the industrial sector has maintained its sectoral share o f 12percent, althoughit experienced some decline inthe 1990s. 1.6 Decentralizationdecisionmakingpower andresponsibilities have been devolved over time to regional and local governments. When Ethiopia emerged from civil war in 1991, the Dergregime was replaced and, in 1994, a new constitutionwas introduced, creating a federal structure o f government. The country's first multi-party elections were organized in 1995. Ethiopianow has a parliamentary federal government administering nine regional states and two administrative councils (AddisAbaba and Dire dawa), which are sub-dividedinto 560 woredas (districts). These woredas, inline with the country's decentralization policy, represent the basic units o f planningand political administration. Below the districts are kebeles or peasant associations. 1.7 Ethiopia has a young andrapidly growingpopulation, which places pressure on cultivatable lands. With a population o f around 69.1 millionin2003, Ethiopia i s the second most populous country insub-Saharan Africa, preceded only byNigeria (140 million). The population has been growing on average at a rate o f two million persons annually from 2000 to 2005 (2.7 percent growthrate), which i s fairly close to the average annual growth rate o f sub-Saharan Africa (2.5 percent). Its population increased bymore than ten millionbetween 1984 and 1994 (Table 1-1) andby an additional 10million by 2001. While the share of agriculture has declined over time, it i s still the primary source of employment for about 80% of the work force It also comprises about 80 to 90% ofmerchandise export eamings (PRSC 2004). -3- Table 1-1: PopulationandFertilityTrends in Ethiopia 1984 1994 2001 MOH DHS Census Census UNPOP 2002 2000 Population (millions) 42.6 53.5 64.4 Inter-Census growth rate (percent) 3.1 2.9 2.5 Life expectancy (years) 44 Male 51.1 50.9 53.4 Female 53.4 53.5 55.4 Total Fertility Rate* 6.8 5.9 H N i A I D S adult prevalence rate 6.6 Numberofadults (15-49) livingwith 2.2 HIV/AIDS (millions) Religion (%) Orthodox 50.5 Muslim 29 Catholic 1.1 Protestant 15.8 Others 3.5 * The rate was 6.4 in 1990 (NFFS) 1.8 The majority o fEthiopians live inrural areas (83%). The urbanpopulation is growing at a much faster rate o f 4.1 percent per annumcompared to the slower rate o f 1.9 percent inrural areas. Large-scale migration bythe rural population insearch o f better employment opportunities inurbanareas can explain this gap. 1.9 Population density is moderate relative to some SSA countries even though it i s twice the average for SSA (Table 1-2). Population density i s very highinthe highlands and lowest inthe eastern and southern lowlands. About 23.2 percent o f the population is concentrated innine percent o f the country, puttingpressure on cultivatable lands and contributing to environmental degradation (MOH 2002). Onthe other hand, about 50 percent o f the land area is sparsely populatedwith nomadic or semi-nomadic tribes living inan arid or semi-desert environment. Thepopulation is young, with 44 percent o f the populationunder the age o f 15. This population structure connotes both ahigh dependency ratio and rapid exponential population growth inthe future. Ifpopulation growth does not decline inthe coming years it i s expected that the population o f Ethiopia will double inabout 25 years. 1.10 The average Ethiopianhouseholdis comprised o f4.8 persons. Inrural areas, there are about 4.9 persons per household, while urbanhouseholds have, on average, 4.2 persons. There are three times as many single-headed households inurban areas in rural areas (13 percent versus four percent). Ethiopian households are predominantly headed by males; less than 25 percent are headed by females (DHS 2000). 1.11 Approximately 85 percent o fhouseholds rely on agriculture as their main source of livelihood. The average annual expenditure for an Ethiopian household in2000 was Birr5401,60 percent ofwhich was spent on food andonly 1.1percent o fwhich was spent on health and medical care. -4- 1.12 Access to basic social services i s limiteddespite efforts madeby the Government o f Ethiopia (GOE) to ensure access. The SSA average for access to improved sanitation i s 55 percent as compared to only 15 percent inEthiopia. Approximately 24 percent of Ethiopians have access to improved drinkingwater. This is slightly less thanhalf of the SSA average (55 percent). 1.13 Life expectancy is 42 years, which is slightly lower than the SSA average o f 46 years. Sixty-one percent o f Ethiopiansare illiterate, which is much higher than the SSA average o f 39 percent. 1.14 The success of public healthinitiatives depend on the awareness and literacy o f the citizens. Thus, low literacy levels inEthiopiapose a major challenge inachieving public health goals, a factor that needsto benotedand incorporated inplanning,program implementation, and information, education and communication interventions. The primaryschool gross enrollment rate (GER) has tripledfrom 20 percent in 1993/94 to about 62 percent in2001/02. However, Ethiopia's primary GER i s still lower than the SSA average o f 86 percent (Ethiopia at a Glance 2002). Evenifthe adjusted GER o f 68 percent is used (makingthe rate comparable to the analysis of grades one through six used inother countries), it i s only ahead o f certain countries including Sierra Leone, Guinea, Sudan andthe Democratic Republic o f Congo (Education CSR Draft 2004). 1.15 While the Ethiopianconstitutionrecognizes the equal rights o f women and men, the country's traditional societal structure renders women ina vulnerable position. Traditional harmfbl practices are common: 80 percent o fwomen have undergone some type o f circumcision. The illiteracyrate for adult females is highat 66 percent (compared with 51percent for adult males). An intense workload (Ethiopian women work an average o f 15-18 hours per day and many domestic tasks are highly labor intensive) and early marriage (the average age at first marriage was 17.6 years in 1998) are common. Limitedstudies andpolice andmediareports suggest that violence against womenis quite highand increasing every year (SGCA 2004). In2000, women occupied a very small percentage o f key government decision makingpositions: 7.7 percent inthe House o f Representatives; 5.6 percent inthe House o f Federation; 13 percent inregional councils; and 14percent inkebele councils (Ashenafi, EWLA, 2000). PURPOSE THE HEALTH OF SECTOR COUNTRY STATUSREPORT 1.16 The EthiopiaHealth Sector Country Status Report (HSCSR) aims to consolidate knowledge inorder to lay the groundwork for discussing andrefining strategies and policies inthe health sector inEthiopia. Intheory, the developmental sequence is first to prepare the HCSR; then to discuss it with government counterparts; and lastly to collaborate with the government on designing a broad agenda for policy reform and implementation. Inpractice, however, the sequence has unfolded differently inEthiopia. The preparationo fthe HSCSRbegan inJuly 2002, however, a draft Poverty Reduction Strategy Document was already prepared and approvedby the WB and IMFBoards in September 2002. The mainobjective of Ethiopia's Sustainable Development and Poverty Reduction Program (known as SDPW, the Ethiopianversion o fthe PovertyReduction Strategy Program(PRSP) is to reduce poverty by enhancingrapid economic growth and -5- maintaining macro-economic stability. A reduction inchild and maternalmortality rates is amongthe key objectives o f the EthiopiaSDPRP. One key strategic option o fthe PRSP for reducing maternal and child mortality i s to expand the provision o f essential health and nutrition services to the rural poor ofEthiopia. 1.17 The World Bank Country Assistance Strategy (WBCAS) for 2003-2005 will provide support to Ethiopia's SDPRP and thereby assist inthe country's program to reduce poverty and achieve the Millennium Development Goals (MDGs). Inparticular, the WBCAS seeks to enhance pro-poor growth, improve humandevelopment outcomes, reduce vulnerability, and improve governance. The HSCSR i s also expected to contribute to the medium-term health sector strategic planningprocess for the period 2005-2010 andpreparation ofthe Health Sector Development Program 3 (HSDP3), a share o fwhich will be funded under the Poverty Reduction Strategy Credits (PRSCs). 1.18 To contribute to the SDPRP, the WBCAS, the medium-term sector strategic planning process, the Ethiopia HSCSRreport seeks to: (a) Consolidate andimprove health sector knowledge, with a particular focus on identifyingkeyhealthnutritionpopulation (HNP)issues for the poor inEthiopia; (b) Provide input into the preparationo fHSDP3 andthe PRSCs, as well as to the revised version o fthe SDPRP based on a menuo f strategic options for the health sector, andmake recommendations for public expenditure reform andpoverty reduction; and (c) Establish an objective benchmark for tracking subsequent policy development and dialogue. 1.19 To structure the analysis ina systematic manner, the Ethiopia HSCSR will follow the HNP and PRSP Framework, identifyingthe key factors at the household, community and health system levels that have an impact on health outcomes. -6- Figure 1-1: HNPFRSP Framework: Determinants of Health Related Poverty Outcomes Source: ClaesonM.et a12001 cited in Soucat andDiop 2001 1.20 Inadditionto this introductorychapter, the EthiopiaHSCSRis comprisedo fsix other chapters. It is structured inthe followingmanner: Chapter 2 describes basic health outcomes inEthiopia with comparisons over time, betweenurbanand rural areas and across regions and income levels. Chapter 3 analyzes (to the extent that data allow), the factors at the household and community levels that affect health outcomes. These include knowledge about health issues such as appropriate feeding o f infants; health-seekingbehavior; and utilization o fpreventive health and reproductivehealth services, as well as basic services o f curative care for child and maternalhealth. Chapter 4 examines household expenditures on healthcare. This section on household spending will describe the pattern o fhouseholdout-of-pocket spending inrelationto income andtypes o fservices used. Chapter 5 assesses the performance o f the Ethiopian health service delivery system. The performance o f the sector is analyzedby comparing indicators o f coverage o f key health interventionsby region, urbadrural classifications, and income groups. Chapter 6 examines how public spending is allocated across different levels of careby region and by urbdrural location. The chapter compares the actual level o f financing with the Federal Democratic Republic o f Ethiopia's (FDRE) intended levels and determines whether adequate levels o f resources are allocated to address the needs o fthe poor. Chapter 7 evaluates potential financing options and corresponding costs, as well as the impact o f Ethiopia's efforts to increase health service coverage. -7- The chapter places a particular focus on effective preventive and curative health interventions. 0 Chapter 8 outlines the strengths o f the health sector and other policy issues to be used for future discussions emerging from the analysis. 1.21 The HSCSR relies on existing data sources including: the Demographic and Health Survey (DHS) 2000 for Ethiopia; (b) Welfare MonitoringSurveys (WMS); the HouseholdIncome, Expenditureand Consumption Survey (HICES) 1995/96 and 1999/2000; reports produced by the Program and Planning Department (PPD)/MOH, reports from the service andprogram departments o fthe MOH; facility level surveys including the Policy andHumanResource Development (PHRD) HealthFacilities 1996 Study; and other sector reports such as those from the Health Sector Development Program (HSDP). 1.22 To set the stage for the rest o fthe report, a summary o fHNP status indicators and HNP service indicators are presented bywealth quintiles (Table 1-1). 1.23 Wealth-based differentials inhealth status and services indicators underscore the gap between the rich and the poor inEthiopia, which, as the next sections will show, is still relatively lower than the gaps inother countries. Inparticular, infant mortality rates (IMR) are more than 16percent higher andunder-five mortality rates (USMR) are 31percent higher among children from the poorest quintile (compared to children from the richest quintile). Severe underweight is almost 260 percent higher inchildren from the poorest quintile than inchildren from the richest quintile. Around 17 percent o f the children from the poorest quintilehadnone o f the standard immunizations, while only 6 percent o f the children from the richest quintile were lacking immunizations. Oral rehydrationtherapy (ORT) use duringepisodes o f diarrhea is more than five times higher inwealthy households thaninpoorhouseholds. Antenatal care (ANC)ismorethanthree times higher among the women from the richest quintile, and deliveries attended to by trained professionalsis more than 25 times higher. A more extensive analysis o f inequitieswill be presented later inthis report. The evidence presented here should sufficiently underscore the need to closely examine health sector related issues in Ethiopia andto assess successful and unsuccessfulpolicies targetedto assist the poor in order to enhance the responsiveness of H" policy and programs inaddressing equity issues. 1.24 This report will also study urbardrural and regional differences. National averages tend to mask regional differences, particularly within the context o fEthiopia, a country comprised o f 11regions (nine regions and two administrative urban councils: Addis Ababa and DireDawa). These regions have different agro-climatic zones; levels of development capacity and organization; and population size and characteristics, resultingindifferent health outcomes (Table 1-3). -8- 1.25 The regional states and administrative councils are differentiated into three broad categories (HSDP PAP 1998): 0 Large, central, highly-populated regions: Tigray, Amhara, Oromiya and SNNF'R; 0 Urbanregions/administrative councils: Addis Ababa ,DireDawa andHarari; and 0 Newly emerging, peripheralregions: Afar, Somali, Benishangul-Gumuz and Gambella. 1.26 Tigray, S W R and three out o fthe four emergingregions (Afar, Benshangul Gumuz and Gambella) have poverty head count ratios that exceed 50 percent. Tigray has the highest level o fpoverty ratio at 61 percent. The emergingregions generally have less favorable health indicators; less developed healthinfrastructure, including a more limited availability of qualified healthproviders andmanagers; and a higherpercentage of pastoralist communities than do the other regions. 0: I -10- .IBg P h .I Q .I 4 9 w c 0 * r0 aue Q Y aua I 3 EM 3 0 I n 8 4 zB 0 0 .I u v1 0 .. P 5 3 a2 -12- 2. HEALTHOUTCOMES 2.1 This chapter analyzes the status o fmaternal and child healthoutcomes, which are keyindicators targeted bythe Millenium Development Goals (MDGs). The analysis includes: 0 Basic health outcome indicators with comparisons over time; 0 An assessmento fthe burdenofhealthproblems onthe poor relativeto the rich; 0 An analysis o fthe levels andtrends ininequities over a periodoftime; 0 Sub-national analysis o f health outcomes betweenurbanand rural areas and across regions; and 0 A description o fthe key healthproblemsthat affect the poor includingpriority diseases that contribute most to the burdeno f disease, child andmaternal mortality, etc. CHILDMORTALITY 2.2 Child mortality has declined inEthiopia over the past 15 years andthe decline has been more pronouncedover the last ten years. Figure 2-1 presents neonatal, infantand under-fivemortality rates for the three most recent five-year periods before the Demographic andHealth Survey (DHS) 2000. Nonetheless, almost one inevery ten babies borninEthiopia (97 per 1,000) does not survive to celebrate its first birthday, and one inevery six children dies before its fifthbirthday. Under-five mortality rates (USMR)are 21percent lower now thanit was five to nineyears ago. The corresponding decline inneonatal andpost-neonatal mortality over the same period i s 29 percent and 21percent, respectively. -13- Figure 2-1: Ethiopia and the Global Trends i Infant Mortality and Under-Five Mortality .. I 6 0 . 140 120 g - loo tg BO r 42 60 ' . 40 20 0 10 IOU 1000 low0 IOOWO ON1 p r mplta. Atlas msthcd (sumnt USI) Source:World DevelopmentIndicators,World Bank, Wash Ii 4.5 , Figure 2-2: IMR and Poor/Rich Inequalities inVarious Countries + Peru +Turkey + Bolivia 3.5 4.0 . +indonesia *Egypt . 3.0 Paragua~B%mcan Rep 2.5 1 + Colombia +Vietnam Philippines India CAR 6 2.0 - +Nicaragua +Cameroon Madagascar, Mozambique + Senegal + Cote r(yyoire Benin 1.5 - G~~~~~~~~4 Ghana Kazakhstan +Zimbabwe +Malawi 1.0 - *e Uzbekistan+Namibia +Chad I 0.0 J 0 20 40 60 Population Average (IMR) 80 100 120 140 160 2.3 How does Ethiopia fare compared to other countries with regards to child survival relative to per capita income? Figure 2-1 and Figure2-2 indicate that although Ethiopia has very highIMR andUSMR, the rates are lower than those o f countries with similar per capita incomes (Ethiopia's scatter plot point is left ofthe trend line inboth cases as depicted inFigure 2-1). Figure 2-2 confirms that while Ethiopia's IMR is high, intra- country inequities between rich and poor are low. Going forward, Ethiopia should try to maintain these low inequity levels while reducing the highlevels o f child mortality. -14- Figure2-3: Trends inUSMRinEthiopiaComparedto Other Regionsof the World 3 0 0 .__I_---- ~ -Sub-Sa ha ran Africa +South Asia 2 5 0- -Latin America and Caribbean --SCDeveloping countries rs 2 0 0 .--CEthiopia 1 5 0 2 1 0 0 9 50 oc 1 9 6 0 1 9 7 0 1980 1 9 9 0 1 9 9 5 2 0 0 0 Y e a r Source: UNICEF,2002 Table 2-1: Trends inIMR of Selected Countriesinsub-SaharanAfrica, 1960-2000 Trends in IMR Decadal decreasein IMR (negative indicate increases) Rank in Rank in Country 1960 1970 1980 1990 2000 1960-70 1970-80 1980-90 1990-2000 1980-90 1990-200( CAR 187 149 121 115 115 20.3 23.1 5.2 0.0 8 9 Chad 195 149 124 118 118 23.6 20.2 5.1 0.0 9 8 Congo 143 100 88 83 81 30.1 13.6 6.0 2.4 7 6 Congo DR 175 147 130 128 128 16.0 13.1 1.6 0.0 11 7 Ethiopia 180 160 143 128 117 11.1 11.9 11.7 8.6 4 5 Kenya 122 96 73 63 77 21.3 31.5 15.9 -22.2 2 12 Malawi 205 189 157 146 117 7.8 20.4 7.5 19.9 6 1 Mozambique 180 163 140 143 126 9.4 16.4 -2.1 11.9 12 4 Sudan 123 104 86 75 66 15.4 20.9 14.7 12.0 3 3 Tanzania 142 129 106 102 104 9.2 21.7 3.9 -2.0 10 , 10 Uganda 133 110 108 100 81 17.3 1.9 8.0 19.0 5 2 Zambia 126 109 92 108 112 13.5 18.5 -14.8 -3.7 13 11 Zimbabwe 97 86 69 53 73 11.3 24.6 30.2 -37.7 1 13 Source: UNICEFwww.childinfo.or. 2.4 Table 2-1 shows that Ethiopiahas experienced a slow but steady decline inIMR since 1960, with an average IMRreduction o f 10percent each decade. The country fared particularly well duringthe 1980sand 1990swhen many o f the other SSA countries showed stagnation or even increases inIMR.4 Figure 2-3 shows the trends inunder-five mortality inEthiopia between 1960and 2000 and compares it with other regions o fthe world. It indicates that Ethiopia's mortality rate, which used to be higher thanthe SSA More analysis is needed to explain this trend. Some possible contributing factors could be price stability and community health agents mobilization to undertake growth monitoring and health promotion activities during this period. -15- average in 1960, i s slowly falling towards the SSA average. However, it is still high compared to South Asia and other developing countries. 2.5 Reaching child survival MDGs at the current pace will be challenging. Inorder to reach the child survival MDGtarget by 2015, Ethiopiawould have to reduce under-five mortality at the rate o f 5.2 per 1000 live births each year starting inthe 1990s. However, between 1990 and 2000, the rate of decrease o f under-fivemortality has only been about 1.9 per 1000 live birthsper year (Figure 2-4). Moving forward, Ethiopia would have to reduce child mortality by 7.4 per 1000 live births per year between 2003 and 2015 to achieve the MDGtarget. This is extremely challenging given the country's past track record as well as the plethora o funmet needs for child survival inEthiopia, which this report will highlight. However, through appropriate, cost-effective strategies, many o f the factors contributing to child mortality canbe mitigated. 1 Figure 2-4: Achieving MDGfor Child Survival - Achieve MGD 250 (Decrease of 5.2 percent points per Year) Current Trend (Decrease of 1.9 percent points per year) 1 +Required trend (7.1 percent point per year from 2000) 50 Wealth-based inequities remain large, yet they are lower relative to those inother countries with similar per capita incomes. While IMR and U 5 M R are highinall regions andincome groups, on average, wealthier urban children are surviving longer. The infant mortality rates are 96.5 and 114.7 inurbanand rural areas respectively. U 5 M R are 148.6 and 192.5 inurban and rural areas respectively. Regional variations are even more pronounced (Figure2-5): Addis Ababa has the lowest IMR (81) and under-five mortality (113), while Gambellahasthe highest IMR(123) andunder-five mortality (233). -16- Figure 2-5: RegionalVariationinIMR and USMRinEthiopia 2 5 0 D I M R I U 5 M R d 9 2.7 The differentials inchildmortality bywealth quintiles are also prominent. For example, the IMR inthe poorest quintile is 93.5 while inthe richest quintileit is 80.5. Likewise, the U 5 M R inthe poorest quintile i s 149.6and 114 inthe richest quintile. Girls have lower IMR (110) andU 5 M R (178) relative to boys (124 and 197 respectively). 2.8 Highmortalityrates can be partly related to living conditions and highincidence of illness. 2.9 Table 2.2 shows the reportedmorbidity by age and income quintile duringthe two months prior to the survey. Overall morbidity is 27 percent, but it is much higher among those older than 50 years and younger than five years. Reportedmorbidity inchildren less than five years old duringthe two-month survey periodwas 34 percent (Table 2-2)5 Reportedmorbidity does not differ significantly by income quintile. Table 2-2: Morbidity by Age Reported inthe Two Months prior to the Survey Two sources of data are available to assess child morbidity levels in Ethiopia. The Welfare Monitoring Surveys (WMS), 2000 sought information about prevalence of illness in all age groups o f population.. The other source o f child morbidity is the DHS 2000. InDHS 2000 child morbidity relating to acute respiratory illness and diarrhea during two weeks prior to the survey was sought. -17- 2.10 Table 2-3 reports overall morbidity by regions and income quintile. Reported morbidity is highest in Benshangul (38 percent) and Dire Dawa (36 percent) and lowest inAddis Ababa (17 percent), the capital of Ethiopia and the most urbanized among the regions. The national rich to poor ratio is 1.0, indicating that the reported incidence o f illness among the rich and poor is the same. The rich to poor ratio i s highest in Harari (1.3) and lowest inDire Dawa (0.7). Table 2-3: OverallMorbidityduringthe Two Monthsprior to the Survey by Regionand Income Quintile Region Yes N o Poorest 2nd Poorest Middle 2nd Richest Richest Rich to poor ratio Tigray 31 69 33 34 30 31 29 0.9 Afar 25 75 27 17 23 30 30 1.1 Amhara 29 71 28 27 29 31 31 1.1 Oromiya 26 74 26 26 25 27 26 1.o Somali 33 66 21 32 38 37 31 1.2 Benshangul 38 62 37 41 35 38 40 1.1 SNNPR 26 74 27 24 24 26 27 1.o Gambela 33 67 33 29 29 30 41 1.2 Haran 25 75 19 26 28 24 25 1.3 Addis Ababa 17 83 22 18 16 17 17 0.8 Dire Dawa 36 64 49 39 30 35 35 0.7 National 27 73 27 26 27 29 27 1.o Source: WMS 2000 2.11 The top ten reasons for outpatient visits, inpatient admissions and death from MOHservice statistics are summarized inTable 2-4. A majority o fthe top ten causes o f morbidity are communicable diseases. -18- Table 2-4: Top Ten Causesfor Outpatient Visits, Inpatient Admissions and DeathinEthiopia Outpatientvisits Inpatient Admissions Death Number % Number % Number % 1 All types of 549,632 15.5 All types of 31,470 20.4 All types of I204 27.0 malaria malaria malaria 2 Helminthiasis 253928 7.2 Deliverieswlo 14,695 9.5 All types of TB 511 11.5 complication 3 Acute upper 200,178 5.7 Bronchopneumo 6767 4.4 Bronchopneumoni 278 6.2 respiratory nia a infection 4 Dysentery 170,403 4.8 All types of TB 6608 4.3 Primary atypical, 194 4.4 other & unspecified pneumonia 5 Gastritis and 132,638 3.7 Dysentery 4348 2.8 Tetanus 101 2.3 Duodenitis 6 Bronchopneumo 124,336 3.5 Other 4049 2.6 Lobar pneumonia 89 2.0 nia complications of pregnancy, childbirth & the puerperium 7 Infectionsof 117,588 3.3 Relapsingfever 3777 2.5 Hypertension 90 2.0 skin and subcutaneous tissue 8 All other 82,579 2.3 Abortion wlo 3653 2.4 Dysentery 82 1.8 infective and sepsis or parasitic toxaemia diseases 9 All other 81,648 2.3 Primary 3322 2.2 Pyrexia of 68 1.5 diseases of atypical, other unknown origin Genito-urinary & unspecified system pneumonia 10 Primary atypical, 74,742 2.1 Helminths 1015 2.0 Relapsingfever 42 0.9 other, and unspecified pneumonia Total of all the 1,787,672 50.5 Total of above 81774 53.1 Total of all the 2659 59.6 above cases case above cases Total of all 3,542,231 100.0 Total of all 154032 100.0 Total of all cases 4459 100.0 cases cases Source: PPD, MOH Health and Health-related Indicators. 2002103 Note: Data does not include Amhara, Oromia, and Somali (three ofthe largest regions inEthiopia) 2.12 The incidence of illness contributing to avoidable deaths caused by acute respiratory illness ARI (24.4 percent) and diarrhea (23.6 percent) are higher among under-five children inEthiopia than inSSA comparison countries (Table 2-5). On average, childrenunder five-years-old experience about two episodes o f serious illness per year.6 Acute Respiratory Infection (ARI) is one of the major causes of childhood morbidity and mortality throughout the world. Diarrhea has been selected for analysis because dehydration due to diarrhea is a major cause of death among young children. -19- Table 2-5: ARI and DiarrheaIncidence (2000) Percent of childrenunder 5 Percent of childrenunder 5 with ARI in with diarrheainthe two Country the two weeks prior to the survey weeks prior to the survey CAR 28.2 26.5 Chad 12.5 31.2 Nigeria 11.3 15.3 Ethiopia 24.4 23.6 Kenya 20.1 17.1 Malawi 12.3 16.1 Mozambique 11.8 20.7 Tanzania 13.9 12.4 Uganda 27.1 23.5 Zambia 12.7 23.5 Zimbabwe 15.8 13.9 Source: UNICEF, 2002 2.13 Figures2-6 and 2-7 show the prevalence o fARI and diarrhea duringthe two week periodprior to the survey inthe poorest andthe richest quintiles along with the population averages for selected countries. Differentials exist between the rich and the poor quintiles [the prevalence o f diarrhea inthe poorest quintile (25 percent) is higher thaninthe richest quintile (19 percent)], butthe gap appearsto benarrower thaninother countries. Figure2-6: ARI in ChildrenUnder Fiveduringthe Two Week Periodprior to Survey Sorted by Income quintiles 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 -20- Figure2-7: Diarrhea in Children under Five duringthe Two Week Periodprior to Survey Sortedby Incomequintiles 40 0 35 0 30 0 25 0 20 0 15 0 100 5 0 2.14 Based on DHS 2000 results, Tigray (29.2 percent) and Benshangul Gumuz (29.6 percent) have the highest ARI prevalence rates while Addis Ababa has the lowest rate (10.4 percent). Rates for children living in SNNPR (29.4 percent), Oromiya (25 percent), Gambella (27.4 percent) and Benshangul Gumuz (26.3 percent) are higher compared to other regions. On the other hand, children living in Addis Ababa (12.2 percent) have the lowest prevalence o f diarrhea, while those living in SNNPR have the highest prevalence (30 percent) as can be seen in Table 2-6. These results are discussed further inSection 3 o fthis report. Table 2-6: DiarrheaIncidence amongChildrenUnder 5 Years Old Poorest Richest Below Above poverty Average quintile quintile poverty line line Prevalenceof diarrhea children <5 years Nationalaverage 25.4 19.3 24.1 21.0 22.6 Regionalvariation Tigray 18.3 13.2 18.3 17.2 17.7 Afar 23.1 19.5 16.2 16.4 16.3 Amhara 16.5 14.8 19.2 18.0 18.8 Oromiya 27.3 24.2 26.0 24.6 25.4 Somali 11.5 25.5 20.1 18.2 19.3 Benishangul-Gumuz 32.1 22.9 30.3 22.2 26.9 SNNPR 29.4 27.3 30.4 28.4 29.6 Gambella 30.1 25.8 27.9 25.5 26.8 Haran 27.9 20.0 25.8 22.9 23.6 Addis Ababa 12.5 12.8 12.8 Dire Dawa 27.7 17.0 32.1 19.2 21.3 Source: DHS 2000 -21- 2.15 On average, diarrhea and pneumonia are the maincauses o f early death inyoung children inEthiopia. The relatively large proportion o fhighlands inEthiopia results in malaria having an epidemic profile inthese areas, incontrast with the more common ' endemic profile o f SSA7. Malaria is estimated to have caused only six percent o fthe cases of child mortality inEthiopia, but it i s the leading cause o f total morbidity (measured by outpatient visits andinpatient days) andmortality, detrimentally affecting labor productivity and economic growth.' According to recent estimates validated by international experts, a majority o f deaths inchildren under five inEthiopia canbe attributed to diarrhea (24 percent), a disappearing cause of deaths inmanypoor countries, andpneumonia (28percent). Measles (2.2 percent) is less o fthreat thanit was a decade ago; the reduction ofmeasles-related deaths probably contributed to the reduction inchild mortality inthe 1980s and 1990s. On the other hand, HIV has emerged as a growing cause o f early deaths o f children (6.2 percent). CHILD MALNUTRITION 2.16 HighmalnutritionratesinEthiopiapose a significant obstacle to achievingbetter child health outcomes. Ethiopiahas among the highest underweight and stunting rates among young children in SSA (Table 2-7). Almost one of out two children (about 47 percent) are moderately to severely underweight, and 16percent are severely underweight. Chronic malnutrition inEthiopia is worst than inother SSA countries: about one intwo children (5 1percent) is moderately to severely stunted, and slightly more than one infour children (26 percent) i s severely stunted. Onthe other hand, severe to moderate wasting at 11percent is relatively lower compared to other SSA co~ntries.~ 'Malariatransmissionin Ethiopiais seasonal andunstablebecauseofthe vaned topography. Itstransmissionis either perennial, seasonalor epidemic.Ecologicalconditionsat high altitudesdo not normally increasemalariatransmission, howevermajor epidemicsdo occur at high altitudes.Climatic changesrenderpeople vulnerablebecausethey havebeen unable to developthe immunity that comes with regular exposureinfections (Ethiopia Rollback Malaria Consultative * 'Mission Report,2004). Three quarters ofthe landmass (altitude< 2000 m) i s regardedas malariaaffected. About 68% (146 million people) ofthe total populationis at risk of acquiringmalariainfections (EthiopiaRollbackMalaria ConsultativeMission Report, 2004). A majority ofEthiopia's populationlives inthe over-crowdedhighlands,mainly dueto the high prevalence of malariaandother dangeroustropical diseases inthe lowlandregions.Hence, malariahas hugenegative effectson the economy and on laborproductivity. It prevents Ethiopiafrom mobilizing the growth potential of its lowlands, affects privateinvestment decisions inthese area, and contributesto the population andenvironmentaltrap in the highlands(World Bank, CEM 2004). 'Weight-for-age is a composite index of height-for-age and weight-for-height. Being underweight could mean that a child is stunted or wasted or both. Children whose weight-for-age is below minus two standarddeviations from the median of the reference population are underweight, while those whose measurements are below three standard deviations from the reference populationare severely underweight. Height-for-agemeasureslinear growth retardation over a long period and does not vary with the season of data collection. Children who are below minus two standard deviations from the median ofthe reference population are considered short for their age or stunted. Children who are below minus three standard deviationsfrom the reference population are severely stunted. Weight-for height measures bodymassinrelationto body lengthwhich shows current nutritional status and reflects the inability to receiveadequate nutrition during the periodimmediatelybeforethe survey. Wasting canbe due to seasonal food availability or the result of recent illness such as diarrhea. Children whose weight-for-height is below minus two standarddeviations from the median referencepopulationare too thin for their height or wasted. Those who measure below minus three standard deviationsfrom the referencepopulationare severelywasted. -22- Table 2-7: Malnutrition insub-Saharan Africa Underweight Stunting Wasting (weight-for-age) (height-for-age) (weight-for-height) Moderate Moderate Moderate Country and severe Severe and severe Severe and severe Severe Benin 29.2 7.4 25 7.8 14.3 2.7 Burkina Faso 34.3 11.8 36.8 16.6 13.2 2.5 Cameroon 21 4.2 34.6 13.3 4.5 0.8 Central African Rep. 24.3 6 38.9 19.1 8.9 2.1 Chad 27.6 9.8 28.3 13.4 11.7 2.9 Congo 13.9 3 18.8 6.6 3.9 0.9 Congo, Dem.Rep. 34.4 10.2 45.2 24.6 9.6 3.5 Cote d'Ivoire 21.4 4 21.9 7.8 10.3 0.9 Ethiopia 47.1 16 51.2 25.9 10.7 1.4 Gambia 17 3.5 18.7 5.9 8.6 1.2 Guinea 23.2 5.1 26.1 10.1 9.1 2.1 Kenya 22.7 6.5 37.2 17.6 6.3 1.4 Malawi 25.4 5.9 49 24.4 5.5 1.2 Mozambique 26.1 9.1 35.9 15.7 7.9 2.1 Namibia 26.2 5.7 28.4 8.3 8.6 1.5 Niger 39.6 14.3 39.8 19.5 14.1 3.2 Nigeria 27.3 10.7 45.5 25.6 12.4 4.9 Somalia 25.8 6.9 23.3 12.1 17.2 3.5 Tanzania 29.4 6.5 43.8 17.1 5.4 0.6 Uganda 25.5 6.7 38.3 15 5.3 0.9 Zambia 25 59 4 Zimbabwe 13 1.5 26.5 9.4 6.4 1.6 Source: UNICEF, 2002 2.17 Variations inweight by income quintile relative to other countries are shown in Figure 2-8. Ethiopia has one o f the highest malnutrition rates. These rates are similar to those inNepal and slightly lower only to those inBangladesh, India and Niger. However, the ricWpoor gap inEthiopia is less significant thaninmany other countries. -23- Figure2-8: Moderateto Severe UnderweightRates Sortedby IncomeQuintiles 70.0 _..,. - - .__..... .. .. . . . . . __ ..__ .__ __ , . _.__ ..... .., - .._._ ..._ . .. -__... . .. . ... .. . . 1- Poorest Quintile I I I 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Source: Gwatkinet al. 2002, World Bank Figure2-9: RegionalDifferencesinChildMalnutrition RatesinEthiopia 60 EIModerate to severe underweight 50 =Moderate to severe stunting 40 30 20 10 0 Source: DHS2000 -24- 2.18 Regional andurbadrural differences inchild malnutrition are prominent in Ethiopia. Regional differentials are illustrated inFigure 2-9. Prevalence o f underweight is more than three times higher inTigray, Afar, Amhara and SNNPRthan inAddis Ababa. Stunting i s almost twice as highinSNNPR and Amhara compared to Addis Ababa. U r b d r u r a l differences exist, which are as markedas regional differences. Severe to moderate underweight is 15 percentage points higher inrural areas thanin urban areas, and moderate to severe stunting is ten percentage points higher inrural areas comparedto urbanareas. MATERNALMORTALITY (MMR)AND MDGTARGETS RATES 2.19 Information on maternal mortality i s scarce but the available evidence suggests that the rate i s very high.Basedon 1995 World Health Organization WHO estimates that are comparable across the selected countries, the MMR o fEthiopia i s 1,800.'0 This estimate, however, has a very large confidence interval that ranges from 790 to 3,200. Table 2-8 shows the comparative position o f Ethiopia relative to selected countries in sub-Saharan Africa regarding MMRin 1995. Figure2-10 shows the scatter plots o f selected country MMRvis-a-vis per capita GDP. Among the SSA countries, Ethiopia's MMRis higherthanother countrieswith comparableGDPs. Among the countries ofthe world, Ethiopiabelongs to the cluster o f sub-Saharan countries with highMMRandlow per capita GDP. Table 2-8: MaternalMortalityinEthiopia and Other Countriesin sub-SaharanAfrica 2.20 MMRishighandreachingMDGtargets is daunting. The MMRMDGisto reduce MMRbythree quarters between 1990 and2015. For Ethiopia, this would translate into a reduction ofMMR,or annual number o fmaternal deaths per 1,000 women from 15-49years of age from 1994-2000 from 1,800/100,000 live birthsto approximately 450/100,000 between 1990 andthe year 2015. D H S 2000 MMR estimates for 1994-2000 are 871/100,000 births or approximately 9 deaths per 1,000 births (HSDP estimates for loThe maternal mortality ratio (MMR) is obtained by dividing age-standardized maternal mortality rate by the age- standardized fertility rate. It measures the obstetric risk associated with each live birth. -25- 2001/02 are lower, ranging from 500 to 700/100,000 births), which is less than 50 percent ofthe estimatedMMRfor 1990-1995. At present, almost all other countries with a GDP per capita twice as highas Ethiopia's havenot been able to decrease MMRbelow 400/100,000. Achievingthe MMR-related MDG o f 450/100,000 by 2015 will thus be particularly challenging for Ethiopia. Figure2-10: EstimatedMMRfor Selected Countriesin SSA and the World, 1995 25W -- + I + 2m I + Ethiopia I + Ethiopia 100 Iow 1ooW IO0 1wO Iww ODP p r smpila PPP (intwnl1ional I) 2002 WDI GDP per cepila W P (international I) 2002 WDI Source: MMRfromWHO, 2000; GDP fromWDI, 2002; andWorldBank 2.21 MMRis one ofthe most difficult healthoutcomes to measurebecauseitrequires a comprehensive and accurate reporting ofmaternal deaths." Therefore, it would be practical to use another indicator that could assess progress towards achieving this outcome and lessening the obstetric risk associated with each live birth. Inthis report, thepercentage of deliveries attended by skilled professionals, whichthis report examines further inChapter 3, is examined as anindicator ofMMR. 2.22 The MMRinEthiopia from 1994-2000was 1.68. One out o f4 Ethiopian women (25 percent) died from pregnancy or pregnancy related causes during the seven years prior to the DHS 2000. The major causes o fmaternal death are related to emergency obstetric care and complications from unsafe abortions. Abortions account for about 50 percent o ftotal gynecological and obstetric admissions. Otherpotential factors contribute to childbirth andpregnancyrelatedrisks. The first is the low percentage o f pregnant women who receive antenatal care from trained professionals (only 26 percent nationwide). Secondly, very few births are attended by skilled professionals (5.6 percent). Female genital mutilation (FGM) is also widely practiced, which creates "MMR estimates can be obtained from vital registration, longitudinal studies of pregnant women or repeated household surveys. Ethiopiahas no vital registration system nor has there been a national household survey carried out that estimates matemal mortality. There is also the need for large sample sizes to calculate the point estimates with a reasonable degree o f confidence. The DHS 2000 i s the first population based national survey in Ethiopia to incorporate questions on matemal mortality. Country 1 -27- its previous highfertility levels. Figure 2-12 shows the TFR o f selected African countries in 1990 and 2000. Between 1990 and2000, fertility has declined on average o f 0.6percent per woman inEthiopia, which is now comparable to the SSA average. Congo (DRC), Ugandaand Somalia also have highfertility like Ethiopia, although their respective TFRs have remainedunchanged inthe past ten years. Onthe other hand, Sudan, Tanzania and Kenya have shown more significant reductions inTFR compared to Ethiopia. Despite the declining fertility levels inEthiopia, the current rate of change is insufficient to achieve the National Population Policy targets of 4 children per women by 2015. 2.25 However, some encouraging trends are emerging. Fertilityrates have decreased dramatically inurbanareas (even thoughthe rural areas have seen a muchslower decline). As shown inTable 2-8, the TFR (3.3) inurbanareas is much lower than inthe ruralareas (6.4). Table 2-9 shows that Addis Ababa is a particularly special case inSSA, with a TFR o f 1.95 childrenperwoman, which is at the same level as developed countries. The decline inTFR has been extremelyslow inrural areas. TFR is also very high(6.4) inthe poorest quintile comparedto rates intherichest quintile(3.9). Age specific fertility rates (ASFR) indicate that fertility rates are highinall age groups. However, the highfertility rate inthe 15-19 age group inrural areas and the significant differentials inTFR and ASFR among regions are two areas o fparticular concern. Addis Ababa has near replacement level o f TFR o f 1.95, while Oromiya has a TFR level o f 6.4. Table 2-9: TFR andASFR byResidenceand Wealth Urbanhural Wealth Age Overall Urban Rural Poorest Richest Quintile Quintile ASFR 15-19 109.6 60.2 122.8 127.3 70.3 20-24 244.2 148.8 266.1 273.7 160.7 25-29 264.1 156.4 289 295.7 192.4 30-34 248 160.1 264.1 251.1 191.6 35-39 182.9 97.1 198.8 194.8 111.6 40-44 99.9 33.2 109.3 110.9 54.5 45-49 24.1 4.2 27 23.8 0.7 TFR 5.86 3.3 6.39 6.39 3.91 2.26 Itis crucial to addresshighfertility levelsinEthiopiabecause there is a strong linkbetweenpovertyandhighfertility. As stated above, within Ethiopia,the TFR inthe poorest quintile i s 6.4 comparedwith 3.9 inthe richest quintile. An ILO study (2003) confirmed that a strong relationship exists inEthiopia between demographics and the wealth o f a household. Householdswith larger family size and older heads o f family are more likely to fall into poverty than householdswith smaller family size and younger heads. The addition of each additional child increases the incidence o fpoverty. -28- Table 2-10: TFR and ASFR by region Tigray Afar Amhara Oromiya Somali Ben- SNNPR Gambela Harari Addis Dire G u m Ababa Dawa ASFR 15-19 123.8 140.8 152.5 111.4 70.2 121.7 73.2 99.1 97.3 23.1 45.8 20-24 230.6 238.6 249 271.8 220.8 271.8 230.8 198.9 180.8 90.8 131 25-29 243.3 217.4 256.9 289.6 252.2 254.4 272.4 217.1 202.7 116.2 188.6 30-34 263.5 198 236.4 272.1 241.0 235.3 251.7 184.8 197.3 96.7 195 35-39 188.4 99.2 173.7 206.7 177.2 163.8 187.4 139.9 132.6 50.7 105.2 40-44 101.2 69.3 107 97.7 122 83.7 112 43.1 41.9 8.7 50.2 45-49 15.2 16.5 14.3 22.7 43.4 0 49.4 13.4 28.7 3.3 0 TFR 5.83 4.9 5.95 6.36 5.1 5.38 5.88 4.48 4.41 1.95 3.58 ii1 Figure 2-12: Changes inTFR in sub-Saharan African countries including Ethiopia 0 1 9 9 0 1 2 0 0 0 1 C o n g o D R ( 0 % I U g a n d a S o m a l i a E t h i o p i a M a l a w i ( - E r i l r s a (. S u d a n ( - T a n z a n i a K e n y a (. ( 0 % ) ( 0 % ) ( - 1 4 % ) 1 0 % ) 1 1 % ) 1 4 % ) ( - 1 4 % ) 2 8 % ) E t h i o p i a a n d n e i g b o u r i n g c o u n t r i e s Source: UNICEF, 2002 Note: 2000 data for Ethiopia was updatedusingDHS2000. Source:UNICEF, 2002 2.27 Women inEthiopia bear children at relatively young ages. Ethiopian women have more than 50 percent o ftheir lifetime births (3.1) by age 30 and nearly 75 percent o f the total number o f children they will have (about 4.3) by age 35. About 16 percent of Ethiopian women ages 15-19 are already mothers or are currently pregnant with their first child. Slightly more than twice as many women inthis age group who are either already mothers or currently pregnant reside inrural areas rather thanurban areas. There are slightly more than twice as many uneducated mothers andpregnant women inthis age group than those with at least primary schooling (DHS2000). -29- HIVIAIDS 2.28 The HIV/AIDS epidemic has spread rapidly duringthe past years. Currently, Ethiopia is classified as a country with a generali~ed'~ HIV/AIDSepidemic. The first evidence o f HIV inEthiopia was found in 1984, andthe first AIDS case was detected in 1986. Although HIV prevalence inthe 1980s was low, it has spread quite rapidly during the 1990s. MOH estimates that about 2.2 millionpeople inEthiopia are infectedwith HIV/AIDS (two million adults and about 200,000 children). The adult HIV/AIDS prevalence rate was 6.6 percent in2001 (MOH, 2002).16 While this is lower than the 2000 estimate o f 7.3 percent, it should not be automatically interpreted that the HIV/AIDS epidemic is on the decline inEthiopia. The current estimate couldbe a result ofa stabilizationo fthe epidemic, more extensive surveillance data, and/or the reclassification o fEstie as an urbansite. 2.29 HIV/AIDS prevalencerates inurbanareas are significantly higher than inrural areas. The average prevalencerate for pregnantwomen for all urbansentinel sites is 13.2 percent, while the ruralprevalencerate i s 2.3 percent. Evenwhen usingthe extrapolated prevalence rate o f 3.7 percent from bothrural sentinel survey sites and the armyrecruits data (this separate ruralprevalence studyfor armyrecruits ages 18to 25 indicates a prevalence rate of 3.9 percent (MOH))", the urbanprevalence rate i s still about 3.5 times greater than the prevalence rates inrural areas. Addis Ababa has a current prevalence rate o f 15.6 percent. Among the urbansites surveyed, Bahir Dar in Amhara has the highest HIV prevalence rate (23.4 percent), followed by Jijiga inSomali (19 percent), andNazarethinOromia (18.7 percent). 2.30 Basedon the sentinel surveillance data, pregnant women inthe 15-24 year age group make up the demographic groupwith the highest average HIVprevalence (12.1 percent). This statistic represents the number ofrecent infections. Interms o f absolute numbers for bothmales and females, the largest number of HIV-infected people i s inthe 20-29 year age group. 2.3 1 Interms o fnumber o f HIV/AIDSand tuberculosis cases, Ethiopia i s one of the most heavily affected countries inthe world. Although Ethiopia constitutes only one percent o f the world's population, it claims seven percent o f the world's HIV/AIDS cases. Interms o fthe number of infectedpersons, Ethiopia ranks fifthafter South Africa, Nigeria, Kenya and Zimbabwe in SSA. The country ranks second to Nigeriainterms of the numberoforphans who are 14years of age or younger. A generalized HIVIAIDS epidemic refers to a situation where HIV has spread far beyond the original high-risk subpopulations, which are already infected. Prevalence among women attending antenatal clinics is five % or more. l6 M O H estimates are slightly higher than UNAIDS and estimates that 2.1 million children and adults in Ethiopia are living with HIVIAIDS (UNAIDS, 2002). UNAIDS December 2001 data also indicate a slightly lower national adult (15-49 yrs) prevalence o f 6.4 % in Ethiopia. In general, there is underreporting o fHIVIAIDS from rural areas due to lower rates of access to healthcare services as well as the lack o f continuous data from sentinel surveillance sites. Therefore, it i s possible that HIV prevalence in rural areas i s higher. In 2001, there was an additional cause for concem because o f the reclassification o f Estie (a town in South Gonder zone) in the 2001 survey from a rural to an urban site. This reclassification is the main reason why there is a difference in the prevalence rates between 2001 and 2000. In order to address this potential underestimation issue, a separate survey was undertaken to provide additional evidence for rural areas. -30- 2.32 The relative situation o f HIV/AIDS in Ethiopia compared to other countries in SSA is given inTable 2-11. Table 2-11: The Burden of HIV/AIDS inAfrican Countries 2.33 Aside from the negative emotional and social impact o fHW/AIDS onhouseholds and communities, the disease also creates adverse economic conditions. Basedon the data collected by the MOH, about 91 percent of infections occur among adults between 15-49years old, generally the most economically productive segment o f the population. Illness and death inthis age group have negative effects on labor productivity and output, therebyincreasingthe likelihood oflower economic growth. Higher deathrates inthis particular age group also increase the dependency ratio because a smaller number o f young adults must support large numbers o fchildren andthe elderly. TUBERCULOSIS 2.34 The incidenceratio o f all forms of TB in2000 was 397/100,000 persons. This ratio is higher than the SSA average o f 354/100,000 and significantly greater than the averagefor low-income countries o f 233/100,000. Based on FederalMinistryof Health (FMOH) 2002 estimates, the TB incidenceratio has declined to 292/100,000 (Table 2-12). ReportedTB accounts for 3.1 percent o f all deaths. There are no reliable estimates on the real incidence o f TB, andthe reported notificationrates may seriously underestimate the actual burden. About 30 percent o f all TB cases also are HIVpositive. -31- Table 2-12: TB Incidence Ratio Indicator FMOHestimates 2002 Population: 65,3 m. Incidenceratio of all forms of TB 292/100,000 persons 196,000 cases Incidence ratio of smear-positiveTB 123/100,000 persons 82,000 cases Proportion of all estimated incident TB cases that are also HIV-positive 30% 59,000 cases Proportion of generalpopulation having 1.5% ofthe population one millionpersons both latent TB andHIV infectiontogether -32- 3. HOUSEHOLDAND COMMUNITYFACTORS AFFECTINGHEALTH: KNOWLEDGE,ATTITUDE AND PRACTICES 3.1 This chapter analyzes (to the extent that data allow) the determinants o fhealth outcomes inEthiopia with a focus on factors at the household and community levels. This section shares information about healthissues including statistics on nutritional practices for infants; health-seeking behavior; and utilization o fboth preventive health and reproductive health services andbasic services o f curative care for child and maternal health care. Household analysis is important because households produce health outcomes based on the resources they have, their socio-economic characteristics, and their surrounding environment. CHILD SURVIVAL 3.2 Ethiopia has IMRandUSMRrates that are comparable to the sub-Saharan African average. However, as discussed inChapter 2, wealth-based differentials are relatively lower inEthiopia for IMR and USMR. 3.3 Figure 3-1 shows the IMR and USMRacross different wealth quintiles, and Figure3-2 illustrates the concentration curves. IMRandUSMRbywealth quintiledo not demonstrate a monotonic relationship. The rates are highest inthe second poorest quintile as opposed to the poorest quintile. The concentration curves show that wealth- based differentials for USMR are muchhigher than for IMR. 3.4 Table 3-1 provides adjusted hazardratios for child mortality obtained usingthe Weibull Analysis. Three different models are used: the first model has only the proximate determinants; the second model uses only the underlying determinants; and the third model applies boththe proximate andthe underlying determinants o fchildhood mortality. Proximate variables are intermediate variables that directly influence the risk o f mortality. A11 social and economic determinants operate through these variables (e.g. maternal factors such as age, parity and birth interval) to affect child survival. An example of a distal or underlying determinant is poverty, which can lead to child death through malnutrition or bad hygiene. -33- Figure3-1: IMR andUSMRby Wealth Quintilesin Ethiopia I 200 I UlMR UU5MR 160 I 8 O Poorest 2nd Poorest Middle 2nd Richest Richest Wealth quintiles Source: DHS2000 Figure3-2: ConcentrationCurves for IMRandUSMRinEthiopia2000 -34- 3.5 Results indicate that short birthintervals, highbirthorder, low birthweight (smaller children), and young age o fmothers are strongly linkedto highchild mortality levels. The analysis emphasizes the strong role fertility plays indetermining short birth intervals. Religion leads to lower mortality among Orthodox Christians. Mother's education (secondary and up) and wealth are also associated with infant mortality although the relationship is not as strong as the fertility-related variables.". Infants whose mothers received ANC tetanus vaccination have a lower likelihood o f dying, while other services such as ANC and delivery by trained professionals do not seem to have any significant association with child mortality when included inthis analysis.20 The draft Poverty Assessment (World Bank 2004) finds a highly significant relationship between mother's education and child mortality. It specifies mother's education inyears as a continuous variable compared to the specification used inthis report, which isbased on education categories (no education, primary, secondary or higher). 'OInModel-I (using only proximate determinants) only birthorder andbirthinterval are consistently significantly associated with child mortality. InModel-2 using only distal determinants, regional characteristics seem to be weakly associated with child mortality. The most important association factors are religion (lower mortality in Orthodox Christians) and age o fmother (lower mortality in children of older women), and size o f the child (children who are smaller in size at birthhave a higher likelihood o f death) for both infant and under-five mortality. Levels o f a mother's secondary education and above are negatively associated with IMR.Wealth has a moderate effect on child mortality. In the combined model (Model 3), only birthinterval, birthorder, and size at birthwere strongly associated with both infantandolder five mortality. Infants whose mothersreceive ANC tetanus vaccinationare less likely to die. Gambella region i s the only region that has a higher likelihood o f under-five mortality compared to Tigray. TT Tll- -rr-r n m I 3 d 3 -37- CHILD MALNUTRITION 3.6 Child malnutrition on the continent andinEthiopiawas discussed inSection 2.3. This section analyzes the predictors o fchildmalnutrition inEthiopia. Table 3-2 summarizes the adjusted odds for stunting(height-for-age), underweight (weight-for-age) andwasting (weight-for-height). 3.7 Malnutritioni s largely associated with low income, mother's education, low birth intervals, and age o f children. The children inthe richest quintilehave the lowest stunting, Underweight and wasting rates. Children o f educated mothers have a lower likelihood o f stunting and underweight,but not wasting. Higherparity children are more likely to beunderweight, while children with greater precedingbirthintervals are associatedwith lower stunting, but higher wasting. Childmalnutrition is also associated with the age o fthe child, with older children having a higher likelihood ofbeing underweight and stuntedrelative to children who are less than a year old. The recent Poverty Assessment (WB 2004) also finds a significant relationship between education and a child's nutritional status. Inparticular, the impact o ffemale educationis about twice as significant as that ofmale education (though bothhave apositive effect). These results are similar to those found by Christiaensen and Alderman (2003), indicating that householdresources andparental education are the main determinants o f child nutrition inEthiopia.21 They also foundthat maternalnutritional knowledge22also plays an important role indetermining child malnutrition. Therefore, they conclude that enhancing awareness o fnon-normal growth o f children incommunities may be an effective and complementary response to addressing child malnutrition. 3.8 U r b d r u r a ldifferentials are not significant for child malnutrition. However, regional differentials are significant. Tigray has relatively higher stunting and underweight rates than most regions (except for SNNPR which has significantly higher underweight rates), and Somali and Gambella have higher wasting rates. The lowest levels o f child malnutrition were seen inAddis Ababa and Dire Dawa, the two most urbanregions. 21Christiaensen and Alderman also find that food prices play a significant role indetermining child malnutrition. 22Proxiedby the community's diagnostic capability of abnormal growth. -38- -39- BREASTFEEDING 3.9 Infant feedingpractices such as early, exclusive breastfeeding for the first six months of a child's life are important determinants o fthe nutritional status o f young children. Compared with selected SSA countries, Ethiopianmothers fare well interms o f breastfeeding indicators (Table 3-3). Fiftypercent o f Ethiopian childrenare breastfed within one hour o fbirth.23This rate is significantly lower thaninMozambique (81 percent) andinMalawi (72 percent). Maternalhealth education i s one methodto help Ethiopia improve its rates. However, exclusive brea~tfeeding~~ inchildren less than four months old is highat 62.3 percent. Timely complementary feeding in6-9 months old children is 77 percent, which can also be improved to reach the rates seen inKenya andMalawi (90 percent). Table 3-3: BreastfeedingPracticesinsub-Saharan Africa Breast feeding Exclusive Timely Continued Continued started within breastfeeding complementary breastfeeding breastfeeding 1hour rate feedingrate(6-9 rate rate (<4 mos.) mos.) (12-15 mos.) (20-23 mos.) Chad 1996197 23.2 2.0 83.3 84.3 54.4 Eduopia 2000 50.3 62.3 77.5 87.4 75.5 Kenya 1998 58.3 16.8 93.8 85.4 46.2 Malawi 2000 71.9 63.2 97.5 97.7 64.6 Mozambique 1997 81 37.6 87.3 82.1 56.8 Tanzania 1996 59.2 40.3 94.6 90.8 45.6 Source: DHS and UNICEF 3.10 The median durationof exclusive breastfeeding was highest amongmothers in Amhara (4.6 months) and Tigray (3.2 months). Mothers inSomali, Afar, Gambella, Harari, Addis and Dire Dawapracticed exclusive breastfeedingfor less than one month. However, while exclusive breastfeeding is relatively high,Ethiopian households lag behind inother householdpractices. SUPPLEMENTARY FOODS 3.11 Introducing solid foods into an infant's diet i s recommended at about six months because at that age breast milk is no longer adequate inmeetinga child's nutritional needs to promote optimal growth. Only about one inthree children inEthiopia consumes some type o f solid or semi-solid food by six to sevenmonths o f age. This percentage increases gradually, as only 54.8 percent o f children who are eight to nine months old 23 The early initiation of breastfeeding i s important because the first breast milk contains colostrum, a nutritious substance with antibodies that protect newbom children from disease. Early suckling also benefits mothers by stimulating breast milk production; releasing a hormone that helps the uterus to contract; and reducing postpartum blood loss. 24 Exclusive breastfeeding refers to children receiving only breast milk while children who are fully breastfedreceive plain water in addition to breast milk. Exclusive breastfeedingis recommended for the first four to six months of a child's life because breast milk contains all the nutrients necessaryfor children in the first few months of life. Early supplementation is discouraged because it increases the risk of infection for children, especially diarrhea. In a particularly poor environment, supplementaryfoods tend to benutritionally inferior to breastmilk (DHS2000). -40- receive semi-solid or solid food. Almost all two-year-oldchildren(98 percent) are fed solid or semi-solid food. However, only 59.5 percent o f childrenunder three years o f age consume foods made from grains; and a smaller percentage (28.1 percent) consume vitamin A rich foods. An even smaller percentage (9.3 percent) consumed meat, poultry, fish, eggs, cheese and yogurt 24 hours prior to the DHS 2000 survey. IODIZED SALT 3.12 Figure 3-3 shows the relative position o f Ethiopiavis-a-vis other SSA countries in terms o f iodized salt distribution. Less than 30 percent o fthe households inEthiopia use iodized salt.25 Figure 3-3: Iodized Salt and Vitamin A Supplement Coverage in SSA I 0Yosalt iodized Vit. A supplement coverage I 90 n 15 Source: UNICEF 2001 3.13 Table 3-4 summarizes the adjusted odds ratios for use o f iodized salt inEthiopia. Tigray households have a lower probabilityo fusingsalt relative to households inthe other regions. Children from the poorest quintile are also less likely to use iodized salt. Mother's exposure to media and education are positively associated with iodized salt intake. 25Ethiopiaused to obtain iodized salt from Assab. Since the Ethio-Eritrean conflict, Ethiopia has obtained its salt from other sources, which are mostly non-iodized. The Ministry o f Health tried to address this by recommending that non- iodized salt be banned. However, this ban has not been implemented because importing iodized salt was expensive. Local production of salt inAfar was encouraged, but there was no facility to produce iodized salt. Inorder to encourage production o f iodized salt by local salt producing firms, the MOH has recently bought and distributed nine iodizing machines. Staff inthe salt producing firms were also trained on iodization. The effects o f these measures are expected to be noticeable in the future. -41- Table 3-4: Adjusted Odds for Additional Vitamin A Supplementation and Use o f Iodized Salts Vitamin A in Children > LivinginHousehold Using 6 Months inthe Last Six Adequately Iodized Salt Months OddsRatio Std. Err. Odds Ratio Std. Err. Urban(rural) 1.26 0.33 1.34 0.38 Region (Tigray) Afar 0.10 *** 0.03 6.51 *** 2.55 Amhara 1.10 0.20 4.76 *** 1.41 Oromiya 0.51 *** 0.09 7.49 *** 2.19 Somali 0.24 *** 0.08 3.30 ** 1.53 Ben-gumuz 0.45 *** 0.09 13.14 *** 4.70 SNNPR 0.39 *** 0.09 3.46 *** 1.20 Gambela 0.56 * 0.18 11.39 *** 4.88 Harari 1.15 0.32 5.32 *** 2.33 Addis Ababa 0.93 0.33 3.14 *** 1.23 Dire Dawa 1.62 * 0.45 4.05 *** 1.51 Wealth Index (Poorest) zUdPoorest 1.16 0.15 1.55 *** 0.23 Middle 1.41 ** 0.19 1.14 0.18 2"dRichest 1.32 ** 0.17 1.24 0.19 Richest 1.49 ** 0.29 1.47 * 0.30 Householdmember (1-5) 6-10member 0.92 0.09 1.04 0.10 11+ member 1.06 0.23 1.45 0.40 Religion (Others) Orthodox 0.70 *** *** * 0.14 0.39 0.08 Muslims 1.49 0.20 0.49 *** 0.08 Mother's age group (<20 years) 20-29 years 1.12 0.13 1.01 0.11 30-39 years 1.15 0.17 1.18 0.19 40-49 years 1.07 0.23 1.71 *** 0.35 Mother's education (None) Primary 1.27 *** * 0.18 0.97 0.13 Secondary or higher 1.97 0.43 1.28 0.31 Exposure to mass media (None) Yes 1.78 *** 0.28 1.01 0.17 Partner's occupation (Others) Agriculturistshnskilled Parity (0-2) 0.85 0.10 0.80 0.12 3-4 children 1.12 0.13 0.92 0.11 5+ children 1.01 0.17 0.79 0.12 Preceding birthinterval (1St or <2 yrs) 2-3 years 0.99 0.08 1.05 0.09 4+ 0.85 0.08 0.94 0.11 Sex o f the kid(Female) Male 1.03 0.06 0.99 0.06 Age of the kid(0-12months) 1year 1.26 * 0.15 1.10 * 0.12 2 years 1.19 0.13 1.18 0.12 3 years 1.13 0.13 1.07 0.10 4 years 1.04 0.11 0.95 0.09 Numberofobs 8427.00 9262.00 F( 33,501) 7.19 4.22 Prob>F 0.00 0.00 *pF ' 0.00 0.00 0.00 *p C a, Y Lo 0 Lo 0 Lo 0 N N 7 7 -58- 3.39 Significant regional variations are also seen regarding family planning. Compared to Tigray, women inother regions are less likely to know about modem methods and modern method sources; approve o f family planning(except for women in Addis), andperceive husband's approval as beinglow. However, actual use o fmodem methods is more likely inGambella thanTigray. Comparedto Tigray women, Benshagul women are more likelyto consider the ideal number o f children to be more than five. The opposite is true for women inAmhara, Oromiya, SNNPR, Gambella andAddis. Figure 3-9: Various Family PlanningIndicators by Wealth Quintiles inEthiopia Women's approvalofFP IHusband'sapprovalofFP X Knowledge ofmodern method X KnowledQeof source of modern method Women uses any method of contraception - Women Uses modern method of contraception 1001 X 90 J X x 70 301 T t 20 10 - * L * 0 I, 1 Wealth quintiles Source: DHS 3.40 Obtaining the husband's approval seems to be a major restraint. Only inthe richest 20 percent o fthe population can we find a significantly higherproportion o f men approving family planning methodology (60 percent). The involvement of husbands/partners is clearly needed to address demand side issues. -59- Table3-11: Needfor Family Planning(FP)for CurrentlyMarriedWomen inEthiopia(2000) Education No education 35.3 4.6 39.9 11.5 Primary 41.6 16.4 58 28.3 Secondary 29.1 44.8 73.8 60.6 Total 35.8 8.1 43.8 18.4 KNOWLEDGE HIV/AIDS OF 3.41 A very highpercentage of Ethiopian women (85percent) and men (96percent) arefamiliar withHIV/AIDS. A majority (80 percent o fwomen and 71 percent o fmen) cite community meetings as their source o f information on HIV/AIDS. 3.42 Multivariate results shown inTable 3-12 indicate that women from richer, larger households and urbanareas are more knowledgeable about HIV/AIDS prevention. Inaddition, educated women andthose exposedto media aremore aware ofHIV/AIDS prevention methods. Higherparitywomen are more likely to know how to prevent HIV. Younger women are less likely to know about HIV/AIDS intervention. It i s important to intensify information campaign efforts to reach women intheir teens and early twenties as the M O H (2002) sentinel survey findings indicate that the highest percentage o f recent HIV/AIDS infections among women is found inthe 15 to 25 years age group. -60- 3.43 Compared to women inmost other regions, women inTigray have abetter understanding of HIV/AIDS prevention. KNOWLEDGE OF SEXUALLY TRANSMITTED ILLNESSES (STIS) 3.44 I n Ethiopia, while knowledgeof HIWAIDS is very high, knowledge of STIs and their symptoms is much lower. Only 63 percent ofwomen and 81 percent o fmenhave knowledge about STIs. About 25 percent ofwomen and 14percent o fmen didnot know o f any male STI symptom. A similar pattem is observed inthe case o f STI detection for females: 27 percent o fwomen and 41 percent o f men have no knowledge o f any female symptom. Lack o fknowledgeabout STIs is especially highamong the 15-19 year old age group (54.3 percent for women and 43.5 percent for men); those who have never married(50.5 percent for women and 33.6 percent for men); those who havenever had intercourse (52.3 percent for women and41.4 percent for men); andthose who live in rural areas (41 percent for females and 21.6 percent for males). Among regions, lack o f STIknowledge is highest inAfar and Gambella (over 60 percent) compared to Addis (14 percent) and Dire Dawa (16.7 percent). 3.45 Among menwho have hadintercourse, about three percent reported an STI or experienced physical symptoms. O fthe menwho had an STI or associated symptoms, only half sought medical advice or treatment. It i s worrisome that 54 percent o f these mendidnot informtheir partners, and 58 percent didnot take any actionto protect their partners (DHS 2000). -62- Figure3-10: Percentageof thoseI11inthe Last Two Months SeekingCare by Gender Illnessinthe LastTwo Months, and seeking percent of those illseekingcare by gender , 0Had illness $g .. . ......-..-.. ..._ .-, - .-. ... .Consulted.. . .... - -, Ad I Male Female Total I Source: W M S 2000 3.46 The Welfare Monitoring Survey 2000 (WMS 2000) asked questions about illnesshjury during a two monthperiod prior to the survey. Figures 3-10 and 3-11, and Tables 3-13 to 3-16 summarize the results. About 27 percent of respondents reported having one or more health problems over the past two months with the incident being 28 percent among rural populations and 19.5 percent among urbanones. About one out o f three childreninthe 0-4 year old age group experienced healthproblems. On average, reported morbidity is highest inthe five andunder age group and inthe 50 years and greater age group. Morbidity i s highest inBenshangul-Gumuz and lowest inDire Dawa. The poor-to-rich ratio for morbidityis highest inDire Dawa and Addis Ababa. 3.47 On average, out o fthe 27 percent reported cases o finjuryor illness, Ethiopian households sought care for 41 percent o f these cases (38 percent inrural areas and 66.6percent inurbanareas). While there is no variation o f reported incidence o f injury or illness betweenrich and poor households, the national level poor-to-rich ratio for seeking care is 0.68, ranging from 0.54 inAfar to 1.12 inTigray (Table 3-15). While females reported slightlyhigher levels o fmorbiditythanmales, a lower percentage of illfemales -- sought healthcare (Figure 3-11). The likelihood o f a person seeking care is highest inthe under five age group and lowest inthe 50 years and greater age group(Table 3-16). Figure3-11: Rateof I11PeopleSeekingConsultationin the LastTwo Months by Gender and Age D W M m W a i d d d t OWMhWmbAddramnull IMMaldlpdlm ~ IMhaallhpmblsm ' nHadhealthproMem,bu:did n~lmnwl: n t 4 d h d h pmb 1 I 1 I l2 l3 ' 1549 fears 17 I 12 I I 161 I O 1; :* 514 years 11 11 161 I I Fernales Males I Source: W M S 2000 -63- Table 3-13: Reported IllnessIinjury duringthe Two Months prior to Survey by Wealth Quintiles inDifferentRegions of Ethiopia Region Poorest Middle 2nd Richest Average Poor to Poorest Richest rich ratio Tigray 33 34 30 31 29 31 1 Afar 27 17 23 30 30 25 0.90 Amhara 28 27 29 31 31 29 0.90 Oromiya 26 26 25 27 26 26 1.01 Somali 27 32 38 37 31 33 0.87 Benshangul 37 41 35 38 40 38 0.92 SNNPR 27 24 24 26 27 26 1.02 Gambella 33 29 29 30 41 33 0.81 Harari 19 26 28 24 25 25 0.78 Addis Abba 22 18 16 17 17 17 1.32 Dire Dawa 49 39 30 35 35 36 1.42 Total 2 1 26 27 29 2 1 2 1 1.01 Source: WMS 2000 Table 3-14: Reported illnesshnjury during the Two Months prior to Survey inDifferent Age Categories by Wealth Quintiles ~Age category Overall Poorest 2nd Middle 2nd Richest Poorest Richest 4yrs 34.35 33.06 33 34.18 36.42 36.14 5-14yrs 16.71 16.7 15.12 17.2 17.92 17.12 15-49yr 27.24 29.35 27.4 26.69 28.14 24.65 >50 yrs 47.28 47.43 47.59 44.66 47.6 48.28 Source: WMS 2000 Table 3-15: Distribution of Individualswith a Health Problem that Consulted for Treatement by Region Region Poorest 2nd Middle 2nd Richest Overall Poor-to-rich poorest richest average ratio Tigray 51 43 43 46 45 45 1.12 Afar 33 38 46 51 62 48 0.54 Amhara 20 23 26 31 31 27 0.65 Oromiya 46 46 48 48 49 47 0.94 Somali 46 46 48 48 49 40 0.94 Benshangul 55 61 60 65 78 60 0.71 SNNPR 36 39 47 47 53 43 0.68 Gambella 36 39 47 47 53 75 0.68 Harari 36 39 47 47 53 51 0.68 Addis 36 39 47 47 53 64 0.68 Abba DireDawa 36 39 47 47 53 46 0.68 Total 36 39 47 47 53 41 0.68 Source: WMS 2000 -64- Table 3-16: Distribution of Individualswith a Health Problemthat Consulted for Treatement by Age and Income Quintile Poorest 2nd Poorest Middle 2nd Richest Richest Overall <5 yrs 42.43 41.28 41.81 45.93 50.42 44.03 5-14 y r ~ 37.79 36.68 36.14 38.56 39.5 37.62 15-49 yr 39.39 40.54 42.91 43.51 50.93 43.37 >50 yrs 36.46 32.56 35.63 36.91 35.34 35.41 Total 39.35 38.71 40.1 1 42 45.76 41.1 3.48 Comparedto other countries, Ethiopia has one o f the lowest levels o f care-seeking for Acute Respiratory Infection (ARI)and one o fthe lowest percentages o f children with diarrhea who have received ORS (Table 3-17). Figure 3-12 shows the care-seeking behavior for ARI among the richest andpoorest quintiles indifferent countries. The rate o fARI care-seeking among the wealthiest segment o f Ethiopia's population i s lower than the rateinthe poorest populations inmanySSA countries. r1I 90 Poorestquintile A Richestquintile 301 ] W 70 60 - I 50 40 20 Source: Gwatkin et al., 2002 Table 3-17: ART and Diarrhea Incidence and Care-seeking Behavior inEthiopia (2000) Country Percent with ARI taken to a Percent with diarrhea that health provider received ORS packet CAR 41.2 24.0 Chad 21.7 15.6 Nigeria 49.7 34.3 Ethiopia 15.8 13.1 Kenya 57.3 36.9 M a l a w i 46.1 49.7 Mozambique 38.5 41.9 Tanzania 67.5 54.9 Uganda 61.4 48.2 Zambia 70.7 53.9 -65- 3.49 Table 3-18 provides information on the care-seeking rates for diarrhea across wealth quintiles. Seventy-nine percent of the children inthe poorest quintile and 57 percent inthe richest quintile didnot seek any treatment for diarrhea. Sixty-two percent inthe poorest quintile and 36 percent inthe richest quintile didnot receive any home-based treatment. Forty percent o fpeople inthe poorest quintile (compared to only 13 percent inthe richest) were not familiar with ORs. 3.50 Table 3-19 summarizes the results o fmultivariate logistic regression used to assess the independent effects o f various socio-economic anddemographic variables on prevalence and care-seeking rates for diarrhea and ARI. Prevalence o fARI i s lower in urban areas; households with more than five members' agriculturist/unskilled families; andamong older children. Significant regional differences are seeninthe prevalenceof ARI rates with Tigray having a significantly higherprevalence rate relativethan seven other regions. Table 3-18: Diarrhea: Household Care-seeking Behavior inEthiopia by Income Quintile Poorest Richest Below poverty Above poverty Average Quintile Quintile line line N o treatment sought 79.1 56.8 79.8 67.2 74.2 Treatment sought Public sector Hospital 0.7 9.8 0.8 4.8 2.6 Health center 2.6 9.3 2.4 6.2 4.1 Healthpost 0.4 0.3 0.3 1.o 0.7 Community health 0.0 0.0 0.1 0.0 0.1 worker Other public sector 7.7 9.1 7.0 8.7 7.8 including health station Private sector Private 0.9 5.3 0.8 3.1 1.9 Doctorhospital Pharmacyishop 4.2 6.0 4.9 5.7 5.3 Other private sector 4.6 3.5 3.7 3.2 3.5 Treatment given ORS 7.8 33.2 8.5 19.72 13.1 RHF at home 1.4 9.4 3.131 9.082 5.5 Home remedyiothers 7.8 3.9 6.69 7.997 7.2 Others 21.2 18.0 20.28 18.38 19.5 (Injectiodpillsisyrup) None of the above 61.9 35.5 61.4 44.82 54.7 Knowledge of ORS Never heard of ORS 39.6 13.1 42.3 21.7 33.5 Used ORS 2.5 9.3 3.O 6.1 4.3 Heard of ORS 57.9 77.6 54.7 72.3 62.2 Source: D H S 2000 -66- 3.51 Care-seeking rates for ARI are higher inother regions (Somali, Benshangul- Gumuz, Gambella, Harari, Addis and Dire Dawa) compared to Tigray. ARI care i s more likelyto be sought for male children andless likely to besought for children o fhigh parity andolder children. Motherswho are exposed to massmedia are more likely to seek care for ARI. 3.52 The prevalence o f diarrhea is lower inurbanareas; among children with educated mothers; and among older children. Compared to Tigray, children inSN"R, Oromia, Benshangul Gumuz and Gambellahave a higherprevalence o f diarrhea. Comparedto other religions, children who are Orthodox Christians or Muslims have a higher prevalence of diarrhea. ORS use during diarrhea is lower inAmhara compared to Tigray, buthigher inSomali. People inrichquintiles andmotherswho are exposed to mass media are more likely to use ORs. -67- Table 3-19 : Adjusted Odds Ratios for Prevalence and Care-seeking/giving for ARI and Diarrhea Prevalence SeekingTreatment Prevalence ORT use during diarrhea Odds I Std. Odds I Std. OddsRatio 1 Std.Err. Odds 1 Std.Err. -69- Both health posts and health stations provide a greater amount of services to the poor than to the rich (Figure 3-14 and Table 3-20). 3.56 Public hospitals and private hospitals are utilized more by the richest quintile of households, while public clinics, pharmacies andother trained private providers are frequented morebythose from poorest quintile. The households from the poorest quintileutilizepublic hospitals the least. Therich-to-poor ratio is lowest for healthpost andhealth statiodclinics and highest for government hospitals. Figure 3-14 Health Facility UtilizationinDifferent Wealth Quintiles 0Poorest 0 2 n d Poorest .Middle 02nd Richest I Richest r- I Others Pharmacy Otner tramed MsslonIMGO Pr vale Hosp/CI PUOlc post I PLD c C nic PJOIC HC P . ~ CHospsal Table 3-20: Use of Public and Private Facilities by Income Quintile Poorest 2nd Middle 2nd Richest Average Rich-to- Poorest Richest poor ratio Government Hospital 3.2 5.2 6.7 4.9 18.4 8.5 5.7 Health center 26.3 20.3 23.4 28.5 41.9 29.5 1.6 Health statiodclinic 49.5 53.3 44.5 45.9 26.2 42.3 0.5 Healthpost 4.8 5.1 10.0 5.2 0.9 4.9 0.2 Community-basedoutlet 0.2 0.8 1.o 1.4 1.7 1.1 10.3 Other facilities NGO 0.4 0.3 0.0 0.1 0.8 0.4 2.0 Private hospitalldoctoriclinic 11.4 12.0 10.0 10.9 8.6 10.4 0.8 Kebele (during campaign) 3.7 2.3 3.2 2.1 0.8 2.3 0.2 Others 0.6 0.7 1.2 0.9 0.6 0.8 1.o -70- REASONSFOR CHOOSING A HEALTH FACILITY 3.57 Different reasons seem to motivate clients to use different types o fhealth facilities. Positive previousexperience seems to motivate clients to go to all hospitals (public hospital, missiodNG0andprivate). Use o fprivate hospitals, NGO/mission and public hospitals seem to bebasedmore on recommendations. Public clinics andpublic health posts appear to be utilized because o ftheir proximity, while public health centers, publichospitals andNGOs are usedbecausethey are less expensive. Pharmacies are favored because the waiting time is less inthese facilities (Figure 3-15). Public hospitals, private hospitals, andmission/NGO facilities are utilized because o f their high quality of care (Figure 3-15). 3.58 Among all the reasons cited, proximity (38 percent) andquality ofcare (23 percent) emerge as the two most important reasons for selecting a facility. Poorer clients are more likely to mention proximity as their reason for choosing a facility, while rich clients are more likely to cite qualityof care (Table 3-21). The different reasons for selecting a health facility by region are displayed inTable 3-22. 3.59 Inthe DHS2000, women were askedwhether or notthey sought care during illness, and ifnot, their reason for not seeking care; Table 3-23 summarizes the results by wealth quintiles. Overall, 66 percent o fwomen sought care when ill(rangingbetween 56 percent among the poorest to 86 percent among the richest). Among the various reasons cited for not seeking care, the most important reasonwas "no money for treatment" (56 percent) followed by "no health facility nearby" (27 percent) and "non-serious nature o f sickness" (ten percent). Table 3-21: Reasonsfor Choosinga Particular HealthFacilityby WealthQuintile Positive Recommendation Available Cheaper Better Short Other Not experience from other nearby/proximity than other quality time of stated from person / free of than waiting previous charge other consultations Poorest 5 7 42 12 20 5 8 1 2ndPoorest 5 9 38 10 22 6 8 1 Middle 6 8 39 10 23 7 6 0 2ndRichest 8 9 38 9 23 6. 6 1 Richest 8 9 34 9 27 7 6 1 Total 6 8 38 10 23 6 7 1 -71- Table 3-22: Reasons for Choosing a Health Facility by Region I I I I I I I I I Total 6 8 38 10 23 6 1 7 1 1 Figure 3-15: Distribution of Reasons for Facility Choice BPositiveexpenence from previousconsultations W Recommendationfrom other person UAvailable nearby Cheaper than otherI free of charge W Betterqualitythan other Shorttime of waiting W Others Total Pharmacy Mission/NGO Pnvate Hospital Publichealth post Publicclinic Public healthcenter Public Hospital 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% -72- Figure 3-16: Proportion of ResponsesCiting Quality as Reason for Selecting a Particular Facility 35 30 25 20 15 10 - 5 0 Publichealthpost Publicclinic Pharmacy Publichealth Mission/NGO PrivateHospital PublicHospital center Source: W M S 2000 Table 3-23: Reasons for Women Seeking or Not Seeking Care by Wealth Quintile worker is available Source: DHS 2000 3.60 InTables 3-24 to 3-27, householdswere askedwhy they obtainedhealthcare (treatment o f sick child, immunization, maternal services), and the type of facility where care was sought. -73- Table 3-24: Reasons Mentioned for Use of Health Facility for Various Services by Wealth Quintile Poorest 2nd Middle 2nd Richest Average Rich-* Poorest Richest to- Treatmentof sick child 26.4 24.0 29.2 37.3 38.4 30.9 1.5 Immunization 19.8 18.5 21.6 30.1 32.1 24.3 1.6 Familyplanning 6.4 5.1 8.9 11.6 19.0 10.2 3.0 Prenatal, postnatal, and delivery care 4.1 4.1 6.5 7.0 12.1 6.7 2.9 Information on STIprevention 4.5 4.3 7.8 9.8 19.2 9.1 4.3 Information onbreastfeedingandinfant feeding 4.1 3.2 6.4 6.9 14.3 7.0 3.5 Any service 37.4 35.0 41.9 52.6 56.3 44.4 1.5 3.61 The principle motivation for seeking care was either child or reproductivehealth- related (Table 3-24). Large differences exist inutilization rates between urbanand rural areas (urban populations seek healthcare ten percent more often than rural areas). A large gap also exists among income quintiles: exist the wealthiest seek care more often than the poor, particularly for counseling andpreventive services (Table 3-24). The poor-to-rich ratio is lowest for seeking immunization and the treatment o f a sick child and highest for obtaining information about sexually transmitted illness. Table 3-25: Use of Public and Private Health Facilities for Treatment of a Sick Child by Wealth Quintile Poorest 2nd Middle 2nd Richest Average Rich-to- Poorest Richest poor ratio Government Hosvital 3.8 7.1 8.2 5.5 21.6 10.0 5.8 Healthcenter 24.1 19.7 23.0 28.2 37.9 27.7 1.6 Health statiodclinic 53.4 51.5 43.8 45.6 26.2 42.7 0.5 Healthuost 2.3 3.5 9.3 3.6 0.7 3.6 0.3 CommuNtv-basedoutlet 0.0 0.0 0.6 0.3 0.3 0.3 Other facilities NGO 0.0 0.0 0.0 0.1 0.2 0.1 5.8 Private hosqitaYdoctoIJclinic 15.1 17.3 14.0 15.4 12.3 14.5 0.8 Kebele (dunnn camDainn) 0.5 0.0 0.3 0.4 0.2 0.3 0.3 Others 0.8 1.o 0.8 0.9 0.5 0.8 0.6 Table 3-26: Use of Public and Private Health Facilities for Immunization by Wealth Quintile Poorest 2nd Middle 2nd Richest Average Rich-to- Poorest Richest poor ratio Government Hosvital 3.8 2.7 3.8 2.4 19.8 7.8 5.2 Healthcenter 30.1 22.1 23.4 30.1 40.7 30.8 1.4 Healthstatiodclinic 48.8 58.1 48.2 51.1 30.6 45.3 0.6 Healthpost 6.6 6.4 12.5 7.0 1.4 6.3 0.2 Communitv-basedoutlet 0.3 0.9 1.7 2.1 1.9 1.5 6.4 Other facilities NGO 0.8 0.5 0.0 0.0 0.5 0.4 0.6 PrivatehosqitaYdoctoriclinic 2.6 4.6 3.0 3.4 3.8 3.4 1.5 Kebele (during camvaim) 7.0 4.4 6.1 3.5 1.3 4.2 0.2 Others 0.0 0.4 1.2 0.5 0.0 0.4 Source: DHS 2000 -74- Table 3-27: Use of Public and Private Health Facilities for Maternal Health Services by Wealth Quintile Prenatal, postnatal, and delivery Poorest 2"" Middle 2"" Richest Average Rich-to- care Poorest Richest poor Government HosDital 8.8 7.7 9.2 9.4 21.4 13.6 2.4 Healthcenter 26.0 23.0 23.3 26.2 45.9 32.8 1.8 Healthstatiodclinic 60.3 60.7 46.2 56.7 28.7 45.0 0.5 HealthDost 0.6 6.5 13.2 5.8 0.7 4.6 1.2 Communitv-based outlet 0.0 0.0 1.8 0.9 0.9 0.9 48.9 Other facilities NGO 0.0 0.0 0.0 0.0 0.6 0.2 Private hosqitalldoctorlclinic 4.3 2.1 5.4 1.8 2.8 0.4 Kebele (durinp.camDaign) 0.0 0.0 0.0 0.0 1.o 0.0 0.0 Others 0.0 0.0 0.9 0.0 0.0 0.2 Source:DHS 2000 3.62 As shown inTables 3-25 to 3-27, health stations/clinics are the major providers o f care for child immunization and maternal health services, especially among the poor. Health centers are the next mainprovider o f care for these services. -75- 4. HOUSEHOLD HEALTHEXPENDITURES IN ETHIOPIA HOUSEHOLD EXPENDITURESONHEALTHCOMPAREDTO FOODAND OTHER EXPENDITURES36 4.1 Table 4-1 summarizes household expenditures across regions and expenditure quintiles. In2000, Ethiopia's average annual household expenditure amounts to Birr5,309. Addis Ababa's meanhouseholdexpenditure (Birr 11,027) is almost twice that o f the overall country average. Two other urbanizedregions have significantly higher thanaverage expenditures: Harari(Birr 9,490.7) andDire Dawa(Birr 7,421). The regions with less than average expenditures are Amhara, Benshangul, SNNPR and Tigray. 4.2 Food expenditures (an average o f Birr 2,435) constitute six percent o ftotal household expenditures. Regional disparities exist: the share o f food expenditures to total household expenditures ranges from 30 percent inAddis Ababa to 60 percent in Somali. 4.3 There are wide variations inhousehold expenditures by income quintile. The richest quintiles spendmore than five times as much compared to the poorest quintiles. Households fkom the poorest quintile spend 51percent o fhousehold expenditure on food, while the households fiom the richest quintilespend 37 percent on food. 4.4 The average Ethiopian household spends only 0.9 percent (Birr 50) of their total household expenditures on medical and healthcare. This percentage i s small compared to food expenditure shares and especially considering that on average, Ethiopian households spend 0.5 percent o fhousehold expenditureon tobacco products and 0.2 percent on alcoholic beverages. Health expenditures represent close to two percent of total household non-food expenditures. As shown inTable 4-1, this percentage also varies across income levels: the poorest householdsspendless (1.4 percent) than the richest (1.7 percent). 36The data for this section came from Welfare Monitoring Surveys (WMS), 2000 and 1995196 as well as Household Income, Consumption and Expenditure Surveys (HICES), 2000 and 1995/9636.HICES collected expenditure data on food, durable goods, and non-durable goods. Though HICES has limited data on healthcare expenditures, it enables comparison o f the relative levels o f expenditure on medical services and health compared to expenditure on food, tobacco and alcohol etc. across different regions and income quintiles. The W M S 2000 asked the following questions to elicit information: have you faced any health problems during the preceding two month period? ;ifyou have faced health problems, have you consulted anyone about your health?; if you obtainedmedical assistance, from where did you receive it?; why did you choose the health facility?; who was the person last consulted?; and what was the cost o f your last consultation during the past two months? From the above information, the authors were able to compute private health expenditures for consultation indifferentregions and by different providers. However, even after pooling the data from W M S and HICES, the authors could assemble only limited information on household private expenditures on healthcare. The main gaps in the information relate to prevalence o f inpatient care, cost o f inpatient care, cost incurred on different aspects o f care (x-ray, other consultations, travel, cost o f staying inhospital, etc.), costs incurred vis-a-vis severity o f illness, etc. -76- Figure4-1: TotalHealthExpenditure as a Percentageof Non-Food Expenditure by IncomeQuintiles 20% 1.5% 1.oo/o 0.5% Source: HICES 2000 (based on Table4-1 inthis report). 4.5 Expenditures on medical and health care vary widely among differentregions: Annually, households inHarari and Addis spend more than Birr 100, those inTigray and Amhara spend less than Birr 30. 4.6 Households inthe richest quintile spend about ninetimes more on medical and healthcare (Birr 128) compared to the poorest quintile households (Birr 14). The poorest households spend around 0.7 percent o f their total household expenditures onmedical andhealthcare, compared to the richest quintile's spendings o f 1.O percent. 4.7 Pharmaceutical productscomprise about 60 percent (close to Birr 30) o f householdhealth expenditures. Household expenditure on pharmaceuticals rangedfrom Birr20 inTigrayto about Birr 69 inAfar. I Q ) rl d cri Yr N -78- EXPENDITURESLAST ON CONSULTATION 4.8 Table 4-2 summarizes average expenditure for the last consultationprior to the surveyby different regions andbywealth quintiles. The average expenditure for a consultation i s Birr 23.5 (about US$2.7). Expenditures range from Birr 15.3 in Benshangulto nearly Birr 95 inAddis. Average expendituresfor the richest quintile (Birr 37) are slightly morethantwice that o fthe poorest (Birr 15.8). Across the regions, the range between the poorest and richest quintiles is Birr 50.9 to Birr 131inAddis to onlyBirr 9 to Birr23 inAmhara. Thepoorest quintile inAddis spent twice as much (Birr51) as the richest quintile (Birr 23) for a consultationinAmhara. 4.9 Table 4-3 summarizes the amount spent for the last consultationby the type o f facility andincome quintiles. The cost o fhealth care i s highest inpublic hospitals and lowest inhealthposts. Average expenditures for consultation are highest ingovernment hospitals (Birr 70), which are followed by expenditure inprivate hospitals (Birr 43). It i s lowest ingovernment healthposts and government health clinics (around Birr 10). The amount spent on consultation inNGO andprivate clinics are higherthan inpublic clinics. Table 4-2: AverageAmount Spent (Birr) for Last Consultationby Region and Income Quintile -79- Aggregate Poorest 2ndPoorest Middle 2"dRichest Richest Quintile Facility Mea Std. Mea Std. Mea Std. Mea Std. Mea Std. Mea Std. n Dev n Dev n Dev n Dev n Dev n Dev Hospital 70.5 152 50.5 73.1 50.3 89.5 51.1 94.8 74.7 134 89.7 203 .(Govt) Healthcenter 23.2 96. 17.8 29.9 31.9 145 25 138 19.7 32.7 21.2 30 (Govt.) 2 Clinic(Govt) 13.9 41. 13.1 48.8 12.8 17.5 14.4 52.6 13.5 22.4 16.3 47.7 2 Healthpost 10.5 15. 7.85 6.79 11 21 12.6 17.9 9.36 8.92 11.9 17.2 (Govt) 5 Private 43.2 182 23.1 38.5 24.1 28 36.5 69 38.8 51.8 71.6 321 hospitaklini C Missiod 28.7 71. 44.9 155 21.2 26.7 20.4 17.2 39.5 48.7 20.9 18.5 NGO 2 Othertrained 14.1 22. 10.9 12 12.7 12.9 14 19.1 15.1 18.9 19.4 41 health staff 2 4.10 Thepoorest quintile pays less (Birr 50) thanthe richest quintile(Birr 90) in government hospitals. This may be due to the exemption system, which waives fees for persons who are certified as too poor to pay. The cost o f consultation at a pharmacy is Birr 16, rangingbetweenBirr 13 to Birr 18 for the poorest and the richest quintiles. The cost o f consultation at a mission/NGO facility is Birr 29, rangingfrom Birr45 for the poorest quintile andBirr 21 for the richest quintile. EXPENDITURES ONTRANSPORTATIONFOR LASTCONSULTATION 4.1 1 Transportation costs represent an important part o f out-of-pocket expenditures for healthcare inEthiopian households. Table 4-4 summarizes transportation costs for the last consultationby region, type o f facility and income quintile. The average cost o f transportation for a consultation is Birr 15. Transportation cost is highest for government hospitals (Birr 22) and lowest for healthposts (Birr 5). Costs also vary widely in different regions-as highas Birr 73 inGambella and Birr 51inSomali, and as low as Birr4 inDireDawaand Birr5 inHarari (the latter two areasare small, relatively urbanized regions). -80- 4.12 Out-of-pocket expenditures are mostly self-paid. The source o f payment by wealth quintile is given in Table 4-5, source of payment by regions i s shown in Figure 4-2. Self payment o f out-of-pocket expenditure was lowest in Addis and Tigray, while it was highest in SNNPR and Benshangul. Free treatment was highest in Addis, Tigray, Dire Dawa, Harari and Gambella. Overall, the source o f out-of-pocket expenditure varies more significantly byregionthan by income quintile. Table 4-4 : Cost of Transportation for Last Consultation (Birr) Type of Mean Std. Region Mean Std. Quintile Mean Std. facility Dev. Dev. Dev. Hospital 22.0 78.3 Tigray 9.2 31.9 Poorest 11.0 20.6 (Govt.) Healthcenter 9.9 56.0 Afar 15.4 33.8 2nd 15.1 79.5 (Govt.) Poorest Clinic (Govt) 13.8 56.7 Amhara 14.2 33.8 Middle 15.4 67.1 Healthpost 4.6 8.7 Oromiya 16.0 66.0 2nd 18.7 76.7 (Govt) Richest Private 17.0 66.3 Somali 50.7 270.7 Richest 11.3 44.9 hospitaVclinic MissiodNGO 19.3 62.7 Benshangul 17.7 34.7 Other trained 7.7 9.9 SNNPR 13.2 33.5 health staff Pharmacy 11.1 68.9 Gambella 73.0 199.9 Others 13.5 73.3 Harari 4.9 4.5 Addis Ababa 9.5 20.3 Average 14.6 63.0 DireDawa 4.3 4.8 Table 4-5: Source of Out-of-pocket Expenditure by Income Quintile - S f - -82- 5. HEALTHSERVICEDELIVERYSYSTEM 5.1 This chapter reviews the performance o fthe Ethiopianhealthcare system: its ability and effectiveness to meet the basic needs o fthe population with a core set o f healthcare services. The focus is on the supply side o fhealthcare service delivery to the poor, particularly inthe rural areas. POLICY AND INSTITUTIONALFRAMEWORK 5.2 Ethiopia's National Health Policy was approved by the Council o f Ministers in September 1993. This policy i s based on ten principles: Democratization and decentralization o fthe health system; Development o fthe preventive and promotive components o fhealth care; Development o f an equitable and acceptable standardo fhealth service system that will reach all segments o f the populationwithin the limits o f resources. Promoting and strengthening o f intersectoralactivities. Promotion o f attitudes andpractices conducive to the strengthening o fnational self-reliance inhealth development bymobilizing andmaximallyutilizing internal and external resources. Assurance o f accessibility o fhealth care for all segments of the population. Working closely with neighboring countries, regional and international organizations to share information and strengthen collaboration inall activities contributing to health development, including the control o f factors detrimental to health. Development o f appropriate capacity, based on assessedneeds. Provision of health care for the population on a scheme o fpayment according to ability, with special assistance mechanisms for those who cannot afford to pay. Promotion o f the participation o fthe private sector andnon-governmental organizations inhealth care. To achieve the objectives outlined inthis policy, the health care delivery system is beingreorganized from the six-tier system into afour tier system (discussed below). 5.4 Figure5-1 presents the organizational structure o fthe MinistryofHealth. Themanagerial set up o f Ethiopian health services has historically beencentralized. A new HealthPolicy and Health Sector Strategy was adopted inthe mid-1990s bythe Government, which involves the move towards democratizing and decentralizing the health system and strengthening the regional, zonal and district/woreda health departments. The roles and responsibilities o f the Federal Ministryo f Health(FMOH) and Regional HealthBureaus (RHBs) are defined by the national and regional constitutions. -83- Figure 5-1: Ministry of Health: Organizational Structure Legal & Medico Legal Service t Audit Service Public Relations Service 11 rIt1 Organization & Management Service Plan& ProgramDepartment Department -Planning & Budget Team -Program Co-ordination & Monitoring Team -Health InformationProcessing &DocumentationTeam -Finance & Procurement Team ~~~~~ ~~ Pharmaceutical Supply & Administration Service Service I L -Drug Supply Team -Personnel -Drug Storage & Administration Distribution Team andArchives Service -Drug Storage & Distribution Division Monitoring Team -Finance and Budget Division -General Service Division 1 I I -Malaria & other Vector -Babies', Children, & I I -Water Quality, Sewage, -Health Service Team Born Diseases Prevention Youth Health Team I I & Sanitary Control Team -Health Professional & Control Team -Mothers' Health Care I I -Food, Drink, & Hotel Education & Training -Aids & Other Sexually Team I I Pension Organization Team Transmitted Diseases -Family Planning Team I I Control Team -Panel of Assessors Prevention & Control Team -Adolescent I I -TB & LeprosyDiseases ReproductiveHealth I I Prevention & Control Team Team I I -Other Diseases Prevention & I I Control Team I I I-Integrated Diseases Surveillance Team I Health Education Center I J I I -84- 5.5 Public services are going through a deep decentralization process. Ethiopia has gone through two stages of decentralization; the first stage o f which involves the decentralizationo f functions from the Center to the regions. Since July 2002, public services have beenundergoing a deeper decentralization process as the primary responsibility for service deliveryand management o f govemment services are hrther devolved to the woreda~.~'The primary objectives o f the political, administrativeand economic decentralization policy are to increase local participation aimed at strengtheningownership inthe planningand management o f govemment services; to improve efficiency inresource allocation; and to improve accountability of government andpublic service to the population. 5.6 Under the new system, the woredas receive block grants and are responsible for setting priorities, delivering services, anddetermining budget allocations at the local level within the framework o fbroadnationalpolicies (HSDP Final Evaluation, 2003). The woreda council is responsible for the planningand implementation o f all woreda development programs including health services. For example, the woreda is responsible for construction o f health centers (HCs) and health posts (HPs) and for the procurement o f drugs and equipment. However, inactual practice, this process i s still evolving because woredas still depend on regional and central levels for a number o fhealth system related services such as the recruitment and allocation o fhealth personnel and the procurement and distribution o f supplies. 5.7 The rapid decentralizationhas also resultedin some transitional issues, mostly related to rebalancing allocations; lack o fclarity on responsibilities and expenditure assignments; and some disruption inbudget formulation andreporting. These issues are being handled pragmatically by the regions (PER2003) andwill be discussed further inChapter 6. 5.8 Ingeneral, institutional capacityat the woreda level for planningandimplementation of healthprograms and other programs is a concern. Evenprior to decentralizationto the woredas, HSDP IEvaluation data show that halfo f the regions have budget execution rates below 70 percent. Problems inthe planningand implementation o finvestment plans and difficulties inutilizing donor funds arecited as the mainreasons for low execution. Capacity constraints can also exacerbate reporting lags. Improvement o f planning and budgeting skills and acquiring the necessary trained staff to execute these plans inthe woredas are essential steps inmoving implementation forward. 5.9 Inthe neworganizational framework o fthe healthsector, the FMOH's responsibilities comprise policy formulation, standard-setting, issuance o f licenses and qualification o f professionals, establishment o f standards for research and training, and coordination o f external loans and grants. 5.10 Government policy also envisages a greater role for the private sector inhealth service delivery and financing. The enhanced participation o f the private sector will be encouraged (within an appropriate regulatory andmonitoringframework) to ensure coordination o fpublic and private sector activities. 37The Ethiopian Federal Constitution of 1994EC established a four-tier system of govemment. The regions are divided into 66 zones, 6 special Woredas, and550 Woredas. The average population size of a woreda is around 100,000. -85- 5.11 Interms ofregulatorymechanisms, the HealthPolicy documents recognize the involvement o fNGOs inthe Ethiopian healthcare system. Regulatory provisions have beenmade to encourage the activities o fNGOs although there are still some issues regarding length o fNGO appraisal and licensing (discussed below). The Department o fthe Ministry o f Justice (MOJ) and Commission for Disaster PreventionandPreparedness (DPPC) are responsible for registering all NGOs wishing to operate inEthiopia. 5.12 Certificates for the operation o fprivate hospitals are issued only by the MOHo fthe Federal Government o fEthiopia, while certificates for clinics at all levels are issuedby the concerned RHBs on the basis o fthe rules and regulations o fthe MOH. 5.13 According to the guidelines o fthe MOH, the RHBshave the responsibility for supervising, monitoring and evaluating the activities o f all clinics. The supervision o f the operation o fprivate hospitals is the responsibility o f the MOH (Makuria, G and Mengiste, L,1996). 5.14 Another major initiative that has an impact on the implementation o fhealth activities i s the Civil Service Reform Program (CSW), which was introduced inFebruary 2002. Its aim i s to create a civil service which is both efficient and sufficiently competent to achieve the economic, social and political goals o fthe government and to promote a participatory culture. The C S W has five subprograms: (1) expenditure management and control; (2) humanresource management; (3) service delivery; (d) management systems; and (5) ethics. Reforms introduced under the Expenditure Management and Control sub-program are expected to improve budgetary processes and financial management, thereby addressing some o f the issues raised during HSDP I(HSDP Review 2003). 5.15 One o f the important policy measures recently taken by the MOHin2002/03 was the development o f the Health Services Extension Package (HSEP) Initiative which seeks to provide health promotion and extension services to communities. The HSEP intends to provide communities with essential packages of services inthe following four areas: (a) Hygiene and environmental sanitation: excreta disposal, solid and liquidwaste disposal, water quality control, food hygiene, proper housing, arthropod and rodent control, and personal hygiene; (b) Diseaseprevention and control: HIVIAIDS and other STD prevention and control, TB prevention and control, malariaprevention, and first aid; (c) Family health services: maternal and child health, family planning, immunization, adolescent reproductive health, andnutrition; and (d) Health education. 5.16 For a poor country like Ethiopia, where only about 52 percent o f the population has physical access to primary healthcare (PHC), andwhere unfavorable health staff-to-population ratios exist, the move towards complementing facility-based care with outreach services such as the HSEP i s strategically important. 5.17 The HSEP is beingpiloted infive regions. The original MOH design for health outreach was based solely on prevention, hygiene and sanitation education. This design has since been amended to ensure that the two health extension workers (HEWS)who will be assigned to each -86- kebele are also trained to provide reproductivehealth information and services. The HEWs will also liaise with PHC facilities for patient referrals (particularly for highrisk pregnancies and emergency obstetric care). While there is a clear needto expand coverage o f bothpreventive andcurative care, especially inrural areas, the M O Hhas expressed concerns that it mightnot be realistic to expect two HEW per kebele to be able to effectively provide bothpreventive care and some curative-based services. Thus, it would also be important for curative care services to be provided by properly trained health staff. This policyhas experienced some degree o fresistance at the local level, and HPs insome regions are providing curative care. Discussions are ongoing regardingwhether anti-malaria drugs and antibiotics for childacute respiratoryinfections (ART) could be provided as part o fthe family/community-based package o fHSEP services (these are oral medications that could be provided byHEWs or community health agents (CHAs). These issues, as well as the potential contributions o fthe HSEP to the realization o f the child and maternal MDGs, are discussed indetail inChapter 7. 5.18 There appear to be some differences, ifnot contradictions, betweenwhat was intended anddescribed invarious HSEP concept and/or briefingpapers andwhat was pilotedinthe five regions. The pilot started using existingjunior public healthnurses andjunior environmental health technicians who had already beentrained at certificate or diploma level. These health workers (HWs) were not necessarily local residents o fthe Kebele. The majoritywere men (even though the planspecified female HEWs), and the two cadres were trained for different purposes (most probably to divide areas o fresponsibilities although this would need to be clarified) although bothwere dealing with primaryhealth care. 5.19 Preparations are underway inorder to filly launch the program, and training and implementation packages have been developed. To implement the HSEP, the government plans to upgrade the existing HPs and construct new ones in 10,000 rural kebeles inthe next five years. Duringthis period, 20,000 HEWswill betrained anddeployed to HPs. 5.20 Inmoving forward with the HSEP and prior to expandingits coverage, it is essential to learn from the experiences o f the pilot programs and integrate lessons learned in the planning and implementation o f hture activities. POLICY AND PROGRAMREFORMS Health Sector Development Program (HSDP) 5.21 The initial Health Sector Development Program (HSDP), which was drafted in 1993/94, was designed for a period o f 20 years, with a rolling five-year program period. Ithas three main goals: (1) buildbasic infrastructure; (2) provide standard facilities and supplies; and (3) develop and deploy appropriate healthpersonnel for realistic and equitable primary health delivery at the grassroots level. The first phase, HSDP I, was implemented from 1997 to 2002. It sought to: (a) increase access to health care from 40 percent to 50-55 percent; (b) improve the technical quality o f PHC services, including the restructuring o fthe pharmaceutical sector and expanding the supply and productivity o f health personnel; (c) develop an information, education, and communication plan to communicate PHC messagesto isolated areas; (d) improve health systems management at federal and regional levels; (e) improve financial sustainability o fthe health sector; and (f) promote greater private sector investment inthe health sector. -87- Performanceof the HSDPI(1997-2002) 5.22 The measures taken thus far have resulted inincreasingpotentialhealth coverage from 33 percent to 52 percent because o f the steady increase inhealth facilities. However, utilization o fthe available maternal and children services remains low. Less than ten percent o f deliveries are attended by health professionals and trained traditional birth attendants. There has been a very marginal increase inthe number o fwomen who receive antenatal care (from 30 percent in 1996/97 to 30.2 percent in2001/02). EPIcoverage rates are below the end o f the HSDP Itarget of 80 percent with Diphtheria,Pertussis and Tetanus (DPT3) at 42 percent for 2001/02. Some improvements such as the increase inthe number o fhealthpersonnel (especially nurses) were also observed. There is also a risingtrend inmost regions inthe use o f family planning services, andthe national contraceptive prevalence rate rose fkom ninepercent in 1996/97 to 14.6 percent in2001/02. A multi-sector effort to addresstheHIV/AIDSpandemic isalso underway. -88- Table 5-1: OverallHealthTargetsand Goalsof the HSDP,PRSPandMDGs Objective HSDPTargetslMeasures MillenniumDevelopment SDPRPIndicativeTarget (2002103-2004105~ Goals (MDGs) Increase life expectancy of Increase life expectancy at 8511000by 200415 the population birth from 52 in2000101to 50/1000by 2017 58 years Reduce infant mortality Reduceby two thirds, 160/1000by 2004105 from 97 per 1000live between1990and2015 3001100,000 by 2017 births in2001101to 85 Reduce Matemity Reduceby three quarters, Mortality 500-7001100,000 between1990and2015. live birthin2000101to 400-500 Increase access for health Increasehealth care 65% by 2004105 services coverage from 52% in 90% by 2017 2000101to 65% Promote contraceptive 40% by 2017 coverage from 18.7%in 2000101to 65% ExpandEPI coverage from 90% by 2017 41.9% in2000101 to 65%. Increase HealthBudget From5.2% to 8.2% of Share total budget bv 2004105 Enhance health Reducemalariaprevalence Haltedby 2015 andbegun opportunity andpromote from 7.711000 in2001102 to reversethe incidence disease prevention and to 6.211000 control Maintain HIVIAIDS Haltedby 2015 andbegun Reducetransmission by prevalence 7.3% in to reversethe spread of 25% by 2004105. Contain 2001102 the same 7.3% HIVIAIDS prevalence at 7.3% by 2004105 HSDPIIand111 5.23 HSDPI1started inJuly2002 and covers a three-year period from July 2002 to July 2005. It follows the same component format as HSDP I.Manystakeholders consider HSDP I1to be a transitional plan covering three years prior to the start ofHSDP I11(2005 - 2010), which will fall inlinewiththeplanningprocess ofthe SecondNational Development Planofthe FDRE (NDP 11). SDPRP 5.24 The overall objective ofthe Ethiopian Government-led Sustainable Development and Poverty Reduction Program (SDPRP) is to reducepoverty by enhancing economic growth while -89- maintainingmacroeconomic stability. It isbuilt on four pillars: (1) Enhanced Rapid Economic Growth(includingprivateand financial sector development, rural development, vulnerability androads); (2) ImprovedHumanDevelopment (including education, health, HIV/AIDS, water andsanitation); (3) Democratizationand Governance (includingdecentralization, justice system reform, and urbanmanagement); and (4) ImprovedPublic Sector Institutional Performance (including civil service reform, tax reform and ICT). Inaddition, the SDPRP identified key sectoral measures and cross-cutting issues to focus on including education, roads, water and sanitation, HIV/AIDS, health, gender and development. Inhealth, inparticular, it seeks to improve the balancebetween preventive and curative healthcare through a community-based healthcare delivery system aimed at creating a healthyenvironment andlifestyle. 5.25 Aimingto reachthe MDGs, the SDPRP envisages progress inthree interrelated areas: (a) expanded coverage o f current public sector programs andimprovements inthe quality o f service delivery; (b) faster and more equitable economic growth; and (c) a reduction in Ethiopia's vulnerability to weather, sickness and trade-related shocks. Table 5-1 presents HSDP 11, MDGand SDPR targets. Organization of Health Services Delivery 5.26 Healthcare services are provided through four sectors: public sector, private sector, NGO sector and traditional healers. This report was intendedto focus primarilyon the first three vehicles o fhealth care delivery - together comprisingthe "modem healthcare sector.'' However, apart from information on a small number o f facilities, the reviewed literature contain limited statistics on the NGO andprivate sectors. Literature is increasinglymore limited inthe case o f traditional medicine. The Public System 5.27 Inthe mid 1 9 9 0priorto the implementation ofHSDP, thepublichealth systemwas ~ ~ structuredinto a six-tier system: Central referral hospitals (covering app. 588,000 persons) Regionalhospitals @/A) Rural hospitals @/A) Health centers (covering app. 223,000 persons) Health stations (covering app. 45,000 persons) Community health posts (Covering app. 21,000 persons) 5.28 A change inthe service delivery structure to a simpler four-tier system(Figure5-2) was planned duringHSDP I.The mainchange was to replace health stations (HSs) (popularlyknown as clinics) with primary health care units (PHCUs). Each PHCUwould have a health center surrounded by ideally five satellite community health clinics (CHC) or health posts, each serving a population o f 5,000. Thus each PHCUwould serve a total o f 25,000 people. The PHCU is expected to provide comprehensive, integrated and community-basedpreventive andbasic curative services, inparticular: -90- e Maternal and child health care, including immunization, family planning advice and services, nutritional health, and micronutrient supplementation; e Curative services for common ailments such as parasitic infections, diarrhea, acute respiratory infections and tuberculosis; e Minor surgery and life-saving operations such as appendectomies and caesarean sections; e Technical assistanceinestablishing and monitoring environmental and occupational health standards within its catchment areas; e Record-keeping o fbasic vital statistics and disease surveillance; e Training o f CHAs and traditional birthattendants (TBAs) who will staff the CHCs or HPs. 5.29 Each district hospital functions as a referral and training center for ten PHCUs. Zonal I hospitals (ZHs) provide specialist services andtraining while specialized hospitals (SHs) provide comprehensive specialist services, andinsome instances serve as centers for research andpost basic training. Figure 5-2: Structure of the Public Health DeliverySystem (make figure larger) 5.30 Restructuring of thepublic health delivery system is still underway and the new system is not consistently implemented. This situation exists principally because regions have not fully accepted the proposed concept o freplacing health stations byhealth posts that do not provide bothpreventiveand curative services (HSDP reviews and based on discussions duringJuly CSR 2003 mission). The staffing o fHPs with minimally trained staff almost exclusively for preventive purposes has generated substantial debate because o f the view that HPs are not meetingthe population's basic needs for both preventive and curative care. Forthis reason, for example, Oromia region expressed its intention not to establish HPs. Nationwide the number o f H S s has only marginally decreased by two percent from 1996/97 to 2002/03 (fiom 2451 to 2,396) (some regions even increasedtheir H S number. It has been generally -91- difficult to downgrade HSs to HPs, mainlybecause o fpopular opposition to having facilities, especially those inremote areas, that only offer preventive services. 5.3 1 The issue o fhaving the appropriate health service delivery structure is strongly linkedto the issue o f the core service packages, intended to directly address the most pressingneeds o f poor rural areas. These have not been finalized and untilthey are, the staffing and resource allocation issues cannot be adequately addressed. Planning for new facilities andhuman resource development must be based on the targeted needs and how these needs will bemet in terms o fpackaging o f services, types o fpersonnel needed, and service delivery structure. It will be important to have a transitional strategy and guidelines to facilitate the move from the previous service deliverymodel to the more recent design. 5.32 Thegovernment runs a majority of theformal healthfacilities (Table 5-2), andthese numbers have increased significantly over recent years. Seventy-one percent o f hospitals, 94 percent o f HCs, 82 percent o fHSs and all o fthe HPS are runby the govemment. As shown inTable 5-3 the pharmaceutical sector is dominatedbythe private sector: 85 percentof pharmacies, 81percent o f drug shops and all rural drug vendors are privately owned. The regional distribution o f facilities is uneven: urbanareas are better covered thanrural areas. Table 5-2: Distribution of Health Facilities by Ownership and by Region, 2002/03*** ***Facilitiesowned by NGOs (non-govemment agencies) and OGA (Other govemment agencies) ***Includes 5 central hospitals (St. Paul, St. Peter, Amanuel, ALERT, and Black Lion) ****Includes private hospitals Regions are ranked based on the development index used by the GOE (annex 1.1 explains the criteria and also presents other types of indices such as poverty and revenuelcapita). Addis ranks highest interms of development and Somali the lowest -92- Table 5-3: Distribution of Pharmaceutical Retail Outlets By Region & Ownership, 1994EC (2001/02) The NGO Sector 5.33 As o fDecember2002, 508 NGOswere registered with Center for DisasterPreparedness and Prevention (DPPC):'* 377 indigenous and 131 international NGOs (DPPC 2002). About 77 percent o fNGOs are concentrated inAddis, Oromia, SNNPR andAmhara. Regions and areas o f intervention are selected by NGOs themselves, although the DPPC, MOJ, DPPBs, and RHBsmight set nationalandregionalpriorities. The GOEis makingefforts to increasethe number o fNGOsinthe emerging regions (Afar, Somali, Gambella and Benshangul-Gumuz). 5.34 The health sector i s one o f the sectors where faith-based organizations andNGOs started their operations. There are 225 NGOprojects inthehealthsector: the highestnumber for a single sector (Table 5.4). There are also other NGOprojects focused on water supply and sanitation and the environment that have a direct impact on health. Other programs and sectors also have health components. Table 5-4: Sectoral Distribution of NGO Projects (2001) Sector Number of Projects Percent Agriculture 87 7.3 Education and training 97 8.1 Health 225 18.8 Environment 55 4.6 Integratedrural development 124 10.4 Water supply and sanitation 101 8.5 Urban development 31 2.6 Others* 475 39.3 Total 1195 100 the Ethiopian Health Sector: facts, challenges, and suggestions for collaborative environment. *Note: This category includes projects focused on HIV/AIDS, income generation, finding work for orphans, the elderly and the disabled. 38The role o f regulating NGOs was assumed by the DPPC because NGOs in Ethiopia have been traditionally involved in relief and humanitarian activities. Over time, NGOs have increased and diversified their areas o f involvement, and more o f them are starting to focus on development interventions (FDREIHCF 2003). -93- 5.35 Despite the government's interest andpolicy commitment to increasingly involve NGOs inthe healthsector, there appears to belittle articulation on how suchpolicy commitments are to be translated into action. The absence o fNGO guidelines to direct their involvement inthe health sector has created problems. There are two standards for health facilities: one for government facilities and another for private facilities (FDRE 1996). NGO facilities are expected to follow the government facility standards based on the understandingthat these organizations will be transferred to the government inthe future. However, the private hospital guidelines also apply to hospitals constructedbyprivate not-for-profit agencies, including NGOs. 5.36 Legal procedures and guidelines exist for NGO licensing, operation, and follow-up duringimplementation. However, actual processes are more extensive andvary across regions. As a result, project formulation, appraisal and final agreement take time because o f the way the NGO licensing and legal procedures are organized; lack o fcoordination betweenvarious stakeholders; procedural differences across regions; humanresource constraints; and bureaucratic red tape (FDRE/HCF, 2003). 5.37 NGOswhose contributions are not channeled through the government budget also represent an important share o f the total health expenditure. The exact amount o f this expenditure and its impact are not certain. The CSA Survey in 1989EC (1996/97) estimates that NGOsprovided fewer than six percent o f all outpatient visits. However, many NGOSprovide services such as immunization and family planning or nutrition counseling - services that are not accounted for ina survey focusing on coverage o f curative care visits. The Private Sector 5.38 The private sector has expanded but no coherent implementationstrategy and guidelines exist to enhance its participation inmeetinghealth sector objectives. Before 1995, private sector involvement inthe health sector was negligible because there was no legal framework within which private practices were allowed to operate. Since then, a number o f private for-profit hospitals, private for-profit clinics andpharmaceuticals manufacturing firms have opened across the country, mostly inurban areas. The current role and impact o f the private sector inEthiopia i s not addressed sufficiently inrecent literature. This is worth noting because the HSDP strategy calls for "expanded private sector involvement and the development o f innovative strategies and partnerships to leverage the private sector towards public health ends." 5.39 Privateproviders are concentrated in urban areas. InAddis Ababa, inparticular, it appears that significant portions o fhealthneeds are metbythe private sector (for example, as shown inTable 5-5, 50 percent o f the hospitals inAddis are privately-owned while Table 5-6 indicates that 27.5 percent o f all the private clinics are located inAddis Ababa). -94- Table 5-5: Distributionof HospitalsBy Type and Ownership,1994EC (2002/03 Table 5-6: Distributionof PrivateOwned ClinicsBy Type andRegion, 1995EC(2002/03) I Region Types o f Clinics 1 *totals exclude Oromia because disaggregated data were not available 5.40 As shownintable 5.3, thepharmaceutical sector is dominated by theprivate sector. The regional distribution o fthese facilities is unevenwith better coverage inurban areas. 5.41 Apart from drug vendors, there seems to be few private providers outside the towns. Those that exist maybe public HWs providing services on the side, althoughwith the exception o f case studieshecdotal information, there are no firm data to support this. -95- Traditional Healers 5.42 InEthiopia, traditionalmedicine(TM) includes the use ofherbs,the beliefinthehealing powers possessedbyhealers, Holy Water and other remedies for addressing bothphysical and mental illness. 5.43 Little literature exists regarding traditional medicine. While the W M S 2000 pegs the use o f TM at 0.9 percent, the Ethiopian Health and NutritionResearch Institute and WHO estimate that the use o f TM i s 90 percent.39Fromkey interviews duringthe July 2003 site visits, it is clear that TM plays an important role inhealthcare for a largemajority o fthe population. It appears that it i s fairly common for people to seek TM first and modem medicine (MM)only when TM fails. Interviews duringthe July 2003 field visits revealed that inthe cases where TM was sought first andthe patient's healthdid not improve, patients were delayed inreaching a health facility - sometimes to the point that it was too late. Some HWs expressed frustration with this practice, as it often resulted inthe HWsbeingblamed. 5.44 There is ongoing discussion at the MOH about how to better integrate TM into the healthcare delivery system. A task force has beenestablished to develop policy and guidelines. 5.45 Number and Distribution of Health Facilities: There has been a steady increase inthe numbero fhealth facilities providednationally with an emphasis onthe establishment o fHealth Posts and Health Centers as shown inFigure 5-3. From 1996/97 to 2002/03, the number o f hospitals increasedby 36.7 percent (from 87 to 119), health centers have increased by 75.4 percent (from 257 to 412 to 451), and healthposts from 0 to 1432. However, it is interestingto note that health stations, which are supposed to bephased out, only marginally decreasedby two percent from 1996/97 to 2002/03 (from 2,451 to 2,396) with some regions even increasingthe number o ftheir health stations. 5.46 From 1996/97 to 2002/03, the number ofprivate clinics increased by 127 percent (from 541 to 1,229), pharmacies by 53.3 percent (from 197 to 302), drug shops by 101.3 percent (from 148 to 299), and rural drugvendors by 29.3 percent (from 1,460 to 1,888). 39 The1995 Ph.D.dissertation by Dr.Azene estimates the use of TM at 70% -96- Figure 5-3: Number of Health Facilities by Type from 1996/97 to 2002/03* 3000 2500 +Hospitals health centers 2000 healthStations 1500 HealthPosts +Private Clinics 1000 -0- Pharmacies 500 +Drug -Rural Shops Drua Vendors 0 Source: PPDMOH. Health and Health Related Indictors, 2002/03 *Note: 2002/03 data are not available for private clinics, drug shops, and rural drug vendors Access to Health Services 5.47 Approximately 51percent of the population has access to clinical services (provided by HSs and HCs). Coverage increases to about 61 percent when HPs are included inthe coverage calculation, andto 70.2 percent ifprivate clinics are included. Interms of service delivery, it i s estimated that only 75 percent of urbanhouseholds and about 42 percent o f rural households are within ten kilometers o fa healthfacility (Table 5-7). -97- Table 5-7: Potential Health Service Coverage and Visit Per Capita, 2002/03 Source: MOHPPD. Hea Geographical Access 5.48 Distances, travel time and availability ofpublic transportation are very important factors indetermining accessto healthfacilities for thepoor. 5.49 Despite the increase in the number of facilities, geographical access to health services in Ethiopia remains one of the lowest in the world. Geographical access has slightly improved over five years with the average distance to the nearest health facility providingcurative care (hospitalshealth centedhealth clinics) decreasing fiom 8.8 k m s in 1995, to 7.7 k m s in2000 (Table 5-8). Large rural to urbandifferentials exist as the nearest health facility providing curative care i s 1.4 k m s away inurban areas and 8.8 k m s away inrural areas in2000. Regional differentials are also significant: distances are as low as 1.3 k m s inAddis Ababa and as far as 9.8 kms inAfar. The average distance for the poorest quintile o fhouseholds i s 8.8 k m s as opposed to 6.1 k m s for the richest quintile. Table 5-9 charts access to the nearest hospitalhealth centerhealth clinic by income quintile, and and Table 5-10 shows access by regions. Around 30 percent o f households live beyond ten k m s o f the nearest hospital/health centerhealth clinic, this figure does not differ muchacross income quintiles. -98- Table 5-8: Average Distances to HospitalsEIealth Centersmealth Clinics (kms) Urban rural Rural 10.2 9.3 8.8 8.2 Urban 0.9 2.3 1.4 3.4 Income Quintiles Poorest 10 10 8.5 9.5 2ndpoorest 10.1 10.2 8.1 8 Middle 9.2 9.4 7.6 7.5 2ndrichest 8.7 8.8 7.5 7.6 Richest 7.0 8.0 6.1 7.4 Table 5-9: Access to Nearest Hospitalmealth CenterEIealth Clinic by Income Quintile -99- Table 5-10: Access to Nearest HospitalHealth CenterHealth Clinic by Region Region <1 kms 1-4kms 5-9kms 10-14 km 15-19km 20+kms Tigray 7 31 31 19 9 4 Afar 17 20 13 37 3 9 Amhara 8 26 34 14 11 6 Oromiya 7 30 33 16 5, 6 ICnmgli I 19 _ _ I 41 I _1s_ I 13 4 7 ""llylll . _ - _ Benshangul 16 27 27 10 7 13 SNNPR 7 33 31 17 7 4 Gambella 19 36 25 3 11 6 Harari- 32 53 12 3 0 0 -_I__. Addis Ababa 48 48 4 0 0 0 DireDawa 23 65 10 2 0 0 Urbanmural Urban 39.8 54.4 5.2 .1 0.2 Rural 4.2 26.8 35.3 17.6 10 6.1 Average 9 31 31 15 9 5 5.50 Potential coverage is defined within the Ethiopian context as having access to health facilities that are ten k m s away. While this definition may not pose problems with regardto accessing preventive services, the international standard for access to clinical/curative services is a distance o f five kms. Adhering to the international standardis particularly important in Ethiopiabecause the WMS (2000) indicates that most health service users (90 percent) travel by foot to get to the nearest hospitalhealth centerhealth clinic (Table 5-11). Traveling a long distance by foot poses major difficulties for those too illto walk and for parents carrying their sick children. The general condition o froads inEthiopia i s also poor, makingtravel to these facilities more difficult.4o 5.51 Access to curative health services inEthiopia decreases further when the five k m s standard i s implemented, especially inthe case o frural households. Only about 40 percent o f all households have access to curative care that is less than five k m s away. Only about 30 percent ofrural households, compared with 94.2 percent o furbanhouseholds, live less than five k m s from facilities that provide curative care. 40Only about 12 % of the roadnetwork is paved. As aresult ofthe road sector development program, the percentageof roadsin good conditionhas increasedfrom 14 % in 1995 to 30 % in 2001. The share of road density has increasedfrom 21 km/IOOO sq kmin 1994to 29 W I O O O sq kmin2001. However,it is still about40% below the average of 50 k d l 0 0 0 sq kmfor Africa. It is estimatedthat 70% ofthe total area of Ethiopia is morethan a half-day'swalk from all-weatherroads (RSDP PAD 2003). -100- Table 5-11: Means of Transport to Health facilities Dire Dawa 86.2 0.3 0.0 0.2 10.9 1.2 1.1 0.0 0.2 Average 90.2 0.1 0.0 0.1 4.0 0.1 5.0 0.4 0.1 Income HUMAN RESOURCES Availability 5.52 Ethiopiafaces serious human resource constraints in the health sector. For example, even when health officers (HOs) are included inthe estimates, the physicians-to-population ratio inEthiopiaisonly 1:25,958. Whilethis is animprovement from the previousyear's ratio of 1:35,603, Ethiopia has only about .04physicians per 1,000 people compared to the SSA average o f 0.1 per 1,000 people. It has the lowest physician-per-1000-persons ratio inthe world (Figure 5-4). One nurse inEthiopia serves 4,882 persons. This ratio has also improved from the previous year's ratio of 1: 5,236 (Table 5-12). However, this particular figure must be treated with cautionbecause while clinical and staffnurses constitute a largepart (79 percent) o fthe total numberofnurses, it i s not clear whether these nurses graduated either from the two-year diploma program or the one-year certificate program or whether the figures presented have combined nurses graduating from these programs. The HSDP IEvaluation (2003) states that the largest increase innursing staff is made up o fjunior clinical nurses who only one have year o f training and who not well prepared for practical work. zoo -foo000 -103- Table 5-13: Health Personnel: Number and Personnel to Population Ratio, National Level 1996/97 and 2002/03 Health personnel 1996197 2002/2003 1996/97 - 200212003 Number Ratio Number Ratio YOChange Doctors 1,483 1:39,188.80 2,032 1:34,019 37 Health officers 30 1:1,937,233 631 1:109,55 1 2003 Doctors +health 1,513 1:38,412 2,663 1:25,958 76 Nurses 4,114 1:14,126 14,160 1:4,882 244 Health assistants 10,625 1:5,469 6,856 1:10,083 -35.4 Paramedicals 1,788 1:32,503 4,64 1 1:14,894 159 5.54 Attrition ratesfor lower and middle level cadres have been steadily decreasing (HDSP IEvaluation). Average attrition rates for doctors from 1996/97 to 2000/01 is 15.42 percent. There has been a sharp decline from double digit attrition rates from the period 1996/97 to 1999/2000 (ranging from 10.2 percent to 26 percent) to single digit rates in2000/01 (only 4.2 percent) (Kebede2002). 5.55 Based on the annual population growth rate o f 2.9 percent; an annual attrition rate o f 3 percent among public service health staff; and an assumed continued expansion of output from health worker training schools o f2.8 percent; the HSDP Mid-TermReview estimates that adequate staffing levels will not be attained within 25 years. This is based on the following assumptions: the annual population growth rate is 2.9 percent; the annual attrition rate is three percent among public sector staff, andoutput from health worker training schools continue to increase by 2.8 percent. RegionalDistribution 5.56 The distribution o fthe healthcare workforce i s inequitable. There are significant regional differences: ingeneral, the urbanareas have a better healthcare worker-to-population ratio than rural areas. The tables show only public health workers. Giventhat the large majority o fprivate facilities are located inthe urban areas, the coverage there is muchbetter than reflected inthis report; and the difference betweenurbanand rural areas is even greater than these statistics show. A detailed breakdownby type o f healthworker, region and gender is provided in Table 1-2 inAnnex 1. 5.57 As indicated inTable 5-14, among the predominantly rural regions, Afar and Somali fare the worst. These regions are also ranked the lowest interms o fthe development indices usedby the FDFW. Eventhough the most populatedregions (Amhara, Oromia and SNNPR) have the largest number o fhealthpersonnel, they also have among the lowest health personnel-to- population ratios, constrained by a limitednumber o fhealth staff relative to their large population size. These regions suffer more from extremely low nurse and health assistant-to- population ratios. Oromia has the lowest frontline health worker (FLHW)-to-population ratio -104- while Tigray, emphasizing community-basedhealthcare delivery, has the largest number of FLHW compared to other regions. Afar and Gambellahave no specialist physicians, only have general practitioners (MOHPPD 2002/03). Figures 5-6 and 5-7 illustrate the changes in physicians/popuIation and midwives/population ratios from 1989EC (1996/97) to 1994EC (2001/02). Marginalincreases inthe number o fphysicians, includingHOs, canbe observed in. most o fthe regions; however some declines are seen inSNNPR, Benhangul Gumuz and Harari. As shown inFigure5-8, the numbers ofvarious categories ofmidwives relative to population size has increased inall regions, but midwife-to-population ratios (particularly midwife-to- female ratios) remain inequitably distributed. Table 5-14: Population-to-Physician,Nurse, andHealthAssistant Ratios by Region, 2002/03 I**Data for private sector only available for Addis -105- Figure 5-6: Public Sector Physicians and Health Officers per 100,000 Populationby Region (EC1989 and EC1994 or 1996/97and 2001/02) I 35.0 30.0 25.0 20.0 0 1989 15.0 10.0 I1994 5.0 0.0 Source: HSDP IEvaluation 2003 Figure 5-7: Distribution of PublicSector Midwives by Region (EC1989 and EC1994 or 1996/97and 2001/02) Public Sector Midwives per 100,000 Population per Region 10.0 8.0 6.0 m 1989 4.0 1994 2.0 0.0 Source: HSDP Ievaluation 2 003 Gender 5.58 The healthcare workforce is male-dominated. As can be seen from Figure 5-8, based on 2002/03 data from the Center and 10regions (data for Oromia was not available), only about 12percent o fphysicians, 13 percent o fHOs, and 46 percent o fnurses are female. The percentage o f FLHWs is only 58 percent. This is worth emphasizing, as a majority o f the health issues facing the poor are maternal and child health related issues. 5.59 Looking at the breakdown across regions presented inAnnex A-2, mostfemale health workers are located in urban areas. This i s particularly true for doctors, HOs, pharmacists and even for nurses. Addis and Tigray are the only regions where females comprise more than 50 percent o f the total health workforce. Onthe contrary, Benshangul has the lowest percentage of female health staff (19 percent). Most o f the FLHW are located inTigray and Amhara, yet only 61 percent and 49 percent, respectively, are women. -106- 5.60 At the policylevelthere are ongoing efforts to develop genderguidelines andperhaps implementing a gender quota (3 females:1male) for admissionto nursingtraining. However, young women often lack the necessary basic education (ICN 2002) to enter the nursing profession. It will be difficult to significantly increase the number o f females innursing programs untilthe number o f females completing secondary education has increased. In2002, secondary GER for girls was only 14.3 percent (FRDE's PRSP Progress Report, 2003). In addition, married women inEthiopia tend to adapt to their husbans' professional needs rather than makingindependent professionalmoves themselves. Unmarried women, on the other hand, when they do go out on their own, often face security problems when living and working inrural areas. Figure 5-8: Percentage of Females in Each Health Worker Professional Category inEthiopia, 2002/03 12 physicians healthofficers nurses healthassistants 36 Source: M O H B P D Health and Health Related Indicators. Addis Ababa. 2002/03 Staffing Norms 5.61 The staffing standard at various health facility levels, based on the new four-tier system, i s outlined inAnnex 1-3. 5.62 Since the transition to the four-tier system is not progressing as planned, current staffing represents a mix o f the old and the new systems. While this provides some flexibility, it is also difficult to design and evaluate training programs and assess performance. The staffing norms and actual status o fHSs i s unclear, because these facilities were supposed to be phased out and replacedwith HPs. However, regions have continued to construct HPs that offer both preventive and clinical services. HPs have been staffed with primary health workers (PHWs), community health assistants (CHAs) and traditional birthattendants (TBAs). However, communities have resisted the plan to downgrade HSs to HPs, because CHAs and TBAs inHPs are not trained to handle boththe preventive and curative aspects o fhealthcare, despite the highmorbidity IeveIs and limitedhealth service coverage. Some regions such as Tigray, Amhara, Oromia and SNNPR have assignedjunior clinical nurses and upgraded PHWs, replacing CHAs and TBAs inHPs (HSDP MTR, 2001). Site visits to Oromia and SNNPR duringthe July 2003 mission confirm -107- that staffing standards are not adhered to because these regions believe that offering only preventive services does not meet the needs o f the communities. For example, representatives from Oromia state that the minimumservice level that any facility should offer is similar to what H S s currently offer. The H P s visited in SNNPR provide basic curative care such as malaria treatment. 5.63 The current standard number o ftechnical staff set for HCs and district and zonal hospitals (ZHs) does not allow for adjustments based on actual workload or utilization. Hence some regions have adapted the standard to their own requirements or regional realities. For example, the MOH staffing standard only provides for HOs and general practitioners indistrict hospitals (DHs):surgeons and gynecologists are notincludedinthe staffingrequirements. However, DHare expected to serve apopulation size of250,000. Transport costs andtravel time faced by poor patients to reachZHs may serve as substantial barriers to utilizing neededhealth services. Inorderto address this issue, it isreportedthat some regions(Tigray andAmhara) have surgeons and/or gynecologists as part o ftheir standard staffing (MTR 2001). Tigray, inparticular, has three H C staffing standards based on location: H C A i s located inremote areas andprovides emergency surgical care; H C B is located inrural areas andrefers patients for emergency surgical care to the closest DH; andH C C is located inurban areas. Staffing and equipment are revised accordingly; for example, surgery related staffwould be threefold inremote HCs while a physician and nurses shouldbe added to the base staff inurbanHCs to deal with outpatient needs. 5.64 The HSDP I(2003) Evaluationreports that many regions are discontinuing training o f junior staff and FLHW or modifylngcurricula to suit their own needs. For example, Oromia has not established H P s that provide only preventive services. 5.65 Interms of administrative-to-healthstaffratios, theHSDPIEvaluationfindsthatthe numbero f administrative stafftends to be greater than the number o fhealthworkers (ratio o f 2: 1). Inaddition to the large number o f administrative and support staff, a considerable numbero ftrainedHWs occupy non-clinical positions. For example, Addis Ababa Public Health Services' administrative and support staff (about 3,270) exceeds the total number o f HWs. In Benshangul-Gumuz, only five out o f 18 HOs (27.7 percent) are inservice delivery positions while the rest occupy either teaching or administrative posts. InAmhara, 38 percent o f H W s are employed inworeda and zonal offices. Afar has an underutilized 78-bed zonal hospital with 58 technical health staff and 129administrative and support staff. 5.66 Overall, there are staff shortages: there are large numbers o f staff whose skills do not match the community heathneeds for bothpreventive and curative services, and often implementationo f staffing norms vary and needed health service delivery staff are assigned to administrative positions. 5.67 The introduction o f the Health ExtensionProgram, which will be discussed infurther detail inChapter 7, should also entail a clear delineation o froles and responsibilities o f each health staffmember at the HP level. For example, the roles and responsibilities o f TBAs and CHWs vis-&vis HEWSas well as how their positions will be financed, (e.g. will the community beresponsible for paying the TBA and CHW) needs to be determined. -108- Training 5.68 Out o f at least 30 training institutions located inseveral regions (five universities or colleges for higher education, 12 senior training schools, and 16junior training schools-MOWPDD 2001/02), there are 12nursing schools with an annual training output of about 2,226 nurses. 5.69 Thephysical capacitynumber of teachers with a minimumof pedagogicaltraining and availability o fmaterials for training HWshave improved duringHSDP I.Two existingMOE- runinstitutionswithhealthworker training programs (Health FacultyofAlemaya University and Dilla College) started to operate diploma and degree training programs in 1997. New training programs and schools underR H B s were started in SNNPR, Gambella, Somali andBorena. Six other schools were physicallyrehabilitated and two o f them were expanded. As planned, 30 training institutions receivedtraining materials, while 81 teachers (four times more than planned) received some short-term pedagogicaltraining. Inaddition, 17 curricula were revised. Nonetheless, the schools were overloaded beyond their designed capacity. 5.70 From 2001 onwards, private training schools started to open. The EthiopianHealth Professionals Councilwas established in2002. However, it does not have the legal mandate to oversee the training and accreditation o fhealthworkers. 5.71 I n general, training capacity remains inadequate relative to training targets. According to training outputs from 1997/98-2001/02 (Figure 5.9), the number o fpeople trained inthe followingphysiciancategories [surgeons (113%), internists (113%), gynecologists (103%), ophthalmologists (153%)], nurse catagories [anesthetist nurse (118%), clinical nurse (131?40)], pharmacists (197%), laboratory technicians (199%) and FLHW (146%) were greater than anticipated. However actual numberso ftrained doctors, health officers, some nurses (midwife nurses and public health nurses) andradiographers were significantly lower than predicted. The most serious gaps existed inthe numbero f anesthesiologists (28% achieved relative to o ftarget), midwife nurses (43% achieved relative to target) andpublic healthnurses (47% achieved relative to target), radiologists (49% achievedrelative to target) andpediatricians (78% relative to target). Figure 5-9: Planned and Achieved Training Outputs EY90-94 (1997/98 to 2001/02) 7000 6000 5000 4000 ' 0ASDP Target 3000 Ach ewes '90-9 2000 1000 0 I MD + HO Pharmacy Nursing Midwifery Laboratory Enuronmental Radiography Source: HSDP IEvaluation 2003 based on M O H P P D and PAP data Note: While total number of actual nurses trained were greater than expected, certain categories o f nurses, such as public health nurses, did not even reach 50% of the target. -109- 5.72 The medical andnursingschools and training institutions for paramedical professionals attempt to increase the annual output o f trained personnelto meet the demand for health staff. However, ingeneral, the quality oftrained personnel is believedto be unsatisfactory based on existing reviews and evaluations (HSDP IEvaluation, 2003; ICN, 2003; WHO 2002). Schools lack funds and resources for community-oriented training, andhealth facilities are not sufficiently equipped to provide students with adequate practical training (HSDP JRM3,2003). According to the MTR (2001), junior professional schools tend to employ diploma holders as teachers, which i s below prescribed standards. Manyteachers lack training inteaching methods. The training approach used i s mainly cognitive and the curriculumneeds to be strengthened in terms o f community orientation, management approach, problem analysis, team building, and applied research skills. 5.73 Theamount, coordination andplanning of in-service trainingprograms need to be improved. Continuing education hardlyexists (Bach-Baouab et al, HealthManpower Study Proposal, 2002). Regional Training Centres (RTCs) were established to coordinate all continuingeducation andtrainingefforts. However, aside from Oromia SNNPR andAmhara, other regions do not have RTCs. Over the years, the capacity o f the RTCs has declined because o f inadequate budget, staff and training materials (HSDP IEvaluation 2003). 5.74 An overview of themain cadres of healthcare personneland their educational and trainingrequirements are provided inTable 5-15: -110- Table 5-15: Current Types of health care providers and their training Health officer -- Baccalaureate prepared (4 years) Generic (4 years), Accelerated for diploma nurses (3 years) Nurse -- Baccalaureate preparedNurse: ----Generic Program (4 years), Accelerated Program (3 years) Diploma prepared- "senior Nurse" (2 years) Public Health Nurse ClinicalNurse Certificate preparedNurse - "Junior Nurse" or "Assistant Nurse" (1 year) -- Public Health Nurse Clinical Nurse Midwife - DiplomaPrepared-"Senior Midwife" (2 years) - Certificate Prepared- "Junior Midwife" or "Assistant Midwife" (1 year) -- Primary Midwife (6 months) Trained traditional birthattendants -TBA (3 months) Frontlineworkers --- Community Health Agents (3 months) Primary Health Care Workers (6 months) Heath extension Worker *Community HealthAgents (CHWs) are part o fthe healthteam at the HP level, recruited from the local community; and preferably traditional healers. They have 3 months o f training. *Primary HealthWorkers (PHWs) are the coordinators o fthe healthteam onthe HP level. They have 6 months o f training. **Heath ExtensionWorkers are a new cadre o fhealthproviders - healthextension worker or agent (HEWs or HEAs) will be assigned to the HP. They should be at least 10"-grade female graduates. They willhave one year oftraining, andthere will be two HEWsper kebele. Note: There has also beenrecent move to upgrade training o fjunior/assistant nurses to two years Source: ICN2002. *Note: Basedon the November 2003 mission discussions, the roles ofthe CHAs andPHWs are expected to change. They will be expected to provide support to the HEW but working and financing arrangements still need to be confirmed. **updated description basedon November 2003 mission. 5.75 Training curricula needs to be better aligned with intended objectives. Existing evaluations o f health workers indicate that HO training i s generally well conceived interrns o f community orientation, and it has an appropriate focus on health promotion, illness prevention and essential medical services preparing graduates to bemanagers inhealth centers and "extensions" o fphysicians. However, there is a clear need to modify the curricula for junior, mono-disciplinary nursing, midwifery, and frontline classes inorder to better equip the students with practical clinical skills (especially for those working inruralperipheral healthunits). Currently, midwife training standards do not meet those of the international community. Significant changes needto be made inmidwifery training to align it with the FDRE'spublic health policies and to respondmore effectively to maternal and infant health issues using a practical community-basedapproach (ICN 2002). -111- 5.76 About 20,000 HEWs will be trained and deployed to HPs over the next five years. This will be a particularly challenging goal for ruralperipheral communitiesbecause HEWsare requiredto be female; have a minimumeducation level o f 10thgrade; andto come from the kebele that they will serve, ensuringthat they are familiar with the local culture and language. It will also be very important tofactor in lessons learnedfrom the evaluation of the HSEPpilot infive regions as the improvement of the training and deploymentplanfor the HEWs is discussed (MOHKSR Nov 2003 Mission Discussions). Salaries, Incentives and Staff Retention 5.77 The MOHhas taken initiatives to standardizejob titles andoutline salary scales and career structures inorder to motivate andretain health staff. The Qualification Requirements for HealthProfessionals (1999) describes salary scales andoutlines a career structure for formally trained healthworkers. 5.78 The large number o fhealth worker categories provides flexibility for the regions, but makes evaluation o fperformance and quality o f curricula difficult to synchronize. For each type o f cadre there are (inmost cases) five defined career steps (for an Assistant Public HealthNurse (APHN)there are four levels: Junior, Senior APHN, ChiefAPHN and ExpertAPHN). Moreover, job descriptions have been developed for at least 90 health worker categories. There is some overlap among the different job categories (for example, there are at least ten nurse categories), and they can be somewhat confusing given the relatively minor differencesbetween some groupings. 5.79 The HSDP IEvaluation (2003) indicates that there were few recent complaints about salaries and remuneration. Health sector salaries seem to bemore or less inline with the minimumcost-of-living increases andare favorable relative to other sectors. Thismaybe explainedbythe recent salary increases and implementation o f incentive schemes including hardshipallowances. 5.80 Based on available data, on average, base salaries o f health personnel increased by at least 21 percent from 1999 to 2003 innominal terms (40 percent inreal terms). Base salaries o f health assistants increased by about 37 percent innominal terms (54 percent inreal terms). This increase i s explained by the fact that health assistants were previously among the lowest paid health staff (Table 5- 16). -112- Table 5-16: Ethiopian Average Base Salaries (per month) among Selected Health Staff, 1999 and 2003 5.81 On average, medical specialists and general practitioners inEthiopia are paid about 39 times and 24 times the annual GDPper capita, respectively". Professionalnurses are paid on average almost 19 times (ranging from 11.7-27) GDP per capita whilejunior nurses are paid about 17times GDP per capita. 5.82 Public salariesfor health workers appear to be relatively higher than the average in sub-Saharan Africa. Basedon the available data from other SSA countries, the salary-to-GDP per capita ratios for general practitioners inEthiopia are muchhigher than all o fthe five other comparator countries (ratios range from about five inCameroon to 23.5 inBurkina Faso). This comparison also holds true inthe case o fprofessional nurses: those inEthiopia have higher salary-to-GDP ratios than do five other comparator countries (ratios range from two in Cameroon to 13.5 inBurkinaFaso). Eventhe salary-to-GDP ratios for Ethiopia clinical nurses/public health nurses who graduated from one-year certificate courses are higher than the salaries o f state diploma nurses inthe five other countries. Ethiopian physicians and nurses seem to bewell-paid interms o f GDPper capita relative to the other countries, although it is important to note that Ethiopia has the lowest GDP per capita relative to these countries (Table 5-17). 42 While there i s a difference in the time periods of data collection, (2001102 vs. 2003), which should be taken into account, a teacher in Oromiya with a Bachelor's degree or Master's degree eamed on average about Birr 1,182 (including pension and allowances of about 8 %) per month in 2001/02. A Teacher Training Institute-certified teacher eamed about Birr 755 and a Teacher College trainedteacher eamed Birr 797 per month. A teacher for grades 9-12 receivedan annual salary that was 11.8 times GDP per capitain2001102 (EducationCSR 2004). 43 GDP per capita in 2003 of $96 or ETB 821 was estimated based on a total GDP estimate of $6,623 million divided by the estimatedpopulationof 69 million. -113- Table 5-17: Range of Salary-to-GDP per capita Ratios for General Practitioners and Physicians in Six Countries Country General Practioner Diploma Nurse Chad 10.3-18.8 5-10.6 Burkina Faso 7.3-23.5 4.2-13.5 Mauritania 5.67-9.45 3.2-5.7 Cameroon 4.7 1.7 Niger 10.6-20.8 5.3-12.0 Ethiopia 18.3-30 11.7-27 5.83 While salaries relative to GDP are high, Ethiopian medical specialists and general practitioners are paid significantly less than physicians from other regions such as South Africa, the Middle East and the United States. InEthiopia, the average salary for a medical specialist is only US$387 per month while a general practitioner receives about US$236 per month. These numbers make migration very attractive for doctors with prized skills inthe international market, particularly surgeons and obstetricians. 5.84 Although salaries and allowances have improved over time, it is clear that additional incentives must be offered to motivate health workers to stay inthe public sector inEthiopia, especially ifthey are expected to serve inrural areas. According to the preliminary results o f a contingent valuation exercise undertakenby Semeels et al. (2004), a mark-up of about 50 percent inmonthly wages (i.e., Birr350 inadditionto the current startingsalary ofBirr700) would adequately motivate about 80 percent o f current nursing students to serve inrural areas. Approximately 60 to 70 percent o f the current fourth year medical doctor students would be willing to serve inrural areas iftheir current startingsalary increased by 50 percent (i.e., about Birr 700 inaddition to their current average starting salary o fBirr 1300-1400). 5.85 Non-pecuniary issues also affect job satisfaction among health workers. Training and career development opportunities were cited as important concems by healthworkers invarious reports. While most workers interviewed explicitly acknowledged the needto address the health needs inrural areas, concems were also expressed about remaining indefinitely inrural areas without acquiring additional learning, job enrichment and career advancement opportunities (Lindelow et al. 2003). Education opportunities for the workers' children were also cited as important issues (Semeels et a12004). This underscores the need to equip rural areas with basic health and other services. 5.86 Provision o f staff houses was also repeatedly mentioned as a potential motivating factor for higherqualified personnelto remain inremote areas (HSDP IEvaluation). As a result, some regional HSDP I1plans have madeprovisions to support staffhousing. Moreover, it has been noted that health worker morale could potentially improve ifhealth staff were provided with the necessary equipment and materials to enable them to perform theirjobs effectively. The importance o fhaving materials to work with were underscored inthe focus groups discussions among healthworkers conducted in2003 (Lindelow et al. 2003). Some o fthe health workers' concems were stated as follows: -114- e "Inpublic facilities, there aretimes whenhealthworkers are obligedto sterilize gloves for re-use, while they are disposed off inprivate facilities." Health assistant inAddis Ababa e "There is inadequatesupply of materials. It is notpossible to work eficiently and meet expectations.Ifvou try to work with what is available your service will be substandard." Health assistant ina provincial town 5.87 The I C N2003 study found that TBAs are equippedwith one delivery kit each, which i s not adequate to support all o f the deliveries that each TBA is expected to carry out. 5.88 A survey on the quality o fhealthservices management (PHRD 1998)also raisesthe above concems inaddition to the following issues: work overload, staff shortage, unclear job descriptions, budget shortage, unfair promotion procedures, inability to obtain annual leave when needed, lack o f transport facilities, and lack o f adequate care for sick workers. 5.89 There is also a general concern about contracting HIV/AIDS. This fear has increasingly influenced the decision o fhealthworkers to work inpublic healthrather than inclinical services. This concern is compounded by the lack o f a safety policy and inadequate protective materials such as gloves (CSR Team FieldVisit and Lindelow et al. 2003). 5.90 Ingeneral, the levelofsatisfactionregardingsalaries andbenefitshasbeenmixed. Box 5-1 illustrates some o f the views expressed by health workers. However, it is clear that more incentives needto be inplace to attract andretainhealth staff inthe regions. To attract female workers, additional measures must be put inplace including an assurance o f safety when working inremote areas. The HSEPproposes to recruit and train HEWSthat live inthe same kebele as a strategy to address local staff shortages. However, the implementation o f the HSEP inthe short to mediumterm for other healthprofessionals(such as doctors andnurses) ismore limited, andother strategies mustbe put inplace. -115- Box 5-1: Salaries, Benefits, Overalljob satisfaction: What do Health Workers Say? Things are improving ... Concerns "The profession i s good, although there are various "I notadviseapersontojointhehealth would problems. It is about helpingthe poor, particularly sector. Iwant to leave this sector because o f the the public sector .-Health assistant inAddis workload and the l o w payment." -Health assistant in Addis) "Even though there are many problems, Iwould advise even my own children to join the health "No physician would leave the private sector ifhe profession. Any profession has its own unique or she was paid well. By movingto the private hazards and problems. The most important things in sector we can earn 3 or 4 times as much. The Ethiopia are education and health, and the need in payment to physicians needs to be improved ifthere these sectors is great." -Physicianhealth officer in i s to be a genuine drive to help the poor." - Addis. Physiciad health officer ina provincial town "...Now the salary inthe public sector has increased "Although the people inthe rural areas need our to Birr 670per month. Inthe private sector it i s about support, the working conditions are not good for us, Birr 600. This, inadditionto the education and facilities for other basic services are not fairly opportunities that have opened up inthe public distributed inthe country. " -Nursehidwife ina facilities, helped me decide to come back to the provincial town public sector. It seems that the public sector is getting better." -Nursehidwife inprovincial town "Once you are dumped inthe most remote area, no one will remember your transfer back to a central area. Inaddition, there are no medicines, books and you cannot access information and opportunities needed to improve your professional standards. Such problems can be resolvedby policy makers." - Physiciadhealth officer ina small town "Many health workers choose public health. Surgical training is more risky. After the advent o f HIV/AIDS, things have changed." - Physiciadhealth officer inAddis "In some places, sexual harassment is a problem for women unless they live in the facilities..." - Nurselmidwife inAddis 5.91 The HSDP IEvaluation noted some signs o fwork neglect includingcases o fpartial or full day absenteeism. Highstaffturnover amongdoctors moving from hardship areas as well as among staff inRHBswas also noticed. Some absenteeism was mentioned as well inthe focus group discussions conducted by Lindelow et a1(2003). This study showed that some health workers did not respect working hours andwould work inthe private sector or attend to personal commitments duringnormal working hours. 5.92 However, a recent survey o f facilities that were visited unannounced inAmhara indicate that only two out of every 96 healthproviders (2.1 percent) in32 health facilities were absent. This absenteeism rate i s very low compared with the six other countries surveyed, which have absenteeism rates ranging from 19percent inPapua, New Guinea to 35 percent inUganda (Figure 5-10). There still seems to be a relatively high work ethic among health workers in Ethiopia as exemplified by the relatively low absenteeism rates when compared with other -116- countries with higher incomes. The ability to work inthe health sector and be o f service to the poor, inspite o f the challenges inherent inthe medical profession, was appreciated by employees participating inthe healthworker focus group discussions (Lindelow et al. 2003). Figure5-10: Health Care ProviderAbsence Rate Ethiopia Uganda Bangladesh PNG India Indonesia Peru Country Rankedfrom Poorest to Richest IfBHealth Care ProviderAbsence RateI Source: Ethiopia Facility-basedSurvey Draft Findings from Chaudhury et al. 2004. Health Care WorkersAnd ThePrivate Sector 5.93 As the private health sector has expanded over the years, it has attracted health staff fi-om the public sector. This i s interesting to note because based on existing policies, staff trained in public sector institutions are required to spend a certain number o f years working inthe public sector. However, as stated above, inreality this appears not to be the case (Barr, A et al., 2003). 5.94 InAddis Ababamore than 50percent ofthe nurses anddoctors are employed inthe NGO/OGA/private sector. Inaddition, many publicly employed health workers are also doing part-time work inthe private sector. The phenomenon is not limited to Addis Ababa. InAfar, about 30 percent o fthe health workers were involved inprivate/NGO sector work: 50 health assistants were reportedly working as private rural drugvendors, while about 150paid CHWs and 100volunteer TBAs were engagedbyNGOs. There are examples inother regions such as Tigray and Amhara, emphasizing the need to include the private sector inoverall human resource planning and monitoring. (HSDPI Final Evaluation). -117- 5.95 Information obtained based on focus group discussions with health workers reflect the mixed feelings andperceived advantages anddisadvantages o fworking inthe private andpublic sectors. Inparticular, while healthworkers appreciate the higher salariesMand performance-based salary increases, better equipment and less bureaucratic procedures inthe private sector, they also find profit-driven motivation, lowerjob security and lack o f career development unattractive (Barr et al., 2003; Lindelow et al, 2003). Thus inorder to obtain "the best o fbothworlds" many work inboththe public sector (mornings) andprivate sector (afternoons and evenings). While this division o fthe workday is commonly practiced, there is also some resentment about the unofficial privatizationwithin the public sector interms o f informal payment or referral to a provider's private practice. These informal activities are officially not allowed, however, they are becoming increasingly accepted among employers and employees. Policies are currently beingconsidered to allow the combination o fpublic and private work inpublic facilities (Barr, A et al., 2003). 5.96 Various HSDP reviews have already suggestedthe development o f rules and regulations developed incollaboration with the MOE to retain professionals by the government so that the Government would obtain a return on its investment. Incentivesneed to be established inorder for health staff to prefer to remain inthe public sector. Inthis regard, studies are being developed, such as the WE3 supported health worker study, to better understand humanresource dynamics and issues inthe health sector. Inmoving forward, it will be essential to have clearly defined guidelines to facilitate the transition from the six-tier to the four-tier system. These guidelines should also be accompanied by a humanresource (HR) strategy based on a comprehensive humanresource assessment. This HR strategy would need to address deployment; transfer and training o fhealth workers; andthe development o f draft HR guidelines governing the partnership, cooperation and control mechanisms betweenthe public and private sectors (including NGOs). Quality of Health Human Resources Management 5.97 Another study reviewed for this report was the Quality o f Health Services and Management Study (February, 1998).While much o fthe data and specific information (collected August 1997) is outdated, many o f the general conclusions, lessons learned and recommendations are still valid based on the review o f other assessmentsand discussions. This study, however, did not include HPs, a major component o f the current strategy to deliver services. 5.98 To improve the health management system, the study suggests the development and implementationo fthe following: (i) Clear policy andprocedures related to humanresource management and improved skills inpersonnel management; (ii) Proper and regular supervision, including an adequate plan for supervisory activities, and written guidelines for supervisionprotocols; (iii) Relevant data for management decision making; (iv) Well-defined organizational charts, written job descriptions and technical norms; 44Some regionssuch as SNNPR have already introduced incentive mechanisms such as additional allowances andbonuses therebynarrowingthe salary differentials between private andpublic health workers. -118- (v) In-service training andtraining-based on needs assessment; (vi) Access to transport for facilities; and (vii) Adequate budget and participation of staff inthe preparation o fbudgets. 5.99 More effective enforcement and transparencypractices would improve human resourcepolicies andpractices. Healthworker focus group discussions have expressed concerns regarding favoritism with respect to postings, training, promotions andobtaining release from the public sector. It is important to address these concerns as these issues influence howhealthworkers make career and labor market choices. 5.100 Focus group discussions amonghealth workers also underscore the needto improve accountability inbothprivate andpublic health sectors. Although corrupt practices such as briberyandpilferingo fdrugs andsupplies are illegal; they are also rationalized at times because o f the low wages workers receive. The public sector has recently introduced a new system o f performancemanagement, which links salary increases, promotions and training opportunities to healthworker performance. Itwill be importantto assess the system's impact on health worker behavior andperformance, and determine how it can be improved further to make health workers more accountable to users o fhealth services.45It is likely that the deepening decentralization of healthcare management to the woredas may encourage more community or bottom-up approaches to improve accountability (Lindelow et a12004). AVAILABILITY OFMATERIALRESOURCES AvailabilityofBeds 5.101 Ethiopia has vevfew hospital beds. Figures 5-11and 5-12 demonstrate that Ethiopia has a very highpopulation-to-bed ratio comparedto most other countries, including those in SSA. This translates to approximately 0.17 bedsper 1,000 persons, which is less than one-sixth the average for sub-Saharan Africa of 1.1beds per 1,000 population (WDI2003). Table 5-2 in an earlier sub-sectiono fthis report, reports that approximately 81percent of the total number of beds are located inhospitals. 45Some users in focus group discussions have expressed their dissatisfactionwith lengthy waiting times and impolite treatment fromhealthworkers. 10000 1000t 100 100 -1 000 10000 GctP per capita {US$ constant 199B) 9600 8000 7000 ~ 0 0 0 ~~~~ 4 0 ~ ~ 3000 2000 1000 0 -120- 5.102 Regional bed-to-population ratios vary widely, rangingfrom 0.08 inOromia to 2.67 per 1,000 population inHarari. Addis, the mostdeveloped region, has the largest number o fbeds, followed by the larger regions (Tigray, Oromia, SNNPR and Amhara). However, since these regions have to contend with their largepopulation size, with the exception o fTigray, their bed-to-populationratios are less thanthe national average o f 0.20 per 1000. Only Harari and DireDawaare at least equal to or greater than the SSA average o f 1.1bedsper 1000persons (Table 5-18). Table 5-18: Beds by Facility Type; Total number of Beds; and Bed-to-1000 PopulationRatios by Region, 2001/02 Region Beddhealth facility type Total no. of Bed/1000 Hospital I Health I Healthstation Beds population 5.103 Despite the high population- to- bed ratios, bed occupancy rates (BORs) remain low. The latest available national average BOR is 41.4 percent, which is basedonly on data from five regions (Tigray, Somali, Benshangul Gumuz, SNNPR and Harari) and the Center in2002/03. While this is higher thanthe 2001/02 BORestimate of25.4 percent, both figures cannot be comparedbecause six regions andthe Center were represented in2001/02. No data was available for Addis in2002/03, but it was the regionwith the highest BOR(175.2 percent) in2001/02. For both years, all other regions had BORslower than 50 percent. Somali hadthe lowest BOR (7.7 percent) (MOHPPD 2002/03 and 2000/01). ESSENTIAL DRUGS COMMONMEDICINES AND Policy Background 5.104 The goal of the Ethiopianpharmaceutical sector i s to ensure the regular availability and rational use of safe, effective quality drugs at an affordable price. The strategies and the specific objectives related to this goal are described inthe National DrugsPolicy (NDP, MOH 1993GC). 5.105 A number ofmajor legislative and organizational reforms have taken place based on the Proclamation to Provide for DrugAdministration Control 176/1999. Discussions with donors were heldto develop a master plan for the pharmaceutical sector, and the Pharmaceutical -121- Departmentofthe M O Hhas beenreorganized into an autonomous drugregulatorybody and a supply agency. 5.106 New pharmaceutical legislationwas prepared and submitted to the government for approval. The List o fDrugs for Ethiopia (LIDE2002) and its sub-lists have been distributed. This list records the drugs that canbe legally registered andmarketed inEthiopia, which are then categorized by lists by level o f healthcare facility (i.e. by zonal and district hospital, HC, HS, HP, and drugretail outlet) (JRM3 2003). 5.107 A list containing priority drugs that should be available at all times in adequate quantities, especially inthe public sector, i s beingdeveloped as part o f the Basic Health Care Package and will be used as the basis for procurement. However, the EssentialDrugList (1987EC) has not yet been revised as planned (HSDP IEvaluation 2003). 5.108 A policy on supply and use o f anti-retroviral drugs has been developed and distributed throughout the country. The related Treatment Guidelines have been prepared andprinted. Guidelines for ARV Procurement, Storage, Distribution andUse have also beenprepared (JFW3). Sourcing 5.109 Drugs are suppliedthrough the following four channels: (1) the private commercial market; (2) the government parastatal (PHARMID); (3) the MOH and other government agencies (Ministryo f Defense, Research andtraining institutes, etc); and (4) nongovernmental organizations (NGOs),donors, the UnitedNations, and other multilateral agencies. 5.110 The total value o f supply moved through the pharmaceutical market was estimated to be aroundBirr 939 millionin2000/01 (Table 5-19). According to these estimates, 87 percent o fthe country's drugneeds are met through imports (purchase and donation) and 13 percent through local production. The per capita availability of drugs is estimated at around Birr 14 in2000/01 (ESHE/HCF 2002). Table 5-19: Ethiopia: Supply of Pharmaceuticals:Value (000 Birr) by Sources2000/01 Type of Supply Sector Value percent Imports MOH 279,936 Other Government agencies 210,481 PHARMID 151,784 NGOs 52,269 Private for profit 123,726 Sub-total 818,196 87 LocalProduction Government 63,646 ISubtotal 120,459 13 Grand Total 939,655 100 -122- 5.111 Inthe private sector the number o f importers andwholesalers increasedfrom 44 and 17 inEC1989 (1996) to 49 and24, respectivelyinEC1994(2001). Also, the localproductionof pharmaceuticals and medical supplies increasedconsiderably duringHSDP I. InEC1989there was only one manufacturer (state-owned) andone under construction. Currently there are 11manufacturers, two o fwhich are reportedto be licensed byDACA, while ninehave a provisional license (HSDP IEvaluation 2003). Drugoutlets 5.1 12 The number ofpharmaceutical retailers is expandingsignificantly. On average, (as shown inTable 5-20) the number of all types o f outlets for drugs has grown largely over recent years inthe private sector (as shown inTables 5-21, the vast majority o fpharmaceutical outlets are private). -124- DrugAvailability 5.113 The main objective o f the pharmaceutical component o f the HSDP is to ensure a regular and adequate supply o f effective, safe and affordable essential drugs and medical supplies of highquality inthe public, private and NGO sectors. Interviews conducted duringthe July 2003 CSR field mission confirm that drug availability i s a key determinant inthe public's view o f the usefulness of health facilities. Improving drug availability is important not only to facilitate better treatment, but also because the unavailability of drugs is a major factor causing low utilization rates of lower tierfacilities. Since the majority o f householdhealth expenditures are spent on pharmaceuticals (about 60 percent), improvements indrug availability and affordability would contribute to householdwelfare. 5.114 There are significant differences betweenvarious mission reports and evaluations regardingthe status o f drug and equipmentsupply inthe public sector. Table 5-22 shows the principal findings ofthe HSDP IEvaluation on some o f the key issues indrugavailability. Although the LIDE and REDLlist were often not available, the drugs themselves were mostly accessible. Inall but one case, however, storage and inventory control was poor. Availabilityh the EthiopiaRed Cross pharmacies, Special Pharmacies (SP) andprivate pharmacies was adequateduringthe whole o fHSDP (HSDP IEvaluation). Table 5-22: MainFindingsby the HSDPIFinalEvaluationinRegions,Feb.2002 Regions LIDE REDL Basic Availability of Storage and Availability of PACA 2002) Guidelines R-HFs EDs in Inventory Equipmentin R I 1 Control -HFs Benishangul Yes I No I Yes I 100-43% I Poor 60%togood Gumuz I Oromia No No Yes 66% Poor 80-100% Gambella NIA NIA Yes 64% Poor NIA Note: REDL =RegionalEssentialDrug List; ED = EssentialDrugs; R = Regionallevel; HF = HealthFacility level; N/A = Nnt Availahle I 5.115 Interms o f drug availability bytype o fprovider, Table 5-23 shows the findings for drugs instock duringthe visit. Governmenthospitalshavethe highestnumber of selected indicator drugs (82 percent) followed by private drugretail outlets (DROs) and HCs (72 percent for both). Results for private facilities were unexpectedly low. Inthe case o f drugretail outlets, as drug vendor shops are more numerous then pharmacies and drug shops, these facilities are not permitted to carry all o fthe indicator drugs (inother words the type andvariety o f drugs -125- permitted decreases at lower levels o f drugretail outlets). However, private hospitals also have a lower availability thanpublic hospitals (63 percent compared to 72 percent). Table 5-23: Average Availability of the Basket of 10 Indicator Drugs on the Day of Visit by Type of Provider Facility Availability (percent) Government hospitals 82 Private hospitals 63 Private DROs 72 Health centers 72 Red Cross 63 Kenema 70 5.116 I n general, it appears that availability of essential drugs has improved, but that shortages of drugs are still common. For example, duringthe July 2003 field visit, every H S and H C visited inboth Sidama zone (SNNPR) and Arsi zone (Oromia) were out o f the drug Depo-Provera. Most o fthe outlets carried contraceptive pills andusually offered them for free, however the women tended to prefer Depo-Provera even ifit costs two Birrper injection. Even the special pharmacy inAlessa (capital o f the A r s i woreda) was out o f stock. However, the local D K T outlet across the street, as well as the private pharmacies, didhave Depo-Provera instock. 5.117 The availability o f cold chain equipment and supplies has increasedinmost regions, but their functionality hasbeenaffected bythe availability o fspareparts. Regions also raised concerns about the inadequate anddelayed operational budget for outreach EPIactivities (HSDP IEvaluation2003). Personnel 5.118 The number o fpharmacists has fluctuated inrecent years, and currently there i s a clear shortage o fpharmacists and druggists, although the number o fpharmacy technicians has increased significantly. The number inEC1994 (2001/02) is still less than that o f EC1989 (1996/97). At the end o fHSDP I,only 121 out o f about 500 pharmacists were working inthe public sector. 5.119 Pharmacies and drugs stores can only legally be managed bypharmacists and druggists (pharmacy technicians), respectively. However, Table 5-24 shows that about 26 percent o f the surveyedgovernment hospitalpharmacies are being managedbydruggists or pharmacy technicians while another 22 percent are beingmanagedby either nurses or health assistants. Only 48 percent of surveyed H C drug stores are beingmanaged by either nurses or health assistants; another seven percent are being managedbynon-healthprofessionals. Onthe other hand, 98 percent o f surveyed private pharmacies are being managed bypharmacists, and about 78 percent o f private drug stores are beingmanaged by the required druggists or pharmacy technicians. -126- Table 5-24: Qualifications of Personnel in charge by Provider and Facility Type, 2001 Source: ESHE/MOH HCF, National Baseline Study on Drug Supply and Use inEthiopia, 2002 Note: Figures inparenthesesare row percentages 5.120 Interms of prescribingpractices, according to the study conductedby H C F M O H(2002), the average number o f drugs per prescription is 2.1; which i s slightly higher than the HSDP I1 target o f 1.84. However, the percentage o f generic drugs prescribedis about 94 percent; which i s also higher than the HSDP IItarget o f 92 percent (Table 5-25). Table 5-25: Selected Drug Prescription Indicators Indicators Overall average Average number of drugsprescribedper encounter 2.1 Percentage of generic drugsprescribedper encounter 94 Percentage of encounters with an antibiotic prescribed 69 Percentage of encounters with an injection prescribed 21 Percentage of drugs prescribed from the LIDE 98 Special Pharmacies 5.121 The concept behindSpecial Pharmacies (SPs) is to allow patients to obtain drugs when they are not available inthe budgetpharmacies. SPs add a markup o f about 20-30 percent to the cost o f drugs but they are still a lower cost alternative relative to private pharmacies and drug stores. They also raise funds for health institutions. SPs are oAen staffed by at least some health workers (HCFMOH, 2001 and HSDPI Final Evaluation 2003). -127- 5.122 Since the first two SPs were established inAddis Ababa in 1990, approximately 100 SPs have been set-up under the Health Care Finance Strategy (HCFS) all over the country. The creation o f another 150 SPs i s plannedwith support from USAID (HSDP IFinal Evaluation 2003). A crude comparison o f surplus generated by SPs to a hospital's operational budget suggests that surplus from SPs could cover close to 30 percent o f a hospital's operational budget (HCFMOH 2001).46 5.123 Efforts to expand the number o f special pharmacies are faced with many challenges. Firstly, efforts are confrontedbya retentionarrangement problem. At present, almost all SPs have managed to retain 100percent o ftheir proceeds, deposit it ina separate account and use the surplus for priority activities when decided bythe management committee. However, even though this has become an accepted practice, the country's financial law does not support it. Secondly, a shortage o fpharmacy professionals exists. Third, there is a lack o f storage space: SPs have to share limited storage space with budget pharmacies. This arrangement makes control and accommodation o f increasedpharmacy storage requirements due to increased volume o f sales very difficult. Fourth, financial management capacity o f most facilities, particularly inthe rural areas and at lower health service levels, is limited. Most o f the time, SPs use the financial staff o fthe health facility onpart-time basis. Endorsement o fNational Special Pharmacy Guidelines would be a short-term solution, but would elict a potentially negative reaction from the private sector. As price controls are lifted, private retail pharmacies are charginghigherprices. There are incidences, however, when the introduction o f SPs resulted in reduced prices for drugs inprivate retailpharmacies. Thus, the further expansion o f SPs could pressure private retail pharmacies to further cut their prices, which could potentially crowd out private pharmacies. Thus the private sector could also protest because SPs are subsidized bythe health facility that they serve (HCFMOH 2003). AVAILABILITYOFEQUIPMENT 5.124 The HSDP I2003 Evaluation did not find records o f inventories for medical equipment. The Evaluationnotes that there i s no strategy for equipment maintenance and replacement even though national standards are guiding the initial equipment and furnishing o f facilities. Construction o fregional level medical equipment maintenance centers has started inthree regions, andthe centers are expected to be functional by 2003/04. However procurement o f furniture, equipment andworking tools has not yet commenced and training and recruitment o f professional staff i s laggingbehind. 5.125 There are no recent statistics on the availability o f equipment. There is an ongoing health facility surveyas part o f the decentralization study, but it has not been completed. 5.126 The PHRDhealth facility study (1996) collected data on selected facilities and equipment such as the number o fbeds, x-ray machines, refrigerators, sterilizers and vehicles; as well as the availability o f laboratories, operation theatres and/or minor surgery sets inRHBs and inthe sample health facilities. Results are given below inTable 5-26. ~~ 46For example, St. Paul Hospital spends 1.4 million Birr on its operational budget, and its SP recorded a surplus o f almost Birr 290,000 annually during normal periods. In the case of Ammanuel Hospital, the average operational budget was Birr 1.03 million, while the SP generatedan average of Birr 350,000 surplus during the last year. The Tikur Anbesa SP generated&in 1.9 million surplus in 1992EC(1999/00), while the hospital spent 5.7 million Birr in operational costs. -128- Table 5-26: Distribution of Equipment in Hospitals and Selected Facilities - 1995 HIV Total no. Zones with % avail- Region Hospitals Beds X-ray screening of zones operation ability machines centers (a) theatre of operation (b) theater (b/a) Tigray 12 860 5 6 5 3 60 Afar 2 60 2 1 1 1 20 Amhara 11 1289 12 9 10 7 70 Oromia 25 2293 22 20 12 6 50 Somali 3 255 3 4 9 2 22 Benishangul 2 254 2 2 5 2 22 SNNPR 9 816 12 7 16 7 44 Gambella 1 95 1 1 (I)* 100 Harari 5 735 5 2 (I)* 100 Dire-Dawa 3 247 2 1 (I)* 100 Addis- Ababa 16 3016 22 7 6 3 50 Total 89 9920 88 60 Source: PHRD (Access to Supply o f HealthFacilities and Services 1996) - *68Denotes 34(31) 46 regions without zonal subdivisions. 5.127 Based on the above 1995 survey, the ratio o f selected facility equipmentto population was one x-ray machine (working) per 591,136 persons and one HlV screening center per 867,000 persons (current guidelines require one HIV screening center for 400,000 persons). Out o fthe 89 hospitals surveyed, only 46 percent have operationtheatres. (This is extremely inadequate inrelation to the number of outpatient attendances and inpatient admissions in hospitals.) 5.128 A separate survey also undertaken in 1995 indicates that a significant percentage of institutions lack some basic equipment. The results are shown inTable 5-27 below. Table 5-27: Percentage Reported of Availability of Selected Equipment and Transportation by Facility Type-1995 Type of equipment Hosp. HC H S Type of Hospital HC H S (n=14) (n=16) (n=33) equipment (n=14) (n=16) (n=33) Baby scale 86% 94% 64% X-ray 86% na N a machine Adult scale 86% 94% 64% Microscope 79% 81% An Examination bed 79% 75% 67% Lab. 57% na N a Incubator Delivery bed 86% 81% 45% Refrigerator 100% 87% 67% Oto/opthalmoscope 79% 75% Na Washing 43% na N a machine Autoclave/sterilizer 86% 69% 67% Ambulance 21% na na Vacuum extractor na 62% Na Other vehicle 50% 69% na Ultra sound 14% Na Na Motor cycle ... 75% 24% E.C.G. machine Source: PHRD (Survey of Medical and Healthcare Providers -Bicycle 64% Na Na ... 50% 21% 1996) -129- Condition of Health Facility Buildings 5.129 Ina detailed assessment o f a sample o fhealth facilities in 1995, over 50 percent o f the facilities reported leaking roofs, electricalproblems andplumbingand sanitary problems. Overall assessment o fthe condition o f the buildings showed that 15.1 percent and 41.1 percent were inexcellent condition or requiredminor repairs, respectively; and28.8 percent and 15.1 percent needed major repair or total replacements, respectively. Although the trends were more or less similar, there were some variations among the three types of institutions (Table 5-28). Table 5-28: Health InstitutionsBy Type And Building Condition Condition of health I Hospitals I HC H S Total facility Excellent 17.7 11.1 15.8 15.1 ---- 35.3 55.6 36.8 41.1 MajorRepair 29.4 22.2 31.6 28.8 Replacement 17.6 11.1 15.8 15.1 TOTAL 23.3 24.7 52.1 100.0 5.130 Recent data based on the main findings o fthe HSDP IEvaluation (2003) underscore the need to improve the condition and maintenance o f health facilities. The following issues regardingfacility conditions were cited: e Availability o fwater at facilities is inadequate and scarce inabout 30 percent o f PHCUs. e Minimal power supply exists and attempts to connect to an alternative power supply were not fruitful. e Facilities requiring minor maintenance have degenerated because o f lack o f preventivemaintenance activities. Moreover, management o fmedical equipment remains a major concem affecting the continuity o f service delivery. e Rehabilitation o fhealth facilities is often limitedto replacing damagedparts rather than rehabilitating functional flows, correctingthe shortcomings for service delivery, or adapting new healthcare technology for anticipated future expansions. e Fumiture inmany o f the facilities is worn-out and does not fit well inthe working space. Furnitureis often o fpoor quality andnot intended for a health facility. e Budgetswere still low duringthe first year o f HSDP 11. Funds are allocated mostly to vehicle maintenance rather than to medical equipment, buildings and fbmiture. Availability of Transport for Healthcare Personnel 5.13 1 The availability o f operating vehicles inhealth facilities is one o fthe factors influencing the effective delivery of services. -130- 5.132 In1995,28 percent of the reported a number ofvehicles were non-operational. Interms o fregional distribution, the percentage o fnon-operational vehicles ranged from 18 percent for Region, three to 73 percent for Dire Dawa. This data requires careful interpretation as the number o fvehicles for regions like Oromia is underreported. 5.133 The latest HSDP Evaluations indicate that inadequate transport facilities still constrain service delivery and supervision. This is further exacerbated by an inadequate per diembudget for healthpersonnel. Utilization of Health Services 5.134 The rate of service utilization did not match the steady increase o f facilities nor the population growth rate over the five year period o fHSDP I. incidence o f consultationhas The dropped from 49.1 percent in 1996 to 43.4 percent in 1998 and to 41.1 percent in2000/01. Out patient days (OPD) consultation has slightly increased from 0.23 in2001/02 to 0.29 in 2002/03. Utilizationis less than a third ofthe HSDP goal for 2004/05 of 1.O visit per personper year. 5.135 The national average o f total health facility visits increased from 0.27 in2000/01to 0.29 in2002/03 (Table 5-29). In2000/01, bothTigray and Gambellahadthe highest visits percapita at 0.80, while Somali had the lowest number o fvisits per capita at 0.04 (although it increased to 0.09 in2002/03). Gambella's per capita visits declined sharply fiom 0.80 in2000/01 to 0.10 in 2002/03 while Tigray's declined slightly to 0.74. Table 5-29: Ethiopia: Total OutpatientVisits and Visits per CapitabyRegion, 2000101to 2002103 ata becauseo fpartial data providedby Tigray, Oromia and Amhara and unavailability of updated -131- 5.I36 Iti s difficult to do a trends analysis o foutpatient and inpatient flows over time because the readily available data obtained from 1991/92 to 2002103 are generally not presented usingthe same format and categories. Moreover, inmost years, only partial information i s available because data for different regions are missing each year. Consistency of data collection and presentation formats are important issues that must be addressedin order to improve the management information system (MIS): consistency and timelinessof reports must also be addressed, especially within the context of traininghstitutional capacity-building at the woreda level, in order to minimize reporting lags and data recoveryproblems. Reasons for Visits 5.137 Table 5-30 indicates that in2002/03, malaria, deliveries without complication, bronchopneumonia, TB, dysentery, pregnancy complications, abortion, relapsing fever, pneumonia andhelminthiasis were among the top ten major causes o fpatient admissions. Malaria is the leading cause o fpatient admissions. 5.138 Malariawas also the leading cause o f outpatient visits in2002/03. Othermajor causes o f outpatient visits duringthis period were helminthiasis, acute respiratory infection, bronchopneumonia, skin infections and gastric and duodenites. -132- Table 5-30: Top Ten Reasons for Inpatient and Outpatient Visits (2002/03)* Admissions Disease No. of cases YO Disease No.of casesI YO 1 All types of malaria 31,470 20.4 All types o f 549,632 15.5 malaria 2 Deliveries wlo 14,695 9.5 Helminthiasis 253,92 8 7.2 i I complication 3 Bronchopneumonia 6767 4.4 Acute upper 5.7 respiratory infection 2007178 4 All types of TB 6608 4.3 Dysentery 170403 4.8 5 Dysentery 4348 2.8 Gastric and II 132,638 II 3.7 duodenites 6 Other complications o f 4049 2.6 Bronchopneumonia 124336 3.5 pregnancy, childbirth & the puerperium 7 Relapsing fever 3777 2.5 Infections o f skin 117588 3.3 and subcutaneous tissue 8 Abortion wlo sepsis or 3653 2.4 All other infective 82,579 2.3 toxaemia and parasitic diseases 9 Primary atypical, other 3322 2.2 All other diseases 68733 2.3 & unspecified o f Genito-urinary pneumonia system 10 Helminthiasis 1015 2.0 Primary a typical, 74,742 2.1 other and unspecified pneumonia Total of all the above 81774 53.1 Total of all the 1,787,672 50.5 cases above cases Total of all cases 154032 100.0 Total of all cases I3,542,231 1 100.0 Note: Data fIom Oromia, Amhara and Somali are not included QUALITY OFHEALTH SERVICES Technical Quality 5.139 There is a variation in quality of care by wealth quintile, region and residence. Poor, rural women receive lower quality healthcare than rich, urbanwomen. The population-based representative data on technical quality o f care is limited. DHS 2000 collected information on seven type o f services (measurement o f weight, height andblood pressure; sampling o fblood and urine; dialogue about pregnancy complications; information about where to go for pregnancy-related complications) a pregnant women received during antenatal care, which was converted into a quality o f care index. The quality of care index ranged from zero to sevenbased on the services received. The aggregate quality of care score varies significantly by the wealth of the women: a low quality of care index existed among thepoor, while a high index existed among the rich. The quality o f care index also varied by region: Addis had the highest (5.1), while Afar had the lowest (2.0). The quality o f care index was 4.5 inurban areas while it was only 2.4 inrural areas (Table 5-31). -133- Table 5-31: Variation inQuality of Care for Maternal Health Services* by Wealth Quintile, Region and Residence WEALTH QUINTILES Score SD Poorest 2.2 1.7 2nd Poorest 2.3 1.8 Middle 2.3 1.9 2nd Richest 2.5 1.8 Richest 4.3 1.9 REGIONAL VARIATION Tigray 2.9 2.1 Afar 2.0 1.9 Amhara 2.4 2.1 Oromiya 2.5 1.8 Somali 3.7 2.3 Benishangul-Gumuz 2.6 1.8 SNNPR 2.5 1.8 Gambela 3.1 1.8 Haran 4.4 1.9 Addis Ababa 5.1 1.4 DireDawa 4.0 2.2 URBAN/RURAL Urban 4.5 1.8 Rural 2.4 1.8 *Note: Maximumof sevenpoints for seven items:weight, height,blood pressure,blood sample, urine sample, told about complications, andtold where to go for complications) Consumer/Client Satisfaction 5.140 Inthe MOWHCFIESHE Study (WTP, 2001) about 52 percent of respondentsperceived the quality of care they receivedto be good (Table 5-32). Table 5-32: Evaluation of the Level of Quality of Care in Most Recently Visited Facility -134- 5.141 More clients expressed dissatisfaction with thepublic sector relative toprivate and NGOfacilities. About 30 percent o fhouseholds47visiting a government facility ratedthe quality o f care they received to be below average. A smaller percentage o f the households that obtained care from NGOs (14% percent) and private facilities (12 percent) rated the care they received in these facilities to be less than average (Table 5-33). Table 5-33: Respondents'Perceptionof Quality by Different Providers Total 940 113 I 9 1 201 I 1,254 I 100 Source: MOH, HCF. EstimatingWillingnessto Payfor HealthcareinEthiopia.2001 5.142 The main reasons cited for dissatisfaction with the quality o f care obtained from public health care facilities are the following: (a) inconsistent availability o f drug; (b) inadequate skillshowledge and courtesy o f healthpersonnel; (c) inconvenience o f lengthyprocedures; (d) inadequate availability o fdiagnostic facilities; and(e) lengthywaitingtime. The average travel time was almost 3 hours. Waiting time between arrival andbeing seenwas also long, averaging 7 hours at government hospital outpatient departments, 6.2 hours at NGO facilities and 2.7 hours inother private facilities. Respondents considered the consistent and sufficient availability o f drugs an important indicator o f service quality. However, about 37% o f households who visitedpublic health facilities'stated that drugs were not consistently available (MOH,HCF 2001). 5.143 Separate focus group ratedprivate providers as superior to public and NGO facilities interms o fpromptness, reduced length o fwaiting times, availability duringoff-peak hours and holidays, and knowledgeable proficient at handling patients. However, private providers were also considered inferior to large government hospitals because they provided limited laboratory, x-ray and surgical services. The additional tests conducted and higher priced drugs sold at private facilities also ledto excessive charges. NGOproviders were rated favorably inregardto immediate availability o f services and andinterms o f cleanliness. 47 The household survey included 13,932 individuals in 2,473 households. About 10% of individuals surveyed reported an illness/ injury in the two months prior to August 2000 interview. Of those reporting illness, 84% sought formal treatment and 16%sought informal treatment or treated themselves. Of those seekingformal treatment, 76% went to a government facility, 9% went to anNGO facility and 16%visited aprivatefor-profit provider.Only 1%hadbeenhospitalizedinthe past 12months. 48 Three focus groups in Addis and three in Dire Dawawere conducted. Twenty-sevenfocus groups were conductedin the five other regions (Amhara, Addis, Oromia, SNNPR andTigray) with at least one focus group for everythree millionpersons, resultingin a total of 33 focus groups. 49 Knowledgeablecaregiverswere defined as being goodlisteners, courteous, respectfuland tolerant. Caregivers are expectedto beto listento patient complaintsand respondaccordinglyto their needs. -135- 5.144 Client satisfaction surveys were also conducted as part o fthe PHRD grant in 1996. When respondents were asked ifthey had ever faced difficulties inusing health services, 48.3 percent confirmed that they had indeedfaced difficulties inseeking health care: 51.7 percent reported that they had encountered no difficulties. The major difficulties cited were lack o f facilities within the institutions (42.7 percent) and lack o f funds to seek care (33.8 percent). About 23 percent said they didnot have access to essential drugs, and some mentioned the lack o f a cure for their illness as a major fi-ustration. Respondents recommended three priority areas for improvement inthe health sector (Table 5-34): 1) increased availability o f curative facilities; 2) better trained staft and 3) greater availability o f less expensive drugs. Table 5-34: ImprovementsSuggestedby Respondentsfor the HealthSector No SuggestedImprovements Frequency Percent of Total 1 Increase number of clinics, health centers and hospitals 51 52.6 2 Provide better trained staff 14 14.4 3 Make drugs available 8 8.2 4 Make drugs cheaper 7 7.2 5 Increasenumber of beds 6 6.2 6 Increaserooms within existing facilities 6 6.2 7 Provide training on prevention o f epidemic diseases 5 5.2 Total 97 100.0 Source: PHRD(Community Consultation and ParticipatoryDevelopment), 1995 CommunityParticipation(SocialAccountability) 5.145 The 1996 study on the Role o fNGOs and the Private Sector inSocial Service Delivery notes the low rate o f community involvement inhealth service activities. Only 14percent o f NGO institutions surveyed reportedhighcommunity involvement, while the rest reported low involvement. Those institutions reportinghighcommunity involvement operated village HPs andoutreach healthprograms. 5.146 Regional awareness o f HSDP components is very high. Onthe contrary, knowledge o f the various HSDP mechanisms tend to be quite limited at zonal, woreda, and health facility levels. The HSDP IEvaluationnotes that although the Program Implementation Manual provides an opportunity for community andworeda health staff to participate inthe governance o fHSDP, a low number o fthese personnels are actually involved. Efforts to improve local participation were insufficient raising community awareness andproviding stakeholders with adequate guidance. 5.147 Despite the above challenges, some good examples o f strong community involvement do exist. The HSDP IEvaluation cites one example o f an H C with strong community involvement (see Box 5-2). -136- B o x 5-2: Example of Local Community Ownership of a Health Center (HC) One HC inAddis Ababa that i s "community owned" provides a stark contrast to many government owned HCs and underscores the importance o f local ownership. The HC, situated inKebele 18 o f Woreda 5 inthe Mercato area o f Addis Ababa, was founded 22 years ago. The HC is governed by a seven member management board appointed by the community and ledby a female health officer who has served the center for almost 20 years. With an annual budget o f 700-800,000 Birr, the HC i s almost entirely self-sufficient. The entire staff (14 professionals and 12 support staff) i s paid from local revenues, but salary levels are 10-20% lower than in similar government institutions. Previously, the HC obtained some cross-subsidy from the proceeds o n the leases o f a warehouse, a local bakery and an adjacent kindergarten. Currently, only the kmdergarten brings in some additional finds. Inputs from the RHB are limited to free contraceptives, vaccines and occasionally some health learning materials and incidental training courses or workshops. However, the staff indicates a strong desire to be kept abreast o f new insights and developments in the area o f health care on a muchmore regular basis. The fill range of services o f a typical HC is provided, including a fair number o f laboratory services, but excludes DOTS therapy for TB patients. Every day 50-70 outpatients visit the center, and there are two to three deliveries per day. The HC looks very neat and is well organized, and the smiling faces o f both patients and staff members indicate a great sense o f ownership and pride. 5.148 Inaddition to the necessary training inplanningandbudgeting, adequate sensitization o f woreda and kebele stakeholders, focused on the importance o f achieving health sector development goals, must be realized inorder to ensure that the health sector goals are well- integrated into woreda development programs andbudgets. The new HSEP, and its corresponding outreach and family/community services (which will be discussed hrther in Chapter 7),provides opportunities for sensitizing communities and for a greater mobilization o f HEWSto generate community awareness andinterest inutilizing and (possibly managing) health services. -137- 6. PUBLIC HEALTHEXPENDITURES 6.1 This chapter analyzes public expenditures on healthservices. The analysis draws extensively from the Public ExpendituresReview (PER) conducted in2003 andthe National HealthAccount exercises undertaken in 1995/96 and 1999/2000. These expenditures are analyzed against private expenditure data that are extracted from the Household Income Consumption Expenditure Survey (HICES) and Welfare Monitoring Survey (WMS). It also uses information derived from the Health Sector Development Program (HSDP) reviews as well as other documents from the MOHand GOE.This chapter examines: 0 Trends inamounts allocated to health services includingpublic and private, and external andinternal sources o f fbnds; 0 Levels of expenditures on health services inEthiopia vis-a-vis current international experience; 0 Allocation ofpublic spending across the different levels of care, across regions andbetweenrural and urbansettings; 0 The actual financing mix against the FDRE's intendedmix; and 0 Extentto which resources are allocated to interventions respondingto the needs o f the poor. PublicSpendingon Health Services 6.2 Public spending on health services is very low, however bothprivate andpublic spending have been on the increase between 1995/96 and 1999/2000. Recently released official govemment National HealthAccounts (NHA) data for 1999/2000 show that Ethiopia's total health expenditure remains dramatically low. Estimatedper capita health expenditures are around US$5.6 per person, or PPP o f about US$32.7 perperson in 1999/2000, representingabout 5.5 percent o f GDP. Public spending, both domestic andfrom external sources, represents the largest share o f total spending (49 percent). Public spending amounts to US$2.77, representing 2.74 percent o f GDP per capita. However, as i s typically observed inmost low-income countries, private consumptionthrough out-of-pocket spendingalso represents a large share o f this spending (36 percent), amounting to US$1.96, about 1.9percent o f GDP per capita Per capita expenditures on health increased by 25percent @om US$AOto US$5.6) between 1997 and 2002, increasing as a proportion o f GDPper capita by about 49 percent. Bothpublic and private spendingincreased. However, public spending increased more significantly as a result of external sources. Compared to the first NHA analysis done in 1995/96, domestic public spendinghas only slightly increased (Table 6-1). -139- Table 6-2: HealthExpenditurefor Selected Countriesin SSA (1990-98);SSA average(1990-98,2000) Healthexpenditure as percent of Healthexpenditureper capita SelectedCountries in SSA 6.4 This low level of spending mainly reflects a very low resource base or GDPper capita of only about US$110 (Figure 6-1). Using comparable date from 1990-98, Ethiopia's total health spendingas apercentage of GDP (4.1 percent) is comparable to the SSA average (4.3 percent), and slightlyhigher thanthe low-income countries' (LIC) average (4.1 percent). Usingmost recent NHA data, the SSA average increased to 5.9 percent of GDP in2000 (WDI2002). This still places Ethiopia's total health spendingin 19995/96 and 1999/2000 below the recent SSA average, both inabsolute terms andrelativeto GDP. 6.5 Onthe other hand, the private health expenditure share o f GDP inEthiopia is quite high when compared to the LIC average of 1.1percent. Ethiopia's private health spending share of GDP (2.4 percent) remainedclose to the SSA average (2.6 percent) in 1990-98. By 2000, the private expenditure share o f GDP inEthiopia increased to about 2.8 percent compared with the higher SSA share of 3.4 percent. Despite this increase, Ethiopia's share of private expenditures on health compared to GDP i s much lower than Kenya's (6.4 percent) and Tanzania's (3.4 percent) (Table 6-2 and Figure 6-2). -140- 6.6 Whenit comes to publichealth spending, the contrast is more striking: Ethiopia's public health spending as apercentageo f GDP (1.8 percent) in2000 is significantly lower thanthe LIC average (3.1 percent). According to 1990-98NHA data, Ethiopiais close to the SSA average o f 1.7 percent. Yet according to revised averages from WDI 2002, Ethiopiais lower than the SSA average, placing the country thirdbehindNigeriaandUganda interms of low public spending on healthrelative to GDP (Table 6-2 and Figure 6-2). Figure 6-2: Per capitaPublic and PrivateExpenditures(as a percentageof GDP) on HealthinVarious Countries of the World 10 9 8 zU 3 n 2 1 o iI + I 0 1 2 3 4 5 6 7 8 9 10 Private expendlture on health (%of GDP) Source:WorldBank WDI, 2002 -141- Figure 6-3: Per capita Public and PrivateExpenditures(as a percentageof GDP) onHealthinVarious Countriesof the World SSA LIC Kenya Zimbabwe Tanzania Zambia Mali Senegal Ethiopia Ghana Gambia Uganda Nigena 000 100 2w 3w 100 5w BW 1 0 0 800 sw Source: WDI, World Bank, Washington, D.C., 2002 HealthSector Funding: Public and PrivateSector Contributions 6.7 Fundingo fthe health sector inEthiopiais shared equally betweenthe public andthe private sector. Based on NHA estimates, Birr 2.9 billion was spent on health services inEY1992 (1999/2000) representing about Birr46 (US$5.6) per capita (see Table 6-3). Ofthis, approximately 36 percent was out-of-pocket spendingby individuals, including direct payments to private practitioners, traditional healers, private pharmacies and government facilities inthe form of user charges. NGOs contribute a lower, but not trivial amount their contribution reaching close to tenpercent o f all health spending. On the other hand, the contribution o f private enterprises remains marginal at five percent o f total health spending(See Chapter 4 for more information on out-of-pocket spending). -142- Table 6-3: Ethiopia: National HealthAccountsData for 1999/2000 I Millions 1ShareofI BirrperpersonIUS$perperson 1 Birr Total (1999/00) Total expenditure onhealth 2,93 1 46.1 5.6 Generalgovemmentexpenditureon health 979 33% 15.4 1.87 Sources: Authors' estimatesbasedonvarioussourcesincludingNHA 1999/2000, MOH, MOF, IMF Statistics, PER2003. Figure 6-4: Ethiopia Health Spending: Source of Financing, 1999/2000 NGosand "On for Rofit hstitutions Rivateenterprises Donors I Source: Author's calculations based on PER 2003 andNHA 1999/2000 6.8 After out-of-pocket spending, public expenditures represent the largest share ofhealth spending(about 33 percent). Government revenues financedmost ofthe public health expenditures (PER2003). The share o fpublic health expenditures out o f total health expenditures has been declining inrecent years largely as a result ofhigher out-of-pocket and donor spending. It decreased from 41 percent in 1995/96, to 36 percent in 1996/97, and then to 33 percent in 1999100. -143- 6.9 External assistance and loans are the third major source o f financing, particularly for capital expenditures. In 1995/96 assistance and loans financed 10percent ofrecurrent expenditures and28 percent o f capital expenditures, or 15.8 percent o f total health expenditure~.~~ Duringthe course of HSDP Iimplementation, donor resources inthe form o floans andexternal assistanceto the health sector have increased significantly from Birr 63 millionin 1997/98 to Birr437 million in2000/01 (HSDPIEvaluationReport 2003). Despitethis increasingtrend, however, donor assistance to Ethiopia still appearsto be considerably lower than the average donor assistance received by other least developed countries (LDCs)." HealthSpendingandCurativeCare 6.10 A majority of total health spending is allocated to curative care. Table 6-4 indicates that approximately 64 percent o f total healthresources are spent on curative52care and25 percent onpromotive andpreventive5'healthcare (PPHC). Administration costs, whichmainlyrepresent those o f federal andregional health administrations, comprise eight percent o f total spending. Very few resources are spent on training (two percent) andresearch and development (one percent). Pharmaceuticals andmedical supplies constitute about 38 percent o ftotal expenditures. Households financed approximately 74 percent o fpharmaceutical andmedical supplies. Table 6-4: Expenditure by Major Functions (Amount and as YOof Total Expenditures) I I I I Birr (millions) I 1 % Share I Service Functional Classifications Delivery Expansion Total Total Administrative Expenditure 221.2 7.0 228.2 8% Curative ExDenditures 1673.4 211.2 1884.6 64% Inpatient 254.3 153.9 408.2 14% Ourpatient 295.4 57.3 352.7 12% Pharmaceuticals and medical supplies 1,123.7 1,123.7 38% I Promotive and Primary Health Care I 516.9 I 214.0 1 730.9 I 25% I Research and Development 21.5 21.5 1% Training 57.5 8.5 66.0 2% 440.8 Total 2,490.4 (85%) (15%) 2,931.2 100% 50PHRDHealthSector Synthesis Report, 1996 51According to the NHA results (MOH 2003), average per capita donor assistance received by the health sector in LDCs was about US$2.29between 1997-1999,comparedwith less than US$ 1.O receivedby Ethiopia in 1999/2000and2000101. 52 Curative care in this case is composedof inpatient and outpatient services including consultations, diagnostics and treatment usingpharmaceuticalsor other procedures. 53 Promotive and preventive care are comprised of services such as provision of vaccines for the Expanded Program on Immunization(EPI); matemal and child health including vertical programslike Family Planning, Adolescent and Reproductive Health (ARH), Integrated Management of Childhood Illness (IMCI), Nutrition and Safe Motherhood; prevention of non- communicablediseases; and Information, Communicationand Education(IEC) services etc. -145- Table 6-5: Trends inOverall Government Revenues, Ethiopia, 1980-81 to 2001-02 ~ Total Government Revenues Ethiopia Calendar 1973 1974 1975 I976 _.. . 1977 197x 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 Note: 1982E Source: EducationCSR 2004 U - 0 %* \?'?"-?-?9?\c W ~ 0 0 " P - N N - - - N I 6 0 I m I U m 0 C - 1-3s- -150- 6.19 Public spendingonhealthincreased from about 0.9 percent o fGDP inFFY1991 (EFY1983) to an average 1.5 percent o fGDPbetween 1997 and2002 (EFY1990-1994).56 From 1990/91 to 1993/94, the public health expenditure share o f total public expenditures increased from 3.1 percent to 5.2 percent. It thenremained fairly constant at around five percent from 1994/95 to 2000/015' Duringthe period 1995/96-20001/02, only an average of 4.7 percent o f public spendingwas allocated to health(Table 6-9). Table 6-9: ShareofPublic SpendingonHealthinEthiopia,l990,1995/2002 Accordingto BudgetMonitoringData (Percent GDP and Percent of Public Spending) PublicHealth 1990191 1995197 1996197 199719s 1998199 1999/00 2000101 2001/02 Expenditure EFY1983 EFY1988 EFY1989 EFY1990 EFY1991 EFY1992 EFY1993 EFY 1994 Total healthshare of GDP ' 0.88 1.18 1.22 1.47 1.5 1.09 1.47 1.5 Total public health shareof total public expenditures 3.4 5.1 5.31 5.5 5.0 3.2 4.9 4.8 6.20 Ethiopia's share o ftotal government expenditures that go to health is among the lowest in SSA. Malawi, Tanzania, SouthAfrica and Zambia allocated closer to ten percent o ftheir public spending to health, a proportiontwice as large as Ethiopia's allocation (PER2003). CapitalandRecurrentExpenditureson Health 6.2 1 The increase inhealth spending is linked to an increase inbothrecurrent andcapital expenditure. Both capital and recurrent expenditures on health have increased, although the rate o f increase o f the former i s greater than the latter (Figure 6.9). Capital expenditures increased by 553 percent over the period EFY1983 to 1994 (statistics from EFY1990to 2002) innominal terms, andby 244 percent inreal terms. The increase inrecent years (1995-2002) has been substantially less (128 percent innominal terms and 102percent inreal terms). Average capital spending per capita remained low at about US$0.45 from 1995-2002, peakingat US$0.47 per capita in2001/02 innominal terms (US$0.42 inreal terms) (Table 6-10). 6.22 However, data on capital expenditure needto be interpreted with caution. First, all donor- fundedoperations (and many government-financed initiatives organized inthe form o fprojects) are included inthe capital budget, resultinginthe inclusion of some recurrent expenditures such as drugs. Second, the capital budget does not include all project-related expenditure by donors. Third, aid-fundedexpenditures are systematically under-reported, even for those projectsthat are includedinthe budget documents (PER2003). 56 The only exception to this trendwas during the period of the Ethiopia-Eritrea Border Conflict when public spendingon health as a %age of GDP droppedto I.1 % 57 Simllar to the rest ofpublic health expendituretrends, it droppedto 3.2% in 199912000becauseofthe Ethiopia-Eritrea Border Conflict -151- Figure6-9: PublicRecurrent and CapitalHealthExpenditure Trends (1990/91-2001/02) (Current and Constant Prices) +Recurrent Public Health Expenditure - Capital Public Health Expenditure Recurrentexp. (constant pnces) ~ "- ..__. "capitalexpenditures real (constant pnces) 6oo'oo I 500.00 400.00 300.00 200.00 100.00 0.00 1990/91 1991/92 1992193 1993/94 1994195 1995/96 1996/97 1997198 1998/99 1999100 2000/01 2001/02 years Source: PER (03) data, Authors' calculations 6.23 Recurrent spendingincreased significantly by 307 percent andby 114percent inreal terms from EFY83-94 (1990-2002). Over the more recent period of EFY1999to 1994 (statistics from EFY 1995-2002), it increased by a more modest 59 percent innominal terms (42 percent inreal terms). Similar to capital expenditures per capita, the average annual recurrent spendingper capita remained low at about US$0.88 from 1995-2002, reaching US$0.91 in2001/02 innominal terms (US$O.81 inreal terms). These figures are substantially lower than the average per capita recurrent expenditures o f low income countries (US$2.50). Nonetheless, the combined increase o fboth capital and recurrent expenditures is a positive development. 6.24 However, it i s not clear whether the increase has been sufficient to ensure that facility expansion i s accompanied byneeded material and human resource inputs to provide good quality health services. For instance, the latest NHA results (1999/2000) inFigure 6-10 indicate that capital expenditures (expansion o fhealth facilities as well as equipment) comprise the largest share o f total public expenditures (27 percent). This analysis i s supported by the HSDP I2003 Evaluation findings that note that HSDP Iprovided "insufficient attention to the composition of expenditures, and strategic shifts in fundingwere not achieved. Neither were important balances, particularly between capital and recurrent expenditures, maintainedyys*.Anecdotal evidence provided inthe HSDPIreport o f 2003 points out that some newly built facilities are still not functional due to lack o f personnel. 58FMOH, 2003, Report on the Evaluation ofHSDP I,Final Report, Volume 1, pp xv. -152- Figure 6-10: Functional Breakdown of Ministry of Health and Regional Health Bureau Expenditures Health administration 0% 5% 10% 15% 20% 25% 30% I percentage share Source: MOH. Ethiopia's Second NHA Report, 2003. 6.25 Chapters 3 and 5 have shown that both physical access and quality o f services are key determinants o fthe rate o f service utilization inEthiopia. While there i s a clear needto invest in access and quality, allocating sufficient resources to both areas would be extremely difficult ina resource-constrained country. Using several different probit and logit specifications, a study by Collier et al. (2002) suggests that investmentsmade inimprovingthe quality ofhealth services inEthiopia, measuredbyamount offunctioning equipment (proxied byafunctioning refrigerator withback-up power supply); qualified staff (proxied by a nurse inregular attendance); and reliable supply o f material inputs (proxied by a regular supply of antibiotics) would have a larger impact on usage than would investmentsinfacility expansion or increasing the density o f service provision. "W N r - m ION- z.. 0 a2 Y k -154- 6.26 Table 6-11indicates that the recurrent spending share o f GDP increased by 49 percent from 0.66 percent inEFY 1983 (statistics from 1990/91)to 1.0percent inEFY 1994 (statistics from 2001/02). Duringmost o f this period, it fluctuatedbetween either 0.8 or 0.9 percent of GDP.59From 1995/96to 2001/02, the recurrent spending share of GDP increased by 16.5 percent. 6.27 The capital expenditures share o f GDP increased by about 108percent from 0.25 percent inEFY1983 (statistics from 1990191)to about 0.52percent ofGDPinEFY1993 (statistics from 2001/02). From 199996 to 2001/02 the capital spending share of GDP increased by48 percent. It droppedto 0.3 percent o f GDPinEFY1992 (statistics from 1999/2000) as a result o f the border conflict but rose to 0.57 percent o f GDP inthe following year (statistics from 2000/01). Table 6-11: Evolutionof Recurrent and Capitalexpenditureson HealthinEthiopia, 1990/91,1995/2002 (percent of public spending and GDP) PublicHealth EFY1983 E N 8 8 EFY89 EFY90 EFY91 EFY92 E N 9 3 EFY94 Var. Var. Expenditure 1990191 1995/96 1996/97 1997/98 1998/99 1999/00 2000/01 2001102 95-02 90-02 ( Y O ) ( Y O ) Capital share of 2.9 3.8 4.3 5.7 7.0 4.3 5.6 4.5 17.4 53.4 total public capital expenditures Capital of total 0.82 1.37 1.65 2.12 1.77 0.95 1.88 1.63 19.3 98.9 public expenditures Capita share of 0.25 0.35 0.40 0.58 0.56 0.32 0.57 0.52 48.5 116 GDP Recurrent share 0.9 0.6 0.58 0.47 0.32 0.24 0.32 0.32 (47.09) (65.4) of total public recurrent expenditures Recurrent share 2.5 3.7 3.66 3.4 3.24 2.29 2.97 3.13 (16.6) 23.8 of total public expenditures Recurrent share 0.7 0.86 0.82 0.87 0.94 0.77 0.9 1.o 16.5 49 o f GDP Note: 2000/01 a l2001/02 are pre-actuals; Source: Authors' calculations based on MOFED data collected by PER (2003) team and SIMA 2002 59 It also declinedIO its 1983 level (0.7 'A)duringthe BorderConflict (199912000) -155- Allocation of PublicExpenditures 6.28 Allocation o fpublic expenditures across inputshas beenstable with a slight increase in the share allocatedto wages. The Public Expenditure Review conducted in2003 shows a relativelystable distribution ofpublic spending over time (Table 6-12). Wages and salaries represent the largest itemo fpublic spending. Between 1996 and 2001,on average, wages represented about 53 percent o frecurrent expenditures, and medical supplies and equipment amounted to 19percent. Between 1996/97 and 2000/01, there was a progressive shift inspending composition, with an increase inthe percentage allottedto salaries and a corresponding decline inmaterialsandsupplies, operations andmaintenance, grants, contributions andtransfers. As a result, in2000/01, approximately 61 percent o f the recurrent budget paid for salaries, comparedto about 52 percent in 1996/97. About 26 percent went to medical materials and supplies, including medical supplies and equipment (about 16percent) in2000/01,lower than the 1996/97 shares o f 31percent and20 percent, respectively. Table 6-12: Ethiopia: Composition of Recurrent Expenditures, EFY 1989-1994 (Statisticsfrom 1996/97-2001/02) Birr inThousands RecurrentExpenditures Share EN1989 EFY1990 EFY1991 EFY1992 EFY1993 Share Average (Yo) (1996/97) (1997/98) (1998/99) (1999100) (2000/01) (Yo) 1993 1996- EFY1989 (2000/01) 2001 1996/97 By Inputs Wages and Salaries 51.6 190,023 213,010 235,106 234,658 282,854 60.5 53.05 Operation and 8.0 29,439 31,947 80,48 1 61,972 34,3 18 7.3 10.6 Maintenance Materials and Supplies 31.2 114,685 138,767 154,854 101,932 120,739 25.8 29.0 Medical Supplies and 20.0 73,721 96,043 107,394 61,344 76,847 16.4 19.0 Equipment Petrol and Lubricants 1.5 5,374 7,146 8,477 6,789 7,991 1.7 1.6 Other Materials and 9.7 35,590 35,577 38,983 33,799 35,902 7.7 8.3 Supplies Grants, Contributions, 8.0 29,260 17,684 33,036 27,561 23,772 5.1 6.0 Other Transfers Motor Vehicles & 1.3 4,625 6,213 5,627 3,007 5,705 1.2 1.1 Equipment By Function Administration 17.9 65,977 90,863 167,547 131,683 95,984 20.5 24.83 Health centers and 30.2 111,229 118,022 121,775 106,747 142,186 30.4 27.6 Clinics Hospitals 37.7 138,729 157,032 172,561 144,791 177,854 38.1 36.3 Other 14.2 52,099 41,704 47,221 45,909 51,364 11.0 11.07 By government level Regional 82 301,761 332,626 404,590 351,177 408,672 87.4 82.5 Federal 18 66,273 74,994 104,5 14 77,953 58,716 12.6 17.5 Federal Share (%) 18.0 18.4 20.5 18.2 12.6 TotalRecurrent 368,033 407,621 509,104 429,130 467,387 100.0 Expenditures Note: Actuals for 1996-19! ,pre-actuals for 1999/2000and 2000/01 Source: PER 2003 based o MOFED data; Authors' calculations -156- 6.29 National level fundinghas also increased for medicines from Birr 60 million inEFY89 (statistics from 1997/98) to Birr 245 million inEFY94 (statistics from 2001/02) (Table 6-13). Domestic revenue financed a significant percentage o f that increase, from 60 millionbirr in EFY89 (accounting for 100percent o fdrugspending that year) to 104millionBirr inEFY 1994 (accounting for 40 percent of drug spendingthat year). The remaining 60 percent (141 million Birr in 1994) was financed through IDA funds and donations to the Pharmaceutical Administration and Supply Services (PASS).60 Per capita expenditures on drugs, however, are still significantly lower (US$0.44) thanthe HSDP target o f USSl.25. Table 6-13: Data onBudgetandExpenditurefor Procurement of Drugs and MedicalSupplies in the Ethiopia Public HealthSector, EFY 1989-1994 (Statistics from 1997-2002) 6oBased on HSDP IEvaluation Report 2003. As noted in previous sections, the total amount spent on drugs is underestimated because it does not account for donor funds that pass through other channels f I I -158- PublicExpendituresandHospitalPrograms 6.30 A large share ofpublic money has been consistently allocated to hospital care (compared to lower levels ofcare). InEFY93 (statistics from 2000/01), the government spent Birr 178milliononrecurrent expenditureinthe country's 80 public hospitals; while it spent only Birr 142million at the primaryhealthcare level. Similar to recurrent expenditures, over-all capital expenditures are also skewedtowards investments inhospitals, with about Birr 61million spent on hospitals inEFY92 (statistics from 1999/00) compared to only Birr 26 million for primarycare facilities. (See Table 6-14 andFigure6-11). 6.3 1 On the other hand,funding for basic immunization services appears to have declined over the lastpveyears. Fundingfor vaccines was reportedto be Birr 20 million (or less than seven percent o f government recurrent health expenditures) inEFY89 (statistics from 1997/98) and, except for EFY92, it hasbeen evenlower inevery year since. InEFY94 (statistics from 2001/02), expenditures on vaccines was only Birr 13 million, representingless than three percent of the government's recurrent health expenditure. It ispossible that vaccines financed by external agencies inthe capital budgethave to some extent substitutedfor domestic funding, but the available data make it difficult to draw conclusions (PER2003). The non-availability of funds for fuel and per diems was frequently cited duringvisits to some HCs andHPs as the major constraint inprohibiting more children from obtaining vaccines (HSDP 2003). In2001, several activities, including training, outreach, social mobilization andmaintenance, hadto be postponedor cancelled. Inorder to partially addressthis issue, in2002, the central government approved a budget line for EPIinthe MOHaccounts. The budget line is expected to provide a basis for tracking expenditures, analyzing trends, and advocating for more funds. The following three areas will require special attention: (1) reporting against budgets; (2) budget development based on a realistic assessment of available resources; and (3) the financial sustainability o f future program strategies (Candries and Stevenson, 2002). EFY19890 EFY1990 EFY1991 EFY1992 EFYl993 Share Average (1996/97) (1997/98) (1998/99) (1999/00) (2000/01) EFY1992 1996-2000 (1999/00) By Function Health Stations (clinics) 36057 54425 36524 7032 NA 4.7% 13.2 Health Centers 80331 65859 36636 19490 NA 13.0% 21.1 Hospitals 73478 93079 76763 60672 NA 40.6% 38.2 Training Institutions 9601 8051 3211 4811 NA 3.2% 3.1 Support Services 21180 19343 14660 53241 NA 35.6% 19.2 Various Health Programs 22654 10822 11464 4292 NA 2.9% 5.1 By GovernmentLevel Regional 224101 238851 174242 147410 NA Federal 19199 12727 5015 2128 NA Federal Share (%) 8 5 2.8 1.4 Total Capital Expenditures 243,300 251,158 179,257 149,538 -159- 6.32 This pattern o fhigher spending on tertiary and secondary healthcare (about 40 percent) than on primaryhealthcare (PHC) i s often observed throughout the world. The Ethiopian case i s not the most extreme; many countries spend sixty percent and more on hospital care. Giventhat most of the diseases that impose a heavyburden on Ethiopians are those that can be prevented or treated on an outpatient basis through PHC facilities, it is likely that additional resources channeled to PHCwill have a larger impact on healthoutcomes than funds directed to hospital level care. The government budgets since EFY1994 (statistics fiom 2001/02) have projected a shift inemphasis toward primary level care. Itwill be important to monitor whether future actual primarycare and HSEP expenditures reflect this shift inemphasis. 6.33 The 1999/2000NHA report also states that shifting resources to primarycare would also require a well articulatedhospital financing strategy. This strategy would need to clearly outline a planto improve the efficiency ofhospital management so that more funds could be released to PHC. Decentralization 6.34 Decentralizationto the regionshas deepened, but challenges remain regarding budget execution and improvement o f health outputs and outcomes. The public expenditures review also confirms the trend towards decentralization. The share o f public funds spent inthe regions has increased over time relative to the share at central level. Regional recurrent shares have increased from 82 percent in 1996/97 to 87.4 percent in2000/01. Regional capital expenditure shareshave also increased from 92.1 percent in 1996/97 to 98.6 percent in 1999/2000. 6.35 The MOHPPD data indicate a similar proportion o ffederal-to-regional shares interms o f recurrent expenditures. The federal level receives 12percent o f the recurrent spendingbudget and spends 15 percent o f total recurrent expenditures. However, it is interesting to note that while the federal share of capital expenditures is about five percent o fthe total capital budget (Birr 55.7 million of Birr466 million), its actual shareinterms o fcapital expenditures was 69 percent (Birr 210 millionofBirr 305 million) in2000/01. A similar patterni s noted for 2002/03. It will be importantto verify what the MOH's rationale is for spending substantially beyond its capital budget allocation inbothyears. SpendingRates and Budget Execution 6.36 Spendingrates are low in all regions,justijjing the reluctance of thegovernment to increasepublicfunding for health. Budget execution is also very much aproblem. HSDP data show slow budget execution rates (Table 6-15); except for some regions such as Addis, Amhara andGambellathat spent at least 92 percent o ftheir respectivebudgets inEFY 1994 (statistics from 2001/02). A few regions such as Oromia, Afar andTigray have either exceeded their budgets or fully depleted them several times between 1996/97 to 2001/02. However, these are exceptions. -160- Table 6-15: Budget ExecutionRatesby RegionEFY 1989to 1994 (Statistics from1996/97-2001/02) I Expenditure/Allocation(%) EFY1989 EFY1990 EFY1991 EFY1992 EFY1993 EFY1994 Region 1 1996197 1 1997/98 1 1998/99 1 1999/00 2000/01 1 2001/02 1 Harare 90 67 53 52 n.a. Oromia 100 91 I 90 I 57 55 54 Somali 90 60 I 52 I 62 46 30 Tigray 76 99 I 91 I 133 67 88 ISource: HDSP IEvaluation 2003 6.37 Disaggregatingregional expenditures by capital andrecurrent categories, it is interesting to note that in2002/03 (Table 6-16), with the exception of Afar, all of the regions performed significantly better inspending their recurrent budgets (compared to their capital budgets). Table 6-16: Budget ExecutionRates: Recurrent and Capital by Region, 2002/03 Tigray 99 25 78 -161- 6.38 Table 6-17 examines national level budget executionrates byrecurrent and capital categories over a 10-year period. With the exception of three years (1992, 1998 and 2002), compared to the capital budget, a significantly larger percentage of the recurrent budgethas been spent. This could meanthat capital needs relative to implementation capacity tendto be overestimated, andor there could be factors such as donor processes which impede faster execution o f capital budgets. Table 6-17: National Level Recurrent and Capital Budget ExecutionRates, 1992-2002 Year Recurrent Capital 1992 96 98 1993 86 33 1994 93 53 1995 92 59 1996 92 71 1997 104 78 1998 95 214 1999 98 49 2001 95 47 2002* 52 58 6.39 The other potential causes o f general underspendinginclude inadequate capacity for program planninghudgetingand management at the regional, zonal andworeda levels. The problem o funderreporting could also be a contributingfactor. The PER (2003) mentions that donor inflows tendto be overestimated inthe budget at the beginningo f the year and underreported when it comes to actual expenditures. Thus the gap between budget estimates and actual expenditures seems larger than it actually is. There is also the needto adequately orient zonal and woreda stakeholders to health sector development goals andmotivate them to give priorityto improvingthe implementation o fhealth interventions. This point i s discussed in sub-section 6.67, as well as inChapter 5. Regional expenditures vary widely 6.40 In2000/01, per capitaexpenditures across regionsrangedfrom Birr4.7 (US$ 0.55) in Somali to Birr 45.3 (US$5.3) inGambella. The highspending rates inBenishangul-Gumuz, Gambella and Harari result from the fact that although these regions are small and not densely populated, they incurhighadministrative overhead costs. 6.41 Expendituresper capitainthe three urbanregions (AddisAbaba, Dire DawaHarari) are also comparatively highbecause these regions have a relatively large number o fhospitals and serve as referral points for service seekers from other regions. Per capita expendituresinAddis, while highrelative to a number ofregions, seem relatively lower than expected given its income and level of development. However, this could also be a function o f its proximity to central level facilities, resulting in a reducedneed to spend money on facilities and operating costs. -162- 6.42 The most populatedregions, such as Amhara, SNNPR and Oromia, also haverelatively lower per capita health expenditures. Among those highlypopulated yet ruralregions, however, Tigray stands out as allocating the most money on healthon a per capita basis. Table 6-18: RegionalHealthBudget,Expenditures(in Birr 000) andper CapitaExpenditures2000/01 and 2002/03 Per Capita Per Capita Region Budget Expenditure expenditures Budget Expenditure expenditures Addis 115,660 56,550 18.5 149,800 78500000 28.8 Harari 17,230 7,440 44.8 15,500 11,400 64 DireDawa 16,090 6,110 18.5 19,900 11,800 33 Gambella 27,070 9,790 45.3 20,300 13,600 59.6 Ben- 27,100 16,100 27.8 Gumuz 33,490 12,130 22 Tigray 93,320 52,240 13.8 95,600 74,900 18.7 Oromia 298,190 133,870 5.8 542,800 143,300 5.9 SNNPR 219,560 69,830 5.4 186,000 54,100 4 Amhara 193,300 81,900 4.9 263,700 93,500 5.3 Afar 41,830 22,710 18.3 60,100 16,200 12.5 Somali 69,180 17,980 4.7 53,100 27,500 6.9 Note: Regions ranked from most developed (Ac .s) to least developed (Somali) base on GOE development index fexdained inAnnex 5.1 Soiree:PPD/MOH. Health and Health Related Indicators. 2000/01. I 6.43 Similar expenditure patterns are observed inEFY 1994 (2001/02) and EFY (2002/03). In2002/03, for example, amounts at less thanBirr7 inSNNPR, Somali, Amhara andOromia were spent comparedto over Birr 59 inGambella and Harari. 6.44 Regional differences also exist with regard to their allocation o f recurrent expenditures across line itemdinputs. For example, expenditure shares o f materials and supplies range from a low nine percent inSNNPR to about 40 percent inGambella. Expenditure shares for operations maintenance is also low, ranging from four percent inSomali to 11percent inAddis. It has been noted that many external agencies finance drugs and supplies via the capital budget. This could explain the regional variations. However, the percentage o fthe total expenditures allocatedto wages remains highacross regions, rangingfrom 51percent inAddis and Gambella to 79 percent inS"PR (Figure 6-12). -163- Figure 6-12: Ethiopia: Compositionof RegionalRecurrent Expenditures(2000/01) 1 Purchaseof Motor Composition of Regional Recurrent Expenditures Vehicles and Equipment I 100% OGrants, j Contributionsand Other Current 75% Transfers HMaterialsand Supplies 50% Operation and 25% Maintenance ClWages and Salaries Source: PER 2003 6.45 The HSDP IEvaluation indicates that in the larger regions (Tigray, Amhara, Oromiya and SNNPR), 21-39 percent o f total spending was devoted to facility construction and/or rehabilitation; 30-44 percent was spent on operating expenditures; and less than three percent was spent on HRdevelopment. Tigray's Success: Expenditures to Results 6.46 Ithas beenreportedthat Tigray has beensuccessful intranslating public health expenditures into results. Table 6-19 provides average per capita spendinginthe sector by region from 1997-2002 usingselected indicators. Similar to the expenditure patterns observed above for 2000/01and 2001/02, spending has beenhighest inBenishangul-Gumuz, Gambella, Harari, Dire Dawa andAddis Ababa. On the other hand, expenditure per capita is relatively low in Somali andinthe three largest regions (Oromia, Amhara and SNNPR). All regions6' have improved their potential health service (PHS) coverage, indicating an increase in infrastructure/facilities. 6.47 However, in many cases, the increase in PHS coverage did not translate into actual increases in services, Le., an increase in immunization coverage or in attended deliveries. In fact, the national immunization coverage declined by 31 percent, and the national average for attended deliveries decreased slightly. Comparing immunization and attended delivery indicators to per capita spending, those regions that spent more did not necessarily improve their health Performance. For example, immunization coverage in Benshangul and Harari declined, while attended births only marginally increased for both regions, as well as for Gambella. The three largest regions (except Tigray) display similar low levels of performance o f public funds (only Birr 6.0 to 7.0 per capita) usedto finance their health services. Addis did nothave its PHSfigure -164- 6.48 Tigray andAfar also bothhaveper capita spending levels that are greater than the national average andmore than double that o fthe largest regions (Amhara, Oromia SNNPR). Butdespitehigher levels ofspending, Afar's already low EPIcoverage declined from 12to four percent while its attendeddeliveries coverage increased marginally to 2.8 percent, which was below the national average o f 9.7 percent. (HSDP IEvaluation 2003). Tigray appears to be the most successful in translating resources into high impact health interventions. Its immunization coverage increased and i s significantly higher than the national average. The coverage o fpregnant women by attended deliveries i s the third highest among all the regions, andTigray has the highest FLHW-to-population ratio inthe country as well. The region also has strong community-based organizations. InTigray, staffing and equipment are determinedbased on the location o f a facility; i.e. more surgery related staffwould be deployed inremote HCs than inurbanones. Table 6-19: Relation Between Average per Capita Spending (in Birr) byRegionEFYl990-1994 (1997/98 to 2001/02) and some selectedCoverage Indicators at Baseline (EFY 1989,1996/97 ) and inEFY 1994 (2001/02, end HSDPI) Attended delivery 1996197 2001102 1996/97 2001/02 1997/98 2001/02 Actual CapitalSpendingandthe HSDP 6.49 A larger amount o ffundingcomprises actual capital spendingthan the HSDP originally had anticipated. The HSDP Review underscores the disparities between the actual composition o f expenditures under HSDP implementation as opposed to those projected inthe HSDP plan. A completeset of data was availablefor six regionsfrom EFYI990 to 1993 (statisticsfrom I997- -165- 2001), which showed that actual spending on the rehabilitation and expansion of health facilities was significantly higher thanplannedfor in the HSDP. Inthree regions, Tigray (41 percent), Amhara (26 percent), SNNPR (40 percent), capital spendingwas significantly higher thanplanned HSDP expenditures by about 18 percent, 17 percent, and 33 percent, respectively. On the other hand, expenditureson HRdevelopment, pharmaceuticals, health service delivery and quality o f care havebeenrelatively low inall these regions. 6.50 The need to achieve an adequate balance between the expansion andmaintenance o f acceptable delivery standards has beendiscussed extensively duringboththe HSDP Mid-term Review (2001) andthe Overall Review (2003). Coveragelevels in Ethiopia remain low, and given the needs of thepopulation, the expansion targets are not overly ambitious. Yet it will be important to ensure that the recurrent budget will be sufficient to keep up withfacility expansion. 6.51 Discussions with RHB staff during field visits indicate that two factors have contributed most significantly to the financing ofHSDP Ioutside o fthe intra-sectoral priorities set out inthe Program. The first is HSDP's inadequate integration o f the planning andbudgeting processes;62 andthe second is the development of a costing expenditure system that isbased onhistorical expenditure trends rather thanon strategic directions outlined inthe HSDP (HSDP IEvaluation 2003). 6.52 Given the limited available resources, it will be necessary to determine more efficient ways of delivering health services. For example, firther construction o fHPs need to be accompanied by parallel training ofhealthworkers inorder to adequately staff these facilities. In the process o frethinkingthe delivery o fhealthservices, itwill benecessary to re-examine the nature of services offered inorder to make them more responsive to the needs and demands of the population. Inthis regard, the health extensiodcommunity outreach program is a welcome complement to the facility-based services that have beentraditionally offered by the public health system. Donor Funding: 6.53 From 1997-2001, the health sector received a yearly average o fUS$57 million; 9.5 percent ofthe total aid that is available to the sectors (Table 6-20). Meanwhile, agriculture receivedthe highest share o f annual aid at 16.2 percent (US$85 million).However, donor funding is difficult to accountfor because it has traditionallyflowed through extra-budgetary channels. External assistance travels to the government system along three pathways. Loans are includedinthe budget andinthe accounts. Inaddition, most budget supported non-eannarked grants and some other grant hnds are included inthe budget. This is usually done on the basis of commitments presented by donors duringbudget preparationthat are often not reflected inthe government account. Lastly, an unknown amount o f donor funds are providedin-kind. These resources are usually not captured inthe budgetprocess. All extemal technical assistance, direct 62The health budget has been developed using four separate processes: recurrent budget, capital budget financed through treasury resources, capital budget financed through loans and extemal assistance, and off-budget resources. It has been difficult to relate annual HSDP outputs and budgets with these three processes, especially since the budget process has generally been done one based more on incremental increases based on historical requirements rather than having sufficient analysis o f resource requirements. The overall FDRE budget process is also usually based on a one-year time frame while HSDP is planned over a five-year period (HSDP Review 2003). -166- procurement o f pharmaceuticals, transport and equipment for hospitals provided by donors directly are examples o f off-budget donor assistance. (HSDP Evaluation, 2003).63 Table 6-20: Sectoral Distribution of Aid inEthiopia: Average 1997-2001andMostRecent Year Sector Average 1997-2001 2002 (est.) (US$ millions) (US$ millions) Agnculture & Natural Resources 85 16.2% 81 8.1% Transport 80 15.2% 148 14.9% Multi-sector & Area Development 64 12.2% 114 11.5% Health 57 10.9% 109 11.O% `Economic Management' (Primarily 55 10.5% 291 29.2% 6.54 Off-budget fundingenables donors andrecipients to avoid the government's financial procedures (often considered cumbersome) as well as the regional offset (HSDP IEvaluation 2003). However, these contributions are often difficult to track. For example, the government has only partial information on the actual level o f spendingbecause public spending on medicines is largely done with donor funds. As a result, the GOE's ability to accurately determine whether it i s allocating too much or too little o f its own budget for a specific item or budget category is affected. The ability o f regional and woreda level officials to effectively plan byassessingthe amount o fmoney actually available and/or beingspent is diminished Off- budget donor supported programs have also not beentaken into considerationinthe planning process for determing future recurrent costs. Finally, having incomplete expenditure and budget information also affects the assessment o f health sector performance as the lack o f information influences various indicators for analysis, including expenditure per capita (HSDP Evaluation2003 and PER 2003). Cost Recovery Revenues 6.55 Cost recovery does not represent a large share ofpublic health system revenues. Cost recovery has beenpart o f the Ethiopia's health system since the early 1950s. At both government andnon-government facilities, users pay for registration, medical certificates, diagnosis, dental and ophthalmologic services.@Nominal amounts are charged, ranging from small fees (Birr 1to 5) for outpatient registrations, consultations, laboratory tests, and other routine diagnostic procedures, as well as inpatient beds; to higher fees (Birr 10 and above) for prescription drugs and inpatient surgical procedures. 63Note however that this information excludes a number o f sector-specific aid operations that are financed off-budget andor incompletely reported. 64PHRD Health Sector Synthesis Report, 1996. -167- 6.56 Patients canbe exempted ifthey obtain a free paper from their kebele certifylng that they are too poor to pay. Certain services are also free, includingtreatment o f tuberculosis, family planning, and childhood immunizations. Criteria for grantingfree healthcare services is principally based onthe direct monthly income o f the individual. (However, this criterionhas changed over time). Currently, anyone with a monthlyincome of less than Birr 105 would be eligible (MOH/HCF/2001). As a consequence, the majority o fpatients visiting government facilities pay nothing. However, some poor people may still be dissuaded from using services because they have to pay a token amount for services (about Birr 0.50 or Birr 1.O), and must invest time inobtaining the exemption. 6.57 No changes were made to this policy until 1998, with the initiation o fthe new Health Care andFinancing Strategy. When originally introduced, fees recovereda substantial portion of the total costs o f providing the services. However, the level o f fees remained unchanged for almost 50 years, and today it has become almost symbolic. Table 6-21 shows that about 60 percent o f users received a fee waiver and about 66 percent obtained full exemptions (FMOH2003). As aproportiono fGOEhealth expenditures, fee remittancesto the MOFhave declined from 16percent in 1986 to less than six percent in 1995/97. Table 6-21: Proportion of Free Patients to Total Patients and Estimated Foregone Revenue by Health Facility Type of Health Total Number of Percentage of Waived Revenue Foregone Facilities patients Patients (000 Birr) Hospitals at zones 139,648 73 616.9 Hospitals at the 143,874 73 967.1 regional capital Subtotal 283,522 73 1,584.1 Health Centers at zones 163,501 51 176.6 Health centers at 128,517 71 1,240.8 regional capital Subtotal 292,018 60 1,417.4 Grand Total 575,540 66 3,001.6 6.58 Fee totals are traditionally small, yet even these small amounts could make a difference inrecoveringfacility costs iftheywere reinvested. However, usually they are not reinvestedto improve services at point o f deliverybecause the fees are not held at the facility level. With the exception o f SPs and some hospitals inSNNPR, all fees collected are remitted to Regional Finance Bureaus, then forwarded to the MOF, which accounts for them as general government revenues. 6.59 Interms of insurancemechanisms, in 1996, there was only one state-ownedinsurance company that covered 11,000 workers and operated inconjunction with workmen's compensation programs (PHRD Health Sector Synthesis Report, 1996). At present, aside from the government-owned insurance company, there are seven additional private insurance companies inEthiopia (NBE 2000). -168- PublicSpending andthe Poor 6.60 The poorest segment ofthe populationbenefits little from public spending, although utilization o f services i s low across all income quintiles (Table 6-22) (DHS, W M S 2000). The rich-to-poor ratios interms o f utilization are lowest for HPs and health stations/clinics (0.2 and 0.5 respectively), slightly higher for HCs, andhighest for hospitals (about 6.0). Itis interesting to note that the largest shares o fpublic capital andrecurrent expenditures were allocatedtowards hospitals (approximately 40 percent and 38 percent, respectively) in2000/01. 6.61 Based on the latest available data,65the capital expenditure share for health statiodclinics was only about 5.0 percent in 1999/2000. Perhapsthis relatively low figure is a result o f the FMOH's decision to phase out HSs as part o f the move from the six-tier system of health service delivery to the four-tier system. However, HCs also represent a low percentage share oftotal public capital expenditures (13 percent for 1999/2000). The combined share o fPHCUs (HCs, clinics and HPs) interms o fpublic recurrent expenditures was about 30 percent in 2000/01; 38 percent lower thanpublic recurrent expenditures allocated to hospitals. Various healthprograms only represent a very small share of total capital andrecurrent expenditures. 66 6.62 There are marked differentials by income quintile across households regardingthe use o f basic health services. The poorest households consistently have the lowest utilization rates for immunization, assisted deliveries and antenatal care by a trained professional. The richest to poorest ratio (27.0) is highest for the use o f assisted deliveries. About 24 percent o fwomen in the richest households havehad an assisted delivery comparedwith less than one percent of women inthe poorest households. Nonetheless,it is important to note that while income differentials with regard to access are high, absolute levels of use are still low even among the richest households. There is a clear need for improved access to basic health services for young childrenandmothers. While some incremental increases could result from allocating a larger proportion of expenditures from hospitals to PHC, over-all publichealth expenditureswould need to be increased to improve the quality andaccessibility o f health facilities at all levels. Table 6-22: Use of Health Facilities and Services: National Data per Income Quintile I Q1 I Q2 I Q3 1 Q4 I Q5 I Richest toPoorest I Source: WMS, PER03, DHS2003 65Recurrentexpenditure data were available for 2000/01, but capital expenditure data was only available for 1999/2000. 66The recurrent share of various programs i s not as easy to calculate because it has been combined in the "others" category, which has a total share of 11% ofrecurrent spending. -169- Woreda Decentralization: Preliminary Experiences and Issues 6.63 Experiences related to decentralization at the woreda level are still relatively limited. Based on the available information, some transitional issues have emerged as a result o f the rapid decentralization, which commenced inJuly 2002. These issues are mostly relatedto the rebalancing o f allocations; lack o f clarity on responsibilities and expenditure assignments; and budget formulation and reporting. 6.64 Theblock grants were mainly based on apopulation-based formula and did not necessarily correspond to existing obligations. For example, more developedworedas have large numbers o f facilities such as schools andhealth facilities as well as additional administrative staff per capita; inthese cases the block grant was insufficient to cover their operating costs, particularly the staffwages. Onthe other hand, less developed woredas have fewer facilities; tend to have a number o f empty positions due to difficulty inattracting staff; and therefore incur less recurrent costs. According to the PER (2003), the regions are addressing these issues pragmatically through "rebalancing as well as certain ad hoc arrangements and contingency hnds." However, inmany cases, the transfers are only able to cover recurrent expenditures, mainly salaries, thereby increasingthe risk o f unfunded mandates (especially incases of service coverage expansion). For example, inOromia, the block grant allocated for woredas is insufficient to handle the resource needs o f the various sectors. Ifnot addressed, this shortage o fresources could hinder the achievement o f the MDGs (Okubagzhi HSDP Trip Report, 2003). 6.65 The woredas alsoface capacity constraints that tend to increase the gap between budgets and actual spending. MOFEDdata indicate that budget execution was only 80 percent in2000/01, chiefly due to lags incapital spending (PER2003). HSDP IEvaluationdata show that halfo f the regions have budget execution rates below 70 percent. Problems inthe planning and implementation of investmentplans, inaddition to difficulties inutilizingdonor funds, are cited as the principal reasons for low execution. Capacity constraints can also exacerbate reporting lags. Prior to woreda decentralization, significant delays inreporting on sectoral allocation o fbudgets and actual expenditures existed. For example, even by 2003, reporting on actual expenditures by program and sub-item were only available for 1999/2000, which constitutesa lag o f three years. Thus, efforts need to be made to improve partial reporting (PER2003). 6.66 The costs of the additional staffing and infrastructure, which would strengthen the capacity o f woredas to be able to manage their new responsibilities, could be substantial. While the need for institutional strengthening is expected and understandable, there is a risk that this type o f reinforcement might come at the expense o f the strengthening o f essential services such as education or healthcare (PER 2003). 6.67 Another issue to be addressed is the assurance o f the achievement o f national goals within the context of decentralizationto the woreda level. Adequate sensitization o fworeda stakeholders to these goals and to the importance o f achieving them must beundertaken. This becomes particularly important based on the HSDP IEvaluation (2003), which notes that both zonal and woreda level stakeholders were not well informed about HSDP goals. Moreover, capacity buildingactivities interms o fplanning, budgeting and monitoring/supervising must be -170- provided to woreda administrators. Inmoving forward it will be important to ensure that sectoral priorities are achieved, particularly interms o f reaching the MDGs. Inthis regard, some benchmarks should be set focusing on keyperformance indicators with incentives for accomplishment. The SNNPR region has moved forward inthis areaby creating performance contracts for its woreda councils based on a set o f core indicators (CSR February 2004 mission). Futurebudgets for the woredas, as well as pay increases for the woreda council members, are related to woreda performance interms o f these key indicators. Tigray has also established some performance incentives. It will be important to learn from these regional experiences, as well as continue to identify strategies being developed by other regions. Box 6-1: Examples of Early ExperienceswithBlockGrants -171- 7. SPENDINGMORE. SPENDINGBETTER. THE COSTAND POTENTIALIMPACT OF ALTERNATIVE SERVICE DELIVERYOPTIONS FOR HIGHIMPACT INTERVENTIONS INETHIOPIA 7.1 This chapter evaluates the potential cost and impact o fthe country's efforts to strengthen the contribution ofhealth services to achievinghealth outcomes inthe context o f the National Strategy for Development and Poverty Reduction(SDPRP). Inparticular, the chapter examines the potential cost andimpact o f increasing the coverage o fhighly effective preventive and curative health interventions for rural and poor households inaccordance with current and envisioned health service delivery strategies andpolicies. Specifically, the following questions are addressed inthis chapter: e How much extramoney would beneeded to increase the effective coverage o f highimpact health services interventionsfrom the current levelto meetthe HSDP I1target, andthen further to achieve the 2015 MDGtargets? e What results, interms o fthe reductioninchild andmaternalmortality, couldbe expected (on the basis o f the most recent knowledge available) from the disbursement o f these extra funds? 7.2 To respondto these questions, this report initiallyrelied on the MarginalBudgetingfor Bottlenecks (MBB)Tool6'developedby the World Bank, UNICEF andWHO,"8and also validated the results through national and international expert opinion groups and compared the findings with the outcomes o f other studies. 7.3 The MBB, an analytical costing and budgeting tool assisting policy makers to plan and manage healthprograms, helped to: e Guide a country-based process o f identification o fbottlenecks to the successful service delivery o f highimpact interventions; e Calculate the incremental cost o fremoving systemic and intervention-specific bottlenecks to achieve effective intervention coverage; and a Estimate the potential impact o fhealth interventions on health outcomes, such as rates o f child and maternal mortality, HIV/AIDS and malaria-associated mortality. Applying the MBBTool in Ethiopia: Process and Methodology 7.4 The MBB study inEthiopia builds on the collaboration among teams from the World Bank,UNICEF, USAID, WHO andthe EthiopianGovernment. The exercise was ledbythe PlanningDepartment (PPD) of the Federal Ministryo f Health(FMOH) with the participation o f various FMOH departmentdteams including FamilyHealth, TB Control, HIV/AIDS Control, the ''The fact that MBB focuses on marginal and incremental cost and impact makes it a particularly helpful tool to estimate the extra efforts and resources needed to reach the MDGs. Refer to annex 2 for a description o f the MBB approach and tools -172- Health Services ExtensionPackage (HSEP), as well as the Health Care Financing and Health Service secretariats. The USAID-fundedEssential Services for HealthinEthiopia (ESHE) project played an essential role inproviding technical support to the MBBEthiopia project. 7.5 Numerous work sessions were heldto discuss the achievements and constraints inthe health sector and to collect health intervention coverage baseline and cost data needed for the MBBanalysis. TheMBBanalysis relied on existing information at the country levelincluding survey data (DHS andEthiopia Welfare Monitoring Survey) and government documents (program reports, actionplanetc.), especially HSDP I1documents. Additional information from studies outside Ethiopiawere also used when Ethiopia-specific information was not available. 7.6 The analysis followed five main steps: (a) Define the highimpact health interventions, which, ifusedmore frequently by Ethiopianhouseholds andmade more accessible to a larger number o f affected populations; would likely lead to improved health outcomes (based on most recent national and international epidemiological evidence andnational policies); (b) Identify existing and planned service delivery strategies that would improve not only provision, but also demand for the interventions; (c) Identifybottlenecks hamperingthe implementation o f these service delivery strategies; (d) Set health coverage boundaries, i.e. identify how far service delivery can go; and (e) Estimate the potential impact and cost o f various health service delivery options. Step 1:IdentifyHighImpactInterventionsthat Needto be Strengthenedinthe Ethiopian HealthServicesDeliverySystem 7.7 The recent Lancets9series on child survival and newborn health70has re-directed attention to the field o f child health. One o fthe contributions o f the Lancet papers i s a meta-analysis based identification o f health interventions which have been scientifically proven to be effective inreducingchildmortality. A similar effort hasbeenmadebythe WorldBank, WHO and UNICEF inreviewing the literature on the efficacy o f interventions to reduce maternal mortality on the basis o f a Cochran analysis. Evidence from the Roll Back Malaria Partnership and UNAIDS" was usedto identifyeffective interventions for malaria andHIV/AIDS. 7.8 Onthe basis of these meta-analysis reviews and discussions with the FMOH, a list o f Ethiopia-specific potential highimpact intervention activities was defined. The selection criteria for health interventions included knowledge on the efficacy o f MDG-related health indicators; Ethiopia's epidemiological profile; the country's current health policy; andrecent 69Lancet. 2003 Child Survival:361,362 70Lancet, 2005, forthcoming 7'Key references used for this analysis inaddition to UNAIDS guidelines included : 1. Kahn, JG and E. Marseille (2000). "Fighting global AIDS: the value of cost-effectivenessanalysis." AIDS 14(16): 2609-10; 2. Marseille E, Hofmann PB, and Kahn JG. HIV prevention before HAART in sub-Saharan Africa. Lancet. 2002 May 25;359(9320):1851-6. 3. Weidle PJ, Malamba S, Mwebaze R, Sozi C, Rukundo G, DowningR, Hanson D, Ochola D, Mugyenyi P, MerminJ, Samb B, Lackritz E.Assessmentof a pilot antiretroviraldrug therapy programme inUganda: patients'response, survival, and drug resistance. Lancet. 2002 Jul6;360(9326):34-40. -173- implementation experience. Most interventions examined were already recognizedinthe country's national policy. Other interventions were not, butwere included inthe MBB exercise onthe basis o finternationalrecommendations. This was the case, for example, for home-based treatment o f respiratory infections with antibiotics (oral or injectable). Step 2: Identifying Country-Specific Service Delivery Strategies 7.9 The MBB tool proposes three main delivery modes: 1)population-oriented outreach services; 2) family/community-orientedservices; and 3) clinical individual-oriented services. This latter mode is subdividedinto primary, first referral and second referral levels. These delivery modes are service-based as opposed to facility-based. Health intervention activities are also grouped by delivery mode insteadofby the level o f facility delivering the services. For example, population-oriented services are conducted bybothHPs, HCs andmobile units insome regions (for example, Somali). 7.10 Inthe Ethiopiancontext, thenewlydevelopedapproach ofthe HealthServices Extension Package (HSEP) i s the main outreach vehicle delivering population-oriented services to the majority o fthe country. The services delivered are standardized for a given population. In Ethiopia, the services include immunization, vitamin A supplementation, de-worming andvector control (Table 7-1). 7.11 The "community promoters" approach has beentested inboth Tigray and SNPPR for the delivery family/community-oriented health services. Those services focus on health-conducive family practices and behaviors, integrating the support of media and locally trained health promoters to promote hand-washing, breastfeeding, and use ofbednets (Table 7-2). 7.12 Inthe public sector, HCs, hospitals and, sometimes healthstations all deliver clinical services that cater to discretionary illnesses. Inthe private sector, NGO clinics, pharmacists (qualified or not), and traditional healers are also involvedindelivering clinical care (Table 7-3). 7.13 The comparisons between the generic list and the Ethiopia-specific list o f interventions throughthe three delivery modes show that most highimpact interventions are already included inEthiopia's interventionpackage (Tables 7-1 to 7-3). One exceptionis that anti-malaria drugs andantibiotics for the treatment o fchildren's ARI, althoughhighlyeffective, are not recommendedbythe FMOHfor delivery by family/community-oriented services. Those interventions are to bemade available through clinical services comprising of a professional provider (i.e. at HCs and insome regions at health stations level according to current policy). Potentialbenefits and costs o f changing this policy are examined below. -174- Table 7-1: Health interventions included in the HSEPStrategy and Delivered by Population-oriented Outreach Services Ethiopia Health ServicesExtensionPackage(HSEP) Highimpact interventions in f and Review Cost items reventive care for adolescent girls & women of Preventive care for adolescent childbearing age: girls & women of childbearing 1. Essential materials, (k3, Family Planning: Depo Provera@ age: supplies, vaccines Treatment for Irondeficiency inpregnancy Family Planning Tetanus toxoid vaccination Treatment for Iron 2. Humanresource: salary, deficiencyin pregnancy incentive, housing subsidies Tetanus toxoid vaccination reventive Care for Pregnant and Newborn Preventive care for pregnant women and newborns 3. Costto periodic Folate supplementation inpregnancy Tetanus session toxoid vaccination Folate supplementation in IntermittentPresumptive Treatment against pregnancy malaria Tetanus toxoid vaccination 4. Cost to new healthpost Postnatal & Newborn care Intermittent Presumptive Treatment against malaria 5. Cost to mobileteam Postnatal & newborn care 6. IEC. 7. Training, supervision Preventive infant & child care Preventive infant & child care Routine MeaslesDPT3 immunization Routine MeaslesDPT3 Vitamin A supplementation immunization Vitamin A supplementation -175- Table 7-2: Health Interventions iDelivered by Community Health Promoters or Family/Community-oriented Ethiopia intervention packages High impact interventions in Lancetand WHO Review Cost items Preventive maternal & neonatal Preventive maternal & neonatal care: care: Clean home delivery by TBA Pregnant women using insecticide Newborntemperature management 1. Stock of essential treated net and KMC commodities: Newbom temperature management Pregnant women using insecticide bed nets, safe water system, Clean home delivery treated material chlorine, latrine, home deliverq Condom promotion Condom promotion kit, etc. Preventive infant & child care: Preventive infant & child care: Exclusive breastfeeding 0-5 0 Exclusive breastfeeding for children months 0-5 months 2. Cost o f community health Prolongedbreastfeeding 6-11 Prolonged breastfeeding for children session months 6-11months Hygiene/ hand-washing promotion Waterlsanitatiodhygiene promotion Under Fives using insecticide Under-five using insecticide treated 3. Utilization of essential commodities treated nets materials I: Complementary feeding 0 Complementary feeding Supplementary feeding for 4. Incentives malnourished children Zinc prevention 5. Training, supervision and Detection and treatment of monitoring F anagement of maternal, neonatal Management of maternal, neonatal & & childhoodillness: childhood illness: Oral Rehydration Therapy Oral RehydrationTherapy (ORTIORS) Home treatment with antimalarials N o t included Home treatment by cotrimoxazole foI N o t included A N Home treatment o f neonatal sepsis by gentamycine Zinc treatment for diarrhea management ISource: I Authors developedtables basedon HSDP HSEP documents and the Lancet article. -176- Table 7-3: Health interventions includedin the Clinical Individual-oriented Service Delivery Strategy Ethiopia intervention packages High impact interventions in Cost items Lancet and WHO Review Preventive maternal & neonatal Preventive maternal & neonatalcare: care: Delivery by slulled attendant 1. Essentialmaterials, 0 Delivery by skilled attendant 0 Neviraphe and replacement feeding drugs, supplies 0 PMTCT(Nevirapine: 0 Antenatal steroids Prevention of Mother to Child 0 Antibiotics for Premature Rupture of HIV Transmission) Membranes 0 Antenatal steroids 0 Antibiotics for premature rupture o f membranes Clinical primary level care: Clinical primary level care: 2. Humanresources: salary, incentive, 0 , Oral Antibiotics by skilled Antibiotics for pneumonia health worker for pneumonia 0 Anti-malarials by skilled health workerhousing subsidies and neonatal sepsis 0 Resuscitatiodemergency newbom care 0 Anti-malanals by skilled health Management ofRTI/STI worker resuscitation 0 Treatment for iron deficiency in 3. Construction costs 0 Management o f RTIISTI pregnancy 0 Management o f malnutrition including anemia 0 Management o f P H L A (Anti- 4. Equipments Retroviral Drugs) 0 Management o f tuberculosis Clinical first referral level care: Clinical first referral level care: 5. Training, supervisior and monitoring 0 Basic emergency obstetric care Basic emergency obstetric care 0 Injectible antibiotics for Injectible antibiotics for neonatal neonatal sepsis & severe sepsis & severe childhood infections childhood infections 0 Management o f opportunistic infections Clinical second referral level care: Clinical second referral level care: 0 Comprehensive emergency Comprehensive emergency obstetric obstetric care care 0 Prevention & management o f Prevention & management o f complications from abortion complications from abortion (Source: Authors develozled tables based on HSDP HSEP documents and the Lancet article. Step 3: IdentifyingBottlenecksHamperingEffectiveCoverageUsingHighImpact Interventions 7.14 For each service delivery arrangement, the MBB approach helps guide the measurement of five key determinants o f coverage of services. These determinants measure the extent to -177- which the system and the communities are moving toward the ultimate goal o fproviding effective coverage using high-impact interventionsthat will contribute to reducing child and maternalmortality. This step is particularly usefulfor a country like Ethiopia where the institution and implementation capacity gap i s substantial. The bottleneck-identifying process can help the country pinpoint whether gaps exist inthe supply side (humanresources, essential drugs and materials, quality o f services) or inthe demandside (initial and continuous utilization o fthe services). The five key determinants are: e Availability: This indicator includes assessingthe availability o f critical health system inputs such as drugs, vaccines, supplies and/or human resources. This information is obtained from stock registers, personnelinformation systems and facility surveys. 0 Accessibility: This indicator describes the physical accessibility o fhealth services for the clients. Itincludesthe presence o ftrained humanresources at the community level; the number o fvillages reached at least once a monthby outreach services; and the time taken to reach a facility providing basic and emergency obstetric and neonatal care services. 0 Utilization: This indicator tracks the first use o fmulti-contact services (e.g., the first antenatal contact or bacillus calmette guerin(BCG) immunization). Household surveys and service statistics reported at facilities are the main sources o f information. Service records, however, needto be validated. e Continuity: This indicator describes the extent o f achievement comparedto optimal contacts and services (Le., percentage o f children receiving DPT3 or measles immunization, inrelation to the percentage o fwomen receiving three antenatal contacts). Thus, this indicator documents the continuity and compliance o f care. e Quality: This determinant documents the quality o f care as measured by assessment o f the skills of the health workers. Skills are assessedinterms o f the workers' ability to: (a) examine the beneficiary; (b) provide a diagnosis and the requisite interventions; (c) use the equipmentproperly; and (d) advise appropriately. 7.15 Bottlenecks are identified on the basis o f a set o f indicators measuring determinants for each service delivery mode. These country indicators use either accepted international standard indicators or specific system indicators developed to monitor health services achievements inthe country. The value of these indicators was measured using surveys and service data. Measures were thenrevised and validated by expert goups, including the Child Survival Group established with the support of UNICEF, WHO, USAID and the World Bank. Step 4: Setting the Frontiers of Health Service Coverage 7.16 Inorderto simulate the potential cost and effects ofvarious strategies to deliver high impact interventions, various scenarios for reaching the performance frontier o f the Ethiopian health system have been envisioned. The cost and impact o f implementing these scenarios has been examined interms ofvarious options for expanding geographical access and options for removingthe gaps or bottlenecks indemand, continuity and quality. -179- 7.17 Options for geographical access include the following: e Base Access: the current physical access level e HSDP 11: increased access (improving access to healthservices) to meet the targets o fHSDP11, including access to outreach services (65 percent o fthe population) and clinical care (45 percent); as well as some specific targets for differenthealthprograms such as malariaprevention, EPIetc. e Expanded access: This scenario would require significant investmentsin infrastructure, training andremuneration o fhuman resources. This scenario has more ambitious targets o f the HSEP reaching 85 percent o f the population; support for family carehealthpromoters covering 71percent o f households; 70percent the population livingwithin five kmo f a facility providingprimary clinical care; and first- and second-level referral care reaching 60 percent o f the population. e Maximum access: This scenario is the most ambitious andwould likely require significant changes inthe macro-economic and infrastructural contexts o f Ethiopia. This scenario has beenused essentially for projecting potential cost and impact associated with reaching all the healthMDGs; including maternal mortality targets and the addition o f the large scale treatment o f HIV/AIDS patients as part o fthe MDGs needs assessment exercise. This scenario assumes an access target o f 95 percent for the HSEP, 80 percent for community-based promotion services and 70 percent for clinical services. 7.18 Inadditionto options for expansionofgeographicalaccess, other alternativeshavebeen examined for implementingEthiopia-specific strategies to remove the bottlenecks, which hinder achievement o f increased quality, continuity and utilization o f services These bottleneck removal options outline possibleprogressive improvements incoverage (with enhancement o f demand), as well as inthe continuity and quality o f alternative service delivery arrangements (including the proposed HSEP andhealth promotion strategy) (Table 7-4). 7.19 The baseline health service coverage data for each health intervention are collected from the country and publishedsurveydata such as the Demographic and Health Survey o f 2000. Each o f the scenarios has coverage frontiers to measure the extent to which health service coverage can be increased; which, inturn, the established estimates o f the marginal cost and impact o f increasingcoverage with the chosen highimpact health interventions. Frontiers were estimated and validatedby expert groups o f the FMOH; and assistance was provided by technicians from development partner agencies. The settingo f the frontiers was informedby estimates o f access, availability, and elasticity o f demand; Ethiopia's experience indelivering health services; as well as specific studies on the elasticity o f demand and the specific quality- density trade off^.^* 72See Chapter 3, HouseholdBehaviors; and Collier, P. Dercon S., MacKinnon J., 2003 `` Density versus Quality in Health Care Provision: Using HouseholdDatato Make Budgetary Choices in Ethiopia." The World Bank Economic Review 16(3): 425-48. -180- Table 7.4: Ethiopia's Strategies and Key Inputs to Remove BottlenecksProhibiting Health Service Delivery Ethiopia's Strategies Key Inputs Improving Traininganew cadres ofhealthworkers with altemativeskill Training and compensationof Availability mix (healthpromoters andHEW) HealthPromoters Upgradingcadres of obstetric nurses Training and compensationof DrugRevolvingFunds(special pharmacies) HEW Bednets, condoms, ORT, chlorine,chloroquineavailablein Hardshipallowances retailipharmacyoutlets Drug stocks/revolvingfunds Cold chain ineveryhealthpost Additional equipment including Buffer stocks of vaccines cold chainequipment Improving SocialMarketing, Commodities utilizationof services Ruralradiosprograms Ruralradios IECthroughhealthpromoters IECmaterial Fee exemptionsfor the poor Additional drugs No fees for contraceptives,bednets, vaccines, vitamin A Food Conditionalcashtransfers(eg food aid or free bed nets conditionalto use ofimmunization, assisted delivery) Improving Performancebasedincentives(performancecontract between Performancebonusesfor staff Continuity regionandworeda on key indicatorsincludingnumber offully immunizedchildren,number of women usingfamily planning) Matching grants for woredas Improving Increasednumber of supervisors Training and compensationof Quality Participativemonitoring supervisors, trainers, facilitators Refreshertraining 7.20 The tool subsequently allows estimation of the potential impact on the USMR and MMR, as well as the potential incremental cost linked to the implementation of these scenarios. Impact was estimated with the help o f an epidemiometric model that calculates the efficacy o f health interventions and measures the contribution of each intervention to the reduction o fmortality ina residual way (see Annex 2). The Reductionof Bottlenecks:How Muchis Enough? 7.2 1 To respond,to this question, four scenarios o f bottleneck reduction were initially examined. The first scenario is the base situation inwhich gaps indemand, continuity and quality are not addressed. The second scenario (50 percent gap reduction inquality, continuity, andutilization bottlenecks) targets the potential improvement o fhealth services (withinthe current constraints of the health system). These scenarios require few resources but would likely produce only small margins o f improvement. 7.22 The third scenario (75 percent gap reduction) takes into account capacity building activities, including institutional and human resource capacity as well as other incentives. The fourth scenario displays the maximum level o f reduction o f bottlenecks (90 percent), because it calls for significant additional investment inincreasing quality (and therefore demand) -181- byproviding performance-based bonuses, incentives for supervision andmonitoring and demand-side subsidies. 7.23 Each o f the bottleneck removal scenarios reflect the extent to which the service bottleneck will b e tackled and how many resources will be made available. The simulation of the gains and costs o freduction suggests that it is a worthwhile strategy to pursue even given the present geographical access level. At the current level o f access (base access), maintainingthe current cost structure; and reducingbottlenecks indemand, continuity and quality by 50 percent; may contribute to reducingU5MRby 12percent andMMRby five percent at an annual cost o f US$0.34per capita. Reducingbottlenecks by75 percent may furtherreduce the impact on U5MRby27 percent and onMMRby 17percent at a cost ofUS$0.95per capita. Finally, reducing bottlenecksby 90 percent may decrease U5MRby 30 percent and MMRby 20 percent at a cost o f US$1.57 per capita (see Figure 7-2). 7.24 The simulation suggests that it is worthwhile to decrease bottlenecks even though enhancing utilization and continuity translates into usingdemand-side financing (such as conditional cash transfers for outreach and clinical services) andincurring extra travel costs for supervision. The cost is largely offset by the additional impact gained. Adding incentives from the supply and demand sides to create reductions o f 75 percent to 90 percent are also beneficial as these cut-backs would significantly diminish USMR. 7.25 Overall, by reducingbottlenecks by 90 percent, it may be possible to decreaseU5MRby 33 percent andreduce MMRby almost 25 percent, all for an additional US$1S O . Figure 7-2: Impact of the Reduction of Bottlenecks on Quality, Continuity and Demand of Servicesby 50%, 75% and 90% Respectively 1.8I ,35% 30% 25% .-E z 20% E 0 .- S Lzacost 15% ,E U0 S +Reduction in U5MR 10% -8 p! ++Reduction in MMR 5% 0Yo Base 50% 75% 90% Removal of bottlenecks Source: Authors' calculations based on DHS, W M S and M O H data -182- Densityvs. Quality of HealthCareProvision 7.26 Increasing accesswithout reducingbottlenecks or reducingthem partially, would most likely have a small impact at quite a substantial cost. Even expanding access to the maximum people possible within the physical and logistical capacity o fthe Ethiopian infrastructure base (Access Scenario 3) would probably only reduce USMRbyten percent and reduce MMRby one percent at a per capita cost o fUS$2.00. This simulation suggests that merely increasing access buys less results than effectively addressing bottlenecks. (Figure 7-3). This result, obtained through the MBB simulation tool (an essentially non-parametric model based on the country planning exercise), is consistent with the analysis conducted by Collier and et al. (2003) using various parametric models (see Box 7.1). Box 7-1: Density versus Quality In Health Care Provision: current evidence from Ethiopia This analysis done by Collier et al. combines householdsurvey data onhealth care choices inruralEthiopia with budget data on the costs o f healthprovision to analyze the trade-offs between the density and quality o f service provision. Several differentprobit and logit models are usedto assess the accesdquality trade-offs. The analysis concludes that at the current level o f efficiency, an increase inexpenditures o fBirr ten million would raise usage about 0.6% ifspent on quality improvements, but only 0.1% if spent on additional facilities. The authors conclude that given the current allocation of the budget, quality improvements (i.e. increased availability of drugs, personnel and equipment)appear to be more effective inincreasing usage than building additional facilities. Reference: Collier, P. DerconS., MacKinnon J., 2003 Density versus Quality inHealth Care Provision: " UsingHousehold Data to Make Budgetary Choices inEthiopia' The World BankEconomic Review 16(3): 425-48. Figure 7-3: Reduction inMortality and Costs Associated with Increased Access without Addressing Bottlenecks I I 2 -- 10% -m .-m2 c a% 5 cost 1.5 -- E 0 *t 2 I-- *Reduction in U5MR to -Reduction in MMR 3 0.5 -- 0 - 4 0% Base HSDPll Expanded Access Access Source:Authors' calculations based on DHS2001, W M S andMOH data -183- Step 5: Variances inImpact and Cost of AddressingDifferentBottlenecks 7.27 Impact and cost of addressingvarious bottlenecksdiffer significantly. Focusing only on quality improvements would be relatively low-cost and could potentially create significant gains inUSMR.Removingthe bottlenecksinqualityfor all service deliverymodes couldreduce USMRby 10to 15 percent for amodestUS$0.4 per capita. This couldbe obtained mainly through improvingthe quality of family-oriented services and associated behaviors and family practices. However, this improvementwould only have a very limitedimpact on MMR. Addressing bottlenecks incontinuity and demand would provide additional gains, but this would involve doubling or even tripling the cost per capita. Overall, a USMRreduction o f 11percent could be reasonably obtained for US$O.SO per capita. Demand side interventions could be strengthened, for example, by investinginimproving performance incentives and introducing demand-side transfers to compensate for the opportunity cost o fusing services (Figure7-4). Figure7-4: Cost and PotentialImpactof RemovingBottlenecksinQuality, Continuityand Demand Ethiopia 1.8 I r40 1.6 35 1.4 30 F; m 1.2 25 E S .-ErE 3 1 20 .- -Under Five Mortality 2 0.8 si 0.6 15 $ ++MMR 0.4 10 = 0.2 5 0 0 reducing reducing reducing the quality the quality the quality. bottleneck and continuity by 90% continuity and bottlenecks demand by 90% bottlenecks by 90% Source: Authors' calculations, basedon DHS2001, W M S andMOH data -184- The Optimum Combinationof Access and BottleneckReduction 7.28 Different combinations o f access expansion and focus on demand and quality must be envisionedwhen scaling-up services according to national policy (Table 7-4). Increasing access to the level of HSDP targets and, at the same time, reducingbottlenecks by 50 percent, could potentially reduce U5MRby 25 percent and MMRby 13 percent at a cost of around US$1.50per capita. This results ina lower overall impact than using the same amount ofmoney to reduce bottlenecksby 90 percent at a given access level, but this scenario mightbe more politically realistic given that access expansion i s a political priority. Moreover, reducing quality and demand bottlenecks by 90 percent could prove difficult because o f limitedinstitutional and managerial capacity (the assumptions incoverage expansion for a reduction ofbottlenecks o f 90% arepresentedinTable 7.5). 7.29 Aimingfor HSDPaccesstargets andreducingbottlenecksby75 percent would reduce U5MRby 33 percent andMMRby25 percent. This is about the same levelofreduction as decreasing bottlenecks by 90 percent andmaintaining the current level of access, but at a much highercost ofnearly US$2.50per capita. However, itmaybean alternative ifa 90 percent reduction inbottlenecks proves difficult to achieve. 7.30 The optimum scenario o f increasingaccess to reach HSDP targets, inaddition to a 90 percent reduction inbottlenecks, reduces U5MR over 40 percent anddecreasesMMRby one third at acost o fonlyUS$3.00perperson. Yet areductioninquality and demandbottlenecks o f 90 percent mightbetoo ambitious given the challenges o f implementing demand creation schemes. 7.31 Further expansion o f access would likely continue to improve the level ofimpact, namely to a reduction o f 50 percent inU5MRand 37 percent inMMR,but it would be quite costly at nearly US$5.00 per capita. Table 7-4: Trade-offs between Reducing Gaps inDemand, Continuity and Quality and Increasing Access I I I I Incremental I I Incremental I 1Incremental I cost per cost per cost per capita capita capita Bottlenecksindemand, Reduction 3% 7% 10% continuity andquality inUSMR remainunaddressed Reduction 0% $0.01 1% $0.88 1% $2.07 inMMR Reductionof 50% of Reduction 18% 24% 30% bottlenecks indemand, inUSMR continuity andquality Reduction 9% $0.43 13% $1.45 16% $2.80 inMMR Reductionof 75% of Reduction 27% 34% 42% bottlenecks indemand, inUSMR continuity andquality Reduction 17% $1.07 24% S2.43 28% $4.12 inMMR Reductionof90% of Reduction 33% 41% 49% bottlenecks indemand, inUSMR continuity andquality Reduction 22% $1.63 32% $3.08 37% $4.87 inMMR -185- atemal Temperature management and K M C 0% 17.1% 25.7% 1 Id neonatal Insecticide-treatedmosquitonets care 1.8% 17.1% 25.7% infant Breastfeeding for children 0-5 months 38.1% 89.1% 89.1% ndchild care Breastfeeding for children 6-11 months 74.9% 89.1% 89.1% Waterhanitationhygiene 10% 89.1% 89.1% Insecticide-treated mosquitonets 0.2% 17.1% 26% Complementary feeding 34.3% 89.1% 89.1% [anagement of latemal, tonatal & Oral rehydration therapy 13.3% 45.9% 58.5% iildhood illness eeventivecare for lolescent girls & Family planning 6.3% 44.7% 57% omen o f iildbearing age Tetanustoxoid 14.8% 44.7% 57% 75% Peventive care for .egnant women Folate supplementation inpregnancy 6.2% 43.8% 55.8% 72.9% ld Intermittentpresumptive treatment 3.7% 43.8% 55.8% 72.9% Postnatal andnewbom care 10.5% 43.8% 55.8% 72.9% reventive infant Routine MeasledDPT3 immunization 17.7% 46.7% 59.6% 77.9% i d child care VitaminA-P 55.8% 55.8% I 19% 80% reventive Delivery by skilled attendant 2.9% 27% 39.1% 52.2% iatemalk :onatal care Nevirapineand replacement feeding 2.9% 27% 39.1% 52.2% Antenatal steroids 2.9% 27% 39.1% 52 2% Antibiotics re PRM 2.9% 27% 39.1% 52.2% linical Primary Antibiotics for pneumonia 14% 31% 43.6% 55.7% vel illness ,anagement Simple Malaria treatment 14% 31% 44% 56% Resuscitation 14% 31% 44% 56% Managemento f RTYSTI 14% 31% 44% 56% Treatment for Iron deficiency in pregnancy 14% 31% 44% 56% 1 1 Gentamvcin for neonatal semis 0% 31% 44% 56% C l i n i c a l first Basic emergencv obstetric care - - 1% 25.4% 36.8% 40.9% referral illness management 11. Management o f severe urematurity/LBW and neonatal sepsis 0% 25.4% 36.8% 40 9% linical second Comprehensive emergency obstetric :ferral illness care 1% 25.4% 36.8% 40.9% ianagement Prevention and management o f complications from abortion 1% 25.4% 36.8% 40 9% -186- Evaluatingof Potential Returns from Alternative Service Delivery Arrangements 7.32 The various scenarios developed with the help o fthe MBB tool strongly suggest that strategies to increase quality anddemand for services, in addition to enhancing access, would enhance the contribution o fhealth services to the reduction o f child mortality andmaternal mortality. However, the relationship i s not linear (Figure 7-5), and a pattern o f diminishing return is observed for bothmortality measures. As the coverage increases, the cost augments as well, and the cost function assumes an asymptotic shape (Figure 7-6). This implies that setting up feasible targets andprioritizing effective healthinterventionswith limitedresourceshave important policy implications. Figure7-5: DiminishingReturnsonAdditional Resources for Health Services Ethiopia % 6 7 60 5 50-0 .-6 4 40 5m P cost m E 0 5 3 30 .E P E &Under Five MortaliQ P2 tff s 0 3 * 20 -++MMR 1 10 0 0 Reducing the Reducing the Reducing the HSDFllaccess kpanded quality quality and quality, 90% reduction access, 90% bottleneckby continuity continuity and in bottlenecks reduction in 90% bottlenecks by demand bottlenecks 90% bottlenecksby 90% I ISource: Authors' calculations based on DHS2001,WMS and MOH data - -187- Figure 7-6: Cost FunctionEstimateof the Health Service Contribution to ReducingChild Mortality incremental C o s t of reducing U n d e r Five Mortality Eth io p ia 1 4 * + - I 0 20 4 0 60 80 r e d u c t i o n in U 5 M R Source: Authors' calculations based on DHS2001, NHA and MOH data 7.33 Figure 7-7 shows that the three delivery mode packages respond differently to health coverage increases, and therefore show different returns for both child and matemal mortality reductions. Meanwhile, the cost requiredby each delivery mode also differs substantially. These statistics not only validate the usefulness of the stratification o f the three delivery modes, but also imply a strongpolicy effect onprioritizing approaches inservice delivery. -188- Figure 7-7: Cost and Impact of All Three Service Delivery Modes Estimated Impactand Cost: Health Promoters,family and communityservices % 30% t 1.6t A 25% 1.4 .-F - 20% #j E 15% E -Under Five Mortalib .-*0 S 0.2 0'4 01 10% 2 5% . . 0% Reducing the Reducingthe ReducingtheHSDRlaccess hpanded quality quality and quality, 90% reductionaccess, 90% bottleneck by continuity continuity andin bottlenecks reduction in 90% bottlenecks by demand bottlenecks 90% bottlenecks by 90% Estimated Impact and Cost: Health Extension Package, Outreach Services % 0.7 14% 0.6 12% 0.5 .-3 3 0.4 lo% I EzEl cost I++ 8% zE 0 L .-E -Under Five Mortalit 0.3 6% e3 MMR v) zE B 3 3 0.2 4% 0.1 2% 0 0% Reducing the Reducing the Reducing theHSDRlaccess hpanded quality quality and quality, 90% reductionaccess, 90% bottleneck by continuity continuity andin bottlenecks reduction in 90% bottlenecks by demand bottlenecks 90% bottlenecks by 90% -189- Estimated Impactand Cost: ClinicalServices IndividualOriented Services ?i 3 "__-______ 2.5 35% 30% .&' .-a * P 25% o T? cost 0 m E 5 1.5 20% .f -"Under Five Mortalit) P 5 ift 2 1 15% 5 +MMR =I 10% 2 '0 0.5 5% 0 0% bducing the Reducingthe ReducingtheHSDPllaccess Expanded quality quality and quality, 90% reductionaccess,90% bottleneckby continuity continuity andin bottlenecks reductionin 90% bottlenecks by demand bottlenecks 90% bottlenecks by 90% 7.34 The HSEP population-oriented delivery appr~ach'~could potentially contribute to a U5MRreductiono fnine percent at a cost o fUS$0.34 per capita. This couldbecome avery cost- effective approach. However the impact would be likely limitedon MMR (only two percent) as antenatal care services only marginally contribute to matemal mortality. However the use of the matemal mortality ratio (MMR) (as stated inthe MDGtargets) obscures the impact o f familyplanning on the lifetime risk o f dyingofmothers; inthis area, outreach contributes apotential decrease o f 27 percent. 7.35 At each level ofaccess, reducingthe bottlenecks infamily and community-oriented services has the biggest potential impact on USMR (20 percent at a cost o f US$0.75 per capita). Yet the impact o f these services on MMRwould be minimal (barely one percent): these services would not even have an impact on the lifetime risk o f dying, because community level interventions lack effective ways to address matemal health. 7.36 Onthe other hand, improvingclinical care HSDP targets mayreducematemal mortality by 30 percent. However, it is unlikelyto reduce U5MRbymore than 13 percent, at an incrementalannual cost o f nearly US2.00 per capita. 73For HSDPtargets, this translates to reducing bottlenecks by 90% through outreach efforts -190- 7.37 For an incremental increase ofUS$1.00 per capitaper year, it seems that investmentswill bemost effective inthe HSEP and community promoters deliverymodes, which together reduce bothUSMR andthe lifetime risk o fdyingo fmothers by around 30 percent. However, the interventions that are provided through these delivery modes will have very little effect on the MMR. Incorporatingclinical care (including assisted deliveries andemergencyobstetricalcare) would substantially contribute to reducing both the MMR and the lifetimerisk o f dyingby 30 percent, and decrease the USMRby 10percent. It i s important to note that as indicated previously, this strategy would imply improving clinical services, whichwouldrequire a substantial additional investment greater thanthat o fthe other approaches. I I I I E * m sm P E * m - E t. r( m w 5; " E s N N s s vr E N o\ -193- 7.38 For a country with very limitedresources like Ethiopia, it is essential to determine priorities amongthe various delivery arrangements. One important policy consideration is the different types o f capacity and amount o ftime needed to reach coverage targets each service delivery mode will require. The HSEP strategy i s focused on outreach, a service that can be deliveredmost easily bythe public sector, given the network externalities provided by the standardized delivery o f services to homogeneous populations. Governments havebothinternational and domestic experience indelivering services such as immunization, family planningandVitamin A campaigns. The current primaryhealthcaresystem inEthiopiaseems quite well-adapted to these types o f services, as they have experienced relatively positive results from polio immunization campaigns andvitamin A supplementation programs. Therefore, the targets o fthe HSEP may be achieved more quickly than those o fthe other two delivery modes. 7.39 Family/community-orientedservices, on the other hand, entail behavior change and require active householdparticipation, which might take longer to develop. For these services, the role of the private sector, both for- andnot-for-profit (NGOs, CBOs, retailers, community promoters), i s critical. Finally, to improve clinical services, the government must address the gaps inhumanresource and infrastructure capacity, which translates to a longer lagtime for problem solving. 7.40 InEthiopia's HSDP11,theHSEPis constructed as akeypriorityfor the health sector. The HSDP I1is committed first to improving the service coverage o f the HSEP at the end o f its project cycle (2005). This policy reflects a stepwise approach by the FMOHto first address outreach services (including family/community-oriented services), thenresolveproblems inthe areaofclinical services. 7.41 Since the targets for the HSEP can be quickly reached, this method will obviously save more lives o f children under-five and mothers. Takinginto consideration the factor of speed inreaching the targets, a cost-effectiveness analysis was conducted (measured as by a dolladdeath savedratio) to evaluate the three delivery modes (Table 7-7 and Figure 7-8). A schedule for reachingtargets ineach delivery mode is as follows: 2005 for HSEP outreach services; 2010 for community promoter services; and 2015 for clinical services. Outreach services emerge as the most cost-effective method for reducing U5MR (US$1,578 per death saved) and maternal deaths (US$150,347 per death saved). Family/community-orientedservices are also efficient options for improving child health (US$7,269 per death saved). -194- Table 7-7: Cost-effectiveness Analysis of the Service Delivery Packages I - Service delivery mode USMR MBBPredicted Time Schedulefor cost Sfdeath (2000) reduction basedon the Casessaved target reached time schedule (Wcapitaiyear) avoid ratio Outreach services 166 10.00% 2005 46922 0.22 1578 . Family/community based services 166 19.00% 2010 24071 0.52 7269 . Clinicalbased services 166 12 00% 2015 4504 1.24 92632 basedon the Casesaved Service delivery mode kM.R MBBPredicted Time Schedulefor cost $/death (2000) reduction target reached time schedule (Wcapitdyear) avoid ratio 1. Outreach services 871 2.00% 2005 492 0.22 150347 2. Family/community based services 871 0.50% 2010 36 0.52 4901600 3. Clinical based services 871 29.00% 2015 2035 1.24 205060 Source: authors' calculations Figure 7-8: Cost-effectiveness Analysis of the Service Delivery Packages I1 - Dollarmeath Case Saved Ratio USMR MMR Source: Authors' calculations -195- 7.42 This analysis reaffirms that, in general, Ethiopia's strategy o f focusing on utilizing the HSEP i s realistic and promising. The HSEP not only includes outreach services such as immunization, family planning, Vitamin A supplementation, etc., but also serves as a foundation for community-oriented programs, as HEWSwill be trained to provide support and technical guidance to community promoters. Therefore, the implementation o f the HSEP would lead to an increase in health extension service coverage inthe short term, as well as improve family/community-oriented services inthe midterm. SimulatingPolicyOptions: Costs andBenefitsof ExpandingTreatment Expanding theProvision of ARI Treatment 7.43 What would happen ifhealth interventionswere promoted through altemative delivery modes? To address some o fthe policy concems, a simulation exercise is conducted to investigate different policy options (Table 7-9).74 7.44 The international community has beenpromoting community-based management ofbothmalaria andpneumonia, particularly inareaswith low access to health services. The first policy simulation therefore investigates the costs andimpact o f adding basic anti-malarial drugs and antibiotics (cotrimoxazole) for treatment o f child Acute Respiratory Infections (ARI)to the family/community-oriented (health promoter) package. 7.45 The simulations show that by adding these interventions to the healthpromoter package; reducing bottlenecks by 90 percent; and improving access based on HSDP objectives; the USMRmay decrease from 23 percent to 27 percent with an extra cost o f US$0.32 per capita ($1.09 as compared to $0.77 per capita). 7.46 The fact that the effects o f this change i s somewhat limitedmay appear surprising. This is largely due to the fact that although pneumoniacontributes 28 percent to the USMR,the efficacy o f antibiotics at this levelis only 40 percent. Thus, although pneumonia i s responsible for a large proportion o f USMR, an increase ineffective coverage by one thirdmerely results inan attributable reduction inUSMRo f three per~ent.'~ This illustrates how one intervention with limited efficacy is unlikely to singlehandedly cause a major dent inmortality rates, even when addressing one ofthe major causes o f death. 74These policy scenarios are examined in light ofthe HSDPI1targetswith an assumedreduction o f 90% of quality, continuity and demandbottleneck . 750.28*0.4*0.3 -196- Expanding the Provision of Malaria Treatment 7.47 For malaria, on the other hand, efficacy o f home treatment i s high(67 percent). However, since the contribution o fmalaria to child mortality i s small (only six percent), an increase inhome treatment does not have a major impact. For a comparable increase incoverage of 30percent, the expected impact o fcommunity-basedmalariamanagement inreducingthe nationalUSMRis only one percent. However, inhighmalariaendemic areas, inwhich a larger number of deaths are attributable to this illness, the impact i s likely to behigher(as muchas ten percent). An increase incommunity-based malaria treatment wouldbebeneficial inheavily malaria affected areas with low access to health services. e L -198- Figure7-9: Impactand Costs of AddingBasic ClinicalCare at the HPLevel Ethiopia pi&Z 600% 500% 50% ---MMR 400% 40% 300% 30% 200% 20% 100% 10% 0% 0% BaseAccess Base with HSDPll HSDPllwith Expanded Expanded clinical care clinical care with clinical at Health at HP care at HP Post 7.48 One key question for the implementers o fthe HSEP i s whether some basic clinical care should also be added at the HP level. A simulation was done to examine the impact o f decentralizing curative care to the HP level by adding ajunior nurse with clinical skills. The costs and impact o fmoving a limited clinical package to HPs was estimated (Figure 7-9). The estimate included assisted delivery, malaria treatment, antibiotics, PMCT, VCT and STD;76but didnot include emergency obstetric care and injection services. 7.49 Byfollowingthe HSDP targets for HP accessibility (inaddition to areduction o f 90 percent inthe demand, quality and continuity bottleneck), this second strategy would reduce U 5 M Rby 35 percent (attributable to clinical care); as compared to a reduction o f 33 percent ifonly health centers provided clinical care. Adding a skilled attendant at birth(definedas apersontrained inlife-savings skills) at the HP level would further reduce MMRfrom 30 percent to 31percent. At the expanded access level, adding clinical care to the HP would further reduce U 5 M R to 50 percent and MMR from 37 percent to 43 percent (Figure 7-9). 7.50 Finally a third scenario, which included enhanced communicable diseases control activities (CDC) has also been examined. The current package o f CDC already includes TBDOTS; simplemalaria treatment at the primary level and at the H C level; treatment o f complicated malaria at the first referral level; andDOTS for TB treatment at H C level. According to international recommendations, this package could be enhanced7' with incremental resources. These would include additional time/wages, performance incentives, demand-side subsidies; the cost o f additional drugs, defined stock levels o f ~~ ~ 76P M T C T prevention of mother to child transmission o f HIV; V C T voluntary testing and counseling; STDs: sexually transmitted diseases. 77 The enhanced package is composed of malaria combination treatment at primary care level; treatment o f drug resistant TB; ARVs (number is based on 3x5 estimates) for treatment o f HIVIAIDS and treatment o f complications from AIDS at the referral level. -199- drugs (based onthe incidence o fmalaria, TB, and HIV inEthiopia); and records o f drug utilization levels under different scenarios. The cost o fthis package is US$9.00 annually per capita at the current level; for access at the HSDPlevelit is US$13.00; and for expanded access it is nearly US$16.00.'* The additional impact on maternal and under- five mortality has not been estimated as the literaturedoes not provide an adequate level of proof of the impact o f HAART and treatment o fmulti-drugresistant TB on these indicators. For malaria, the literature does provide evidence on the impact: however, as shown above, because o f the low proportion o fU5MR at the national level attributable to malaria, the benefits o fproviding more efficacious treatment is limited, except inhigh affected areas and duringepidemics. HumanResourceImplicationsofthe ChosenPolicyOptions 7.51 The various scenarios also have different implications interms o fbuildingthe HR base for health services. Staffingvaries according to eachpossible scenario, and as access to infrastructure grows, the number o fphysicians and nurses also increase. Followingare the target HR requirements inEthiopia for the year 2015 under several scenarios (Table 7-9).Any significant increase inaccess will require major investments instaff training: fortunately, training o f HEWS and community promoters can be frontloaded and access can increase rapidly. However, when it comes to clinical care, a significant growth inaccessrequires an increase inclinical nurses and doctors, which requires much more time to produce. Table 7-9: Additional HR Implications of ExpandingHealth Service Coverage Current HSDPlevelof accessand Maximum level of access number of 90% reduced bottlenecks and 90% reduced staff with existing health bottlenecks with existing services health services 10,064 31,600 147,356 Community promoters 1,000 10,120 21,454 HealthExtension Workers 12,838 21,576 30,667 Nurses 1,888 3,032 4,665 Physicians '*These additional costs are still relatively l o w because o f the l o w incidence o f malaria and relatively low prevalence of HIV. Any increase in the incidence of malaria, HIV and TB or in the level o f drug resistance will substantially increase this cost. -200- Reaching the Health MDGs in Ethiopia 7.52 Assuming thegovernment can reach its HSEP targets in 2005; then go on to achieve its goalsfor thefamily/community-based service targets in 2010; andfinally meet thegoalsfor clinically-based service levels in 2015; will thisprogress be enough to allow Ethiopia to reach the MDGsfor child survival? According to the MBB simulations, the predicted improvement inhealth service accessibility and quality would speed up the reduction o f U5MR. Yet the current government targets are probably still not quite highenough to achieve the MDG's reduction goal o ftwo/thirds for U5MR (Figure 7-10) through enhancing supply and demand for health services. Onthe one hand, the MBBsimulations mayunderestimate the potential impact o fhealthservices because it only takes into account the impact o fwell-proven interventions. Nonetheless, the opposite might exist because efficacy data o f health interventions rely largely on intemational studies and meta-analysis, not on Ethiopia-specific data. Based on past experience, and despite plannedprogress inefficiency, it is most likely that health sector improvements under SDPRP objectives alone would not achieve boththe child and maternalmortality MDGs targets Figure7-10: PredictionsinAchievingMDGsfor Child Survival 190 Achieving t hetiealth extensjonloutreachservice targets 170 i- x IIx 150 Achievingt he milyicommunity based Achievingthe 130 clinical based serivcetargets Le 9 110 MBB prediction 90 Current trend 70 50 2000 2005 2010 2015 Year -201- 7.53 The question remains: what can be achieved and what resources are needed if the GOE adopts the more ambitious goal ofreaching all of the healthMDGs. To answer this question, in July 2004, the GOE embarked on an exercise to cost the contribution o f the health services to the MDGs; taking as a basis the initial estimates conducted above, yet developing additional service delivery expansion scenarios to be able to reach the health MDGs though expansion only o fhealth services.79 7.54 This section summarizes the results o f this exercise and attempts to estimate how much extra moneywould be needed to increase the healthcoverage from the current level to the 2015 MDGhorizon (should fundingnot be a constraint), yet taking into account the specific geographic, humanandinstitutional context o fEthiopia, a country that is evolving inan increasingly globalized market.80 7.55 Reaching the healthMDGs implies not only a dramatic expansiono fthe production o f keyhighimpact health services, but also the implementation o f mechanisms to ensure adequate demandfor and use o fthose services. On the basis o f the HSDPI1plan andother GOEpolicy documents, five steps for hrther service expansion have been considered. These steps are describedinBox 7-2 and displayed inTable 7-10. Each step allows for a progressive upgrade o f services, strengthening both supply and demand for highimpact services. 7.56 The costing o fthe health services contributions to the MDGshas been conducted for each step of health services development using an incremental approach (Table 7-2). The costing has taken into account the common costs o fremovingthe bottlenecks to implementation, as well as the costs for scaling-up the various service delivery arrangements. The expenditure for each step adds cumulatively uponthe previous one. Each step corresponds to increasingly higher levels o f coverage ofhealth services and associated improvementsinhealth outcomes. 79This is a multi-sectoral exercise aiming at costing the contribution o f other sectors to the health MDGs. This exercise has been conducted by the Govemment of Ethiopia with the support o f UNDP's Millenium Project, the World Bank, WHO, UNICEF, Italian and IrishAid and USAID. The USAID supported ESHE project provided extensive technical support. It takes into account, for example, that the annual wage o f an MD in OECD is 70 to 150 times what it is in Ethiopia; that recent estimates point out that more than 50% o f MDstrained inEthiopia have been migrating inthe past 10 years; and that recent statistics indicate a likely increase in the migration o f highly qualified health staff from low-income to high-income countries in the future. It also considers the potential decrease in cost o f new vaccines such as HiB and HSEP B vaccines, as well as new drugs, such as HAART, over the next few years. -202- Box 7-2: Five Steps of Health Services Expansion in Ethiopia 1. The first step, Information and social mobilization for behavior change, includes all activities related to general health information through the media (TV and radios), social marketing strategies and other social mobilization events. It includes activities outside health services at the workplace, in schools as well as in youth clubs. This step supports activities that trigger awareness o f critical health issues as well as behavior change. The expansion o f those services supports prevention o f HIV as well as prevention of other communicable and non-communicable diseases by promoting behavior change, such as increasing hand-washing, use o f condoms or bed nets, or utilization o f safe water systems. Those services particularly aim at enhancing the level of health specific information among women, a critical activity to substitute for a generally low level o f female literacy in Ethiopia." Specific health education o f mothers has an important effect on child mortality in the same way that general awareness and education on safe sex have been demonstrated to have a significant impact on HIV. These services also aim at promoting the dissemination of key commodities (condoms, bed nets, ORT packets) through the retail and commercial network (kiosk, retailers, pharmacy outlets etc.) 2. The second step i s implementation o f the Health Services Extension Program (HSEP), which entails all the key activities o f the flagship health program developed by the Government of Ethiopia over the last few years. This health services development program includes three major components: 1) An outreach program centered around the rapid one-year vocational training o f Health Extension Workers HEWs (2 per kebele) and construction and equipment o f HPs (12,249 new HPs will be constructed and equipped, resulting ina total o f 13,635). These HEWs are civil servants and will offer key technical services, such as immunization and family planning, to each kebele (5000 inhabitants). 2) A community promotion program centered around volunteer/private sector community promoters/ traditional birth attendants (TBAs) (1 for every 50 households or 250 inhabitants) working under the supervision/ guidance o f the HEWs and providing support to households for behavior change (i.e. breastfeeding, supplementary feeding, use o f bed nets, clean delivery etc.). 3) A program strengthening the quality o f and demand for clinical care [particularly treatment o f Acute Respiratory Infections (AN) and malaria in children, assisted delivery, HIV testing and counseling as well as prevention o f mother to child transmission (PMTCT)] in existing health stations and HCs. 3. The third step is a Clinical First Level Services Upgrade, which includes the expansion o f HCs throughout the country as well as the upgrading o f HPs to offer basic clinical care. It involves the construction and equipment o f 563 new HCs and the upgrading o f 2,167 existing health stations to HCs, in addition to the already existing 423 HCS.~'~~ It also implies the recruitment o f one additional staff with clinical skills ineach HP and the adequate staffing o f registered nurses in all new and old HCs. This step would lead to an increase in the access to clinical care at less than a one hour walk from the household (from 31 percent to 80 percent) and increased access to first level clinical care for adults (including TB DOTS treatment, malaria treatment with ACT, treatment of sexually transmitted infections (STIs) and opportunistic infections, expansion o f HIV voluntary testing and counseling (VTC); and basic emergency obstetrical care including transport). HIV and malaria testing is made available through the use of rapid tests. 4. The fourth step, a Clinical Services Upgrade of Comprehensive Emergency Obstetric Care (CEOC), requires the operationalization o f comprehensive emergency obstetrical care in all new and old Although significant efforts are currently being made by the Govemment of Ethiopia to increase enrollment and primary school completion rates among girls, the benefits o f increased formal education among girls are not going to kick in fully by 2015; the new cohorts of educated girls not having yet reachedthe reproductive age. Some benefits may however be expected from delays in early mamage, with a slight decrease in early pregnancies to be anticipated after 2010. '*Creating atotal of 3,153 HCs at the end of 2008. 83MOH. An Accelerated Expansion of Primary Healthcare Facilities in Ethiopia (2004 - 2008). 2004. Planning and ProgrammingDepartment,Addis Ababa, Ethiopia. -203- HCs o f the country. This implies equipping all HCs with an operation theater and staffmg it with the appropriate number o f nurse midwives and health officers with EOC and surgical skills. This step also entails establishing adequate means o f transport, setting blood banks in all HCs and upgrading existing hospitals into full referral centers for emergency obstetrical care. 5. The fifth step is the Expansion and Upgrade of Referrals of Clinical Care, which entails the expansion and upgrading o f referral services, including all woredas and zonal hospitals. This step would allow Ethiopian health services to upgrade their equipment and lab facilities to offer quality follow-up for HIV patients receiving HAART,*4and also expand referral services for neonatal care and complex emergency obstetrical care, thus contributing further to the reduction o f under five and maternal mortality. Ths would include the renovation and construction o f district hospitals (1 for 250,000 people) to include intensive care neonatal centers, as well as the equiping hospitals and HCs with lab facilities that would allow for the adequate provision and monitoring o f HAART, as well as resistant strains o f TB and malaria. Lab equipment would include automated hematology analyzers, flow cytometers and deep freezers for all new and old H C s and hospitals. This phase also includes the training o f enough M D s and registered specialized nurses to adequately deliver, supervise and monitor the provision o f quality referral clinical care. Table 7-10: social mobilization for behavior change ExtensionProgram (HSEP) Clinical: increase quality and demand for child Drugs, support health and reproductive health clinical services to demand, including basic emergency obstetric care midwifery Step 3 1"level clinical Clinical: improve access and quality o f services for Drugs, & services upgrade all adults including ACT, STI and 01treatment training Upgrade o fhealth posts to offer clinical care Step 4 Clinical services Clinical: Expansion o f upgrade: 1. Expand andupgrade HCs to offer CEOC midwifery & Icomprehensive (including c-sections) obstetric care emergency obstetric I Management care 2. Upgrade HPs to include midwifery services I including 3. Improve quality o f woreda hospitals surgery at HC level Step 5 Clinical services Clinical: MDs, expansion and 1.Upgrade HCs, expand and upgrade woredas registered upgrade: referral hospitals nurses, clinical care 2. Expandtreatment of chronic diseases including hospitals, HAART drugs 84HAART= HighlyActive AntiretroviralTherapy -204- Table 7-11: Key Investment and Recurrent Costs for Each Step of the Health Services Expansion Strategy Ethiopia's Major Investments Major Recurrentcharges strategy Step 1: Information and IEC production Air time social mobilization Training Transfer to NGOs: salaries, IEC material for behavior Radios for households Subsidy to commodities (condoms, IThk, change etc) Supervision, monitoring Step 2 Health Services Commodity stocks, bicycles Annual training of community promoters, Extension Basic training of community TBAs Program(HSEP) promoters Commodities, bed nets, ORT Supervision, monitoring Construction, equipment o f HPs Salaries o fHEWS andmobile strategies Commodities, vaccines, contraceptives Motorbikes Supervision, monitoring Training of HEWS Subsidies to demand for immunization, Stocks of commodities family planning Renovatiodupgrading o f health Malaria tests, ACT, 01, STI treatments, services upgrade stations supervision, monitoring, medicines Additional stock of drugs Training o fnurses Step 4 Clinical services HC Construction Salaries, commodities, transport, upgrade: Upgrade of HC to include CEOC supervision, monitoring comprehensive Upgrade ofreferral hospitals Upgrade o f quality o f existing hospitals. emergency Training o f additional midwives and Subsidies to transport for EOC, obstetriccare health officers contingent demand side subsidy for Cars/ ambulances T assisted delivery Training and salary o f midwives and health officers Step 5 Clinicalservices Renovation andbuilding ofworeda Salary o f MDs and expansion and hospitals, lab services, stocks o f cost o f drugs, additional salary, lab upgrade: referral commodities, training, upgrade clinicalcare additional MDs and nurses -205- 7.57 Table 7-12 displays the average cost per capita over the period2005-2015.85 Figure 7-11shows the gradual increase incost over time along progressive implementation and gradual investment inconstruction, equipment and training. 7.58 Step 1(Information and Social Mobilization for Behavior Change), would cost an average o fU S 1 . 5 per capita over the next ten years, peaking at US$2.11 in2015. This approach could potentially contribute to reversingthe H N incidence from 0.66 to 0.55 per 100,000 people andmaintaining the HIVprevalence at 4.4 percent. Itcould also contribute to an increased level o f information for mothers on child health practices and augment the coverage o f key child survival interventions (includinguse of ITNs, hand- washing and water handling, breastfeeding andnutrition) The scaling up o f this service delivery arrangement would likely create a five to tenpercent decrease inUSMR, primarilyby affectingthe level o finformationandinfluencingthe use ofkey commodities ofhouseholds through social marketing, information and targeted subsidies.86Interms o f HR development, this step involves the training o f communication specialists as well as peer educators amongthe young and high-risk groups. 85Cost figures are displayed in US$ per capita in2004. 86By keeping the HIV epidemic controlled, this program affects child survival by mainly avoiding an increase in child mortality due to HIV, as has been observed in other countries of East Africa with much higher levels of HIV prevalencethan Ethiopia (e.g Zambia, Kenya & Zimbabwe) -206- Table 7-12: Scaling-up Coverage of Health ServicesinEthiopia: Resource Implications, Costs, and Potentia Benefits Ethiopia's Expansionof Humanresource Average Estimatedimpact YIDG strategy facilities implications incremental tchieved (private facilities (for bothpublic and annual cost included) private sector) per capita bet. 2005- 2015 Step 1: Increase in Communication US$I.5 HIV incidence ieverse Information and number of radios specialists and peer decrease from rend inHIV social at kebele level educators increaseby 0.66 to 0.55 per ncidence. mobilizationfor by 308,239 5 fold 100,000 people. jtabilize behaviorchange Reductionof Tend inHIV U5MR of 5-10% xevalence. # o f HPs Health promoters(2 US$3.54 Reductionof child Decreasein Services increases from weeks trainingper mortalityby 60- inder 5 and Extension 1,386 to 13,635 year) increasefrom 70%. nfant Program (9.8 fold 14,527 to 260,000 Reductionof nortality by (HSEP) increase) (17 fold) matemalmortality wo thirds. IncreaseinHEWS by 10%. from 2800 in2005 to Reductionof L 23,225 in2015 (8.3 matemaldeaths fold). (lifetime riskof # nurse midwives dying) by 40%. increasefrom 1,559 to Decreasein child 10,590 (5.8 fold). andmatemal mortality due to malaria. Step 3: First # of HCs Nursemidwives USl.72 Reduction of Further levelclinical increases from increase from 1,559 to mortality due to decrease of upgrade 423 to 2590 (6 15,088 (8.7 fold). malaria by more morbidity fold) than 50%. and Reducedmorbidity mortality due to STI due to malaria Step 4: # of HCs Number ofnurse US$3.50 Reduction of Reduced comprehensive offering CEOC midwives increase matemal mortality maternal emergency increases from from to 1559to 19,443 by 75%. mortality by obstetriccare: less than 100 to (by 11.5 fold). 75% expansionand 3121. Number ofhealth Reduction of child upgrade officers increase from mortality by 70%- 632 to 4,154 (by 5.6 80%. fold). Step 5: Referral # of second Number ofnurse uss9.79 Reduced mortality expansionand referral hospitals midwives increase of HIV+ patients. upgrade increases from from 1559to 22,964 36 to419 (11.6 (by 14fold). Reduced child fold) Number of medical mortality by 75- doctors increasefrom 85% 2,032 to 9,626 by 4.7 I fold Total: US$20.05 vorkers: 1 vear o f tr; ngin vocational schools; h 'se midwives: three years training BA lev Health Officers 4 years o f training, Master Level, MDs, 7 years o f training Doctoral Level. -207- 7.59 Step 2, the Health Services Extension Program, would cost an additional US3.54 per capita on average over the period 2005-2015, peaking at US$5.2 per capita in2015. The outreach andcommunity-orientedprogram(Ethiopia's HSEP) wouldbethe main vehicle for reducinginfant and child mortality, potentially permittingEthiopia to reachthe child mortality MDGtargets. Other benefits o f scaling-up this program include an important contribution to the malaria MDGthrough the increased use o f insecticide treated bednets among children less than five years old andwomen, inaddition to increased treatment o fmalaria at community levelg7.It also contributes to reaching the HIVMDGtarget byintroducingHIVtestingandPMTCTinall existingHCs andhealth stations. This approach is, on the other hand, unlikelyto contribute much to the reduction of the MMRss (likely not more than 10percent). However, by addressing the contraceptives supply bottleneck to respondto current unmet needfor family planning services, the HSEPwould contribute to a reduction o f 40 percent inthe number o f matemal deaths (lifetime risk of dying)". HR development for this step would involve increasing the number o f community promoters/FLHWs (trained for 3-4 weeks) by 17 fold, andincreasing the numberofHEWs, (having at least a tenth grader education and trained for one year) by a factor o f eight. This expansion is already planned and shouldnot pose difficulties over a ten year period giventhe relatively low level o f training required and assuming resources wouldbe available. The training and supervision o f low-skilled workers, as well as the strengtheningo f clinical referralto support these health extension services, would be more challenging. This would require an increase inthe number o fnurses midwives (havingat least a 12thgrade education and trained for three years at the BA level) by almost six fold by 2015. This implies producing an additional 1,500 nurse midwivesper year over a period o f six years, at least doubling the current level production. This couldpotentially happenthrough the augmented number o fprivate schools o fnursing. 7.60 Step 3, UpgradingFirst Level Clinical Care," would cost an incremental average of US$1.72 inaddition to the HSEP number, peakingat US$3.29 per capita in2015. This step would strengthen the quality o f and demandfor first level clinical care at HP, clinic and H C levels, leading to an increase incoverage o fmalaria treatment (including for adults) and treatment o f STI; as well as prevention" andtreatment o f opportunistic infections (includingTB DOTS). This program would achieve the malaria MDGtarget byreducingmalaria-specific mortality by about 50 percent, andthe TB MDGtarget by ensuringappropriate treatment of all non-resistant identified TB cases. This step would require the upgrading o f HPs and health stations with an adequate number o f clinical health workers with one year oftraining (upgrading o f HEWSor existingjunior/assistant nurses). ''Using '*TheMMRi chloroquineas per the current Ethiopiapolicy s measured as the number of matemal deaths over the number of live births; as such it i s sensitive to ''interventionsoccurringduringofpregnancies, pregnancyand labor. By reducing the number family planning leads to fewer deaths of women linked to pregnancy and labor.But family planningdoes not directly affect the MMR, which is the risk ofmothers of dying once pregnant. MainlyPCPprophylaxisfor a cost of about US$lO per patientperyear -208- 7.61 Step 4, Expansion and Upgrade of Comprehensive Emergency Obstetrical Care, would cost an incremental US$3.50 per capita over 2005-2015, peaking at US$ 4.10 per capita in 2015. This step would establish access to and demand for CEOC ineachH C as well as provide assisted delivery services at the HP level. This approach is critical working to achieve the MMR MDG target. It would also provide additional benefits in terms o f the reduction o f neonatal mortality, leading to further decreases in U5MR. The HR implications o f this step are important. The number o f registered BA level nurses and midwives would have to increase by more than 11 fold implying a tripling o f current production over a period o f six years. Another major challenge would be the production o f health officers at the master level, trained to conduct and oversee CEOC at HC level. To sustain this step, the number o f health officers would have to increase by almost six fold. This would require quadrupling the training o f health officers for a period o f five to six years; a significant challenge. For both these categories, the costing takes into account a 35 percent hardship allowance for working in rural areas.91 7.62 Step 5, ExpansionandUpgrade o f Referral Care would cost an incremental US$9.79 per capita over the period 2005-2015, peakingat US$14.1 per capita in2015. This step would upgrade referral care inall woredas, providing for the establishment o f a district hospitalwith referral diagnostic and monitoring capacity to provide support to the HCs. This service upgrade approach would obtain additional gains inunder five and matemal mortality rates, andwould also ensure quality provision o fHAART to all those identifiedas eligible. The HRrequirements for this step are particularly demanding taking into account the targeted five fold increase inthe number o f M D s by 2015. Given that MD training takes seven years, this would suggest increasingthe entry o f students into medical schools in2006 and 2007 by at least 40 fold; without accounting for the brain draidmigration These statistics indicate that the only way to achieve this step will be to import M D s into Ethiopia. As Ethiopiais currently an exporter rather than an importer of M D s due to the highquality of its medical training, this would call for a major strategic shift inorder to retain local physicians and attract international ones. 91This is based on initial data collected for a health worker study. 92Available evidence suggests that Ethiopia trains two MDsfor every one that stays in Ethiopia and three for every one that remains inthe public sector. I 1 (2004c 35 30 25 20 15 10 0 la#% ZDlO 2011 2012 2013 20 x x -210- Figure 7-11: ProjectedCost and Associated Reductionin Child Mortality Linked to Implementationof Services Scale-up Strategies: Ethiopia 2006-2015 -90 -- -70 ,g -- t -60 I -- -50 J -- P -40 5 E -- -30 2 0 E -- -20 4 0 02006-2010 1. Information 2. HSEP: 2. HSEP: 2. HSEP 2. HESP:All 3. With 4. With 5. With 2011-2015 wtreach. "Clinical" "Community modes Clinical Clinical Referral HEW package Promoters" upgrade1st upgrade 2006-2010 level CEOC 2011-2015 Ethiopia cost 600% 60% E -f 500% 400% 40% E 20 .E 300% 30% & .- s n 4 200% 20% tff 5 1M)% 10% 0% 0% Base Access Basewith HSDPll HSDPllwith Expanded Evanded clinical care clinical care with clinical at Healb at HP careat HP Post 1 -211- CONCLUSION 7.64 Overall, this analysis shows that the Health Services Extension Package (HSEP), andthe associated Community Promoters Strategy proposedbythe GOE, shouldbe supported ifhealth services are to significantly contribute to reaching the under-five mortality reduction goal. Ifan annual incremental US$1.OO per capita can be mobilized for Ethiopia's health services, resultinginvestments should be channeled towards outreach and community services provided bythe HSEP and Community Promoters Package that were successfully tested inthe Tigray and SNNPR regions. Together these strategies could potentially reduce boththe U5MR andthe lifetime risk of maternal death byabout 30 percent (on the basis ofrealistic assumptions regardingincrease o f access along the set targets o f HSDP 11). These results are consistent with the experience o f neighboring countries such as Tanzania where a targeted incrementalUS$0.5 per capita invested at district level ledto a reductionofmortality by 40-45 percent, a significantly larger decrease inthe intervention districts than average gains inthe country's mortality rates.93(Figure 7-12). Figure 7-12: Evidenceof the ImpactofIncrementalInvestmentson Strengthening of HighImpact Interventions(Tanzania EHIP) Child MortalityDeclinesin Evidence-basedPlanningDistricts,Tanzania 40.0 CIStiwl of Healthsystem intentellion I 35.1 35.0 5 30.0 C !.25.0 a z 3 20.0 Ln I- c b17. 7 15.0 E +RMiji District v) & 10.0 '0 3 5.0 Souroe MOHTaniania(TEHIPRuRiiDSS AMMPM4togoroDSS) 0.0 1997-98 1998-09 1999-00 2000-01 2001-02 2002-03 Year h 93Source The Tanzania Essential Health Interventions Project IDRC TEHIP (2004) Latest statistics shoh that the U5MRdropped by 43% in Morogoro Distixt bctaccn 1997 and 2003 and by 46% in Rufiji District bctwcen 2000 and 2003 These impressive gains come in the two districts where TEHIP has helped to improve local healthcare planning -212- 7.65 This analysis also points out that the first priority for Ethiopia health services is to maximize the reduction of existing bottlenecks inquality, continuity and demand for high-impact interventions delivered through innovative service delivery strategies. Tackling these bottlenecks only (without expansion o f access) could potentially be achieved at an annual cost o f about US$1.6 per capita, resulting ina reduction o f the U 5 M Rby about one third and the MMRbynearly a quarter. Usingthe same amount of funds to boost geographical access only, without addressing the bottlenecks, would merely result ina ten percent reduction inthe USMR, and a one percent reduction inthe MMR. 7.66 Ifresources could be mobilized up to US$3.00 annual per capita, inorder to achieve HSDP access targets and reduce bottlenecks by 90 percent, the USMRcould potentially b e reduced by 40 percent and the lifetime risk o f mothers dyingby 50 percent. A more ambitious scenario canbeenvisioned ifapproximately US$5.00 per capitaper year could be mobilized, which would reduce U 5 M Rby 49 percent andthe lifetime risk of mothers dyingby 58 percent. Addingthe provision o f additional second generation CDC andtreatment (include treatment for multi-drugresistant TB, resistant malaria, and HAART for AIDS patients) would increase the costs significantly (upto an additional US$16.00 per person per year), resultinginan impact that i s difficult to estimate given the lack o f solid evidence on the effect of these interventions on MDGgoals. 7.67 Adding clinical care services (mainly for malaria, pneumonia andassisted deliveries) either at the communitylevel or at the HP level will provide some benefits, but will also incur significant additional costs. However, the marginalbenefits o f adding these services i s limited; except probably inheavily malaria-affected areas. Benefits must also bebalancedinrelation to the significant HRdevelopment andmanagerial challenges produced by the provision of these services. As discussed inthe above section focused on HR,94 it ispotentiallymore complex for the systemto produce andretain personnel with clinical skills than those with standardpublic health profiles, particularly inrural areas. Clinical services are also more challengingto monitor, supervise and regulate given their highly discretionary and transaction-intensive natures; monitoring and evaluation services would bemore efficiently provided ina secondary phase after the implementation of the HSEP and HealthPromotion Packagehas triggered capacity- building,institutional developmentandthe establishmento f abackbonefor the health system. ~~ 94 SeeChapter 5 -213- 7.68 Under current Ethiopian health policies working towards the health services extension objectives o fHSDP 11, the contribution o fhealth services to the achievement of MDGtargets could be substantial. Bydoubling the current public spending on health, health services could contribute to reducing child mortality and the life time risk o f dying o f mothers by about 40-45 percent Yet, this number would be hardly enough to reachthe MDGs. More ambitious objectives, interms o fhealth service delivery coverage permitting Ethiopia to reach all o f the MDGs, would require significantly more resources, especially humanand financial resources. Limitingthe spread o fHlV inaddition to reducing child mortality bytwo-thirds could potentiallybe achieved at an annual cost o f US$5 per capita, doubling current total health expenditures. Reachingthe malaria MDGs for adults would add about US$l.72 per capita. Achieving the maternal health MDG targets would bethe most challenging interms o f mobilizing humanresources; likely requiring an additional US$3.5 per capita. Finally, expanding referral andhospital care andprovidingtreatment for chronically illpatients (including highlyeffective anti- retrovirals for HIVpatients) would be the most expensive component, amounting to anadditional US$9.8 per capita. -214- 8. BUILDINGONEXISTINGSTRENGTHSAND ADDRESSINGPOLICYISSUESFOR IMPROVED HEALTHOUTCOMES 8.1 This section outlines strengths inthe health sector that could be targeted to reinforce health sector objectives. It also identifies key policy and strategic issues for further discussionwith the GOE. 8.2 The GOErecognizes health as a vital component inpoverty reduction and seeks to incorporate health on policy, strategic andoperational levels. Despite its position as one of the poorest countries inthe world, Ethiopia has been able to improve some key health indicators. Infant and child mortality rates have declined and are lower thanthose inother countries with similar percapita incomes. Malnutritionrateshave also decreased over time, although these rates are still among the highest inthe world. Ethiopiahas also beenparticularly successful inincreasing coverage rates for certain standardized interventions (i.e. polio immunizations and vitaminA distribution) andincreating awareness around family planning and HIV/AIDS. However, while the country has madeprogress in these areas; Ethiopia has not been successful in implementing other low-cost interventions, including the use of ORT during diarrhea episodesand the use of bed nets. Inaddition, Ethiopia has not been able to capitalize on its success in conducting a polio immunization campaign to deliver other immunizations; nor has it achieved increased awareness o f STDs at a level comparable to HIV/AIDS awareness levels (despite the development o f successful information campaigns for the latter). While generating awareness and demand for family planning,the approach has not been as successful inmeetingthe demand for contraceptives. These deficiencies require improvements ininformation exchange and service delivery channels. 8.3 Thus, it is essential to work to maximize existing information and service delivery channels that are successful. Onthe topic o fHIV/AIDS, for example, village meetings were the most frequently cited sources o f information (80 percent o f women and 71 percent of men) inthe DHS. An effective strategy would study the ways these meetings and other village forums couldbe used to disseminate other types o fuseful information and services. Analyses also indicate that mother's exposure to media i s positively associated with improved maternal healthcare and children's nutritional status, as well as improved knowledge and use o f family planning. However, media coverage i s not extensive inEthiopia," which suggests that increasing access simply to rural radios, for example, could contribute to behavior change and would likely have an impact on child mortality. The cost andimpact simulations show that there is a strong potential for decreasing USMRby supporting family-oriented services and providingboth information 95Only 14 % of women and 27 % of men have access to some form of mass media. Radio i s the most commonmedia source that men and women are exposed to although only 10% of women and 25 % of men listen to the radio on a weekly basis (DHS2000). -215- andsubsidies for key commodities. Yet the question remains: how shouldbethe incrementalresources for the sector support information and community based services? 8.4 Improvement of coordination among different health services is an essential issue to address; for example, existing implementation capacities must be taken into account when adding activities to successhl programs. 8.5 Inequities exist in terms of outcomesand utilization rates between rural-urban areas, income levels and regions. Urban-rural differences are more marked interms o f outcomes andprevalence rates: urbanareas have lower diarrhea andacute respiratory prevalence rates for young children, as well as inferior infant mortality and stuntingrates. Urban areas also have greater physical access to health facilities: at least 94 percent o f households are withinfive kmo f facilities that provide curative services, compared to only 30 percent inrural areas. Regional differences interms o f access to facilities and healthpersonnel are also prominent: Afar and Somali generally fare the worst, especially interms ofhealthpersonnel-to-populationratios. Although utilization rates of health services vary according to income levels, absolute utilization rates are still low across all income quintiles. Income differentials are more striking interms o f service utilization rates; for example, the richest quintile benefits from higher immunization rates and assisted delivery services relative to the poorest quintile. While wealth-based inequalities exist, these are still relatively low compared to those inother countries. The use o f services, even among the richest households, is consistently quite low. While the rich-to- poor ratio i s 27 interms o f assisted deliveries, the utilization rate o f this service for the richest quintile is only 24 percent. 8.6 The low coverage andutilization rates underscore the need for strategies that will increase access to andquality o f services. Access to a nearbyfacility and a high quality of service are the two major motivationalfactors leading to increased use of facilities. Thus, the augmentationinthe number o f facilities must be accompanied by increases in the availability and quality o f drugs andwell-trained staff. Supply o f familyplanning services also need to catchup with rapid demandcreation. There is concern as to how to ensure the financing and implementation o fthe main supply-side intervention currently proposedby the GOE inthe HSEP within the current decentralization context. To strengethen the HSEP, especially duringthe initial implementation stage, the addition o f other outreach activities (Le., additional mobile teams, or child or family health days) i s suggested; ifadequate need and space exist for this type o f strategy. 8.7 Demand-side interventions also need to complement supply-side interventions. Very low utilization o f services bythe poor inurban areas (i.e., the low percentage o f assisted deliveries and utilization o f available services such as antenatal care) suggests that supply-side interventions are inadequate ifimplemented inisolation. The budgeting- impact simulations indicate that investingindemand side interventions may prove more effective in-and-of-themselves than expanding access and quality only. The GOEplans to address these issues through the expansion o f a combination o f community-based approaches (the healthpromoters package) and enhanced use o f the media. Health promoters are trained to support activities that promote behavior and value change by utilizing resources from boththe public and the private sectors. Creating awareness -216- assists ingeneratingdemand for services. For example, inorder to address malnutrition, mothers should be informed about appropriate feeding practices, use o f locally available food items, and other healthy behaviors such as hand-washing. These activities will require partnershipsbetween the public andprivate sectors, communities andNGOs in order to ensure access to commodities such as bednets, condoms, and ORT, as well as to create an enabling environment for behavior change. One practical way that these sectors couldpartner i s through the social marketingo f soap and safe water systems. The level o f subsidy providedto these activities, as well as to the modedmechanisms for applying transfers, must be determined. Thus thefollowing series of questions arises: Which community promotion activities should be financed by the government, Le., training o f promoters; cost o fbed nets and ORs; and information campaigns? What other demand- side interventions could prove to be potentially promising inEthiopia? Can cash transfers or vouchers be utilized on a trial basis? And can those transfers be linked to the use o f other activities (Le., a free bednet for women who attend antenatal care or packets of ORT given to childrenwho come for immunization)? 8.8 The degree to which these interventions could succeed also depends largely on the ability o f implementingagencies to monitor and evaluate household compliance with the established actions. Improvements inmonitoring and evaluation are also needed to measure impact and to document lessons learned. As part o fthe development o f a national action plan for child survival andto facilitate HSEP roll-out, there i s ongoing collaboration between the GOE, UNICEF, WFP, USAID, &d the WB regarding implementation of an enhanced community promoters package to strengthen the delivery of an integratedprevention and essential nutrition package. A small pilot OCS program will be initiated inSNNPRin56 woredas andlater expanded to 325 food-insecure woredas nationwide. Female community members will volunteer to promote vaccination andgrowth monitoringhtritional screening. Discussions are also underwaywith WFP regarding food supplementation for malnourished children. Recent discussions seem to indicate that the nutrition screening and food supplementation activities will take place separately; however it would be worth considering combining these interventions as an integrated package that could be provided to households. 8.9 Both supply- and demand-side interventions must take into account regional differences. For example, the WB Country Economic Memorandum underscores the fact that malaria and other tropical diseases affect the lowlands; and trypanosomiasis also has severe consequences (both for livestock andpeople) inthe western lowlands and the valleys leading down to them. From a economic development perspective, investing in malaria and tsetse fly control inthese areas could result insignificant economic retums. 8.10 Therealiq that Ethiopia has a low per capita income and limited skilled human resources must be recognized when discussing the needfor supply- and demand-side interventions. It will therefore be important to examine strategies for the short to medium term; while ensuring that a long-term approach is also established. Interms o f human resource capacity, as the Ethiopian educational system can feasibly only produce a limitednumber of physicians and nurses inthe short- to medium-term, the country will provisionally implementutilizing a predominantly low-skilledpopulation. The MOHhas beenparticularly resourceful indefining alternative skill mixes that correspond with the -217- national epidemiological situation and implementation constraints. To some extent, the health officer assists inaddressing the shortage o f general practitioners. Inaddition, the HSEP has adapted to delivering low technology standardized services that do not require diagnostic or therapeutic skills. It relies on a cadre o f eight to tenth graders with one year o f training to provide outreach services for highimpact services such as immunization, familyplanning services or vitamin A supplementation. The profileo fhealthpromoters (usually community members with primaryeducation) is well adapted to the Ethiopian context. 8.11 However, there is still a gap in the human resource development strategy, as the approach lackspersonnel that are able toperform skilled deliveries and other slightly more complex clinicalfunctions. Reducing the MMR is among the key objectives o fthe Ethiopia SDPRP. Although the HSEP program (when combined with community extension services) is expected to reduce child and infant mortality rates (therefore also decreasing the number o fwomen dying inchildbirth); it will actually have limited impact on the MMR.A reduction inthe MMRwill only occur ifthere is an increase inthe availability o f skilled healthprofessionals who can perform clinical services (particularly skilled deliveries but also basic emergency obstetrical care). Actions must also be undertaken to improve abortion safety." However, several questions remain: What actions can be taken by the Ethiopian government to ensure the availability o f skilled staff! Should the GOE also entertain the use o f a phased approach byproviding additional training to some o f the HEWSinthe short-term inorder to buildHRcapacity to perform clinical services ? 8.12 How can Ethiopia attract and retain higher skilled workers? Available evidence indicates that salary differentials for those who work inrural areas (i.e., the hardship allowance received for working inemerging regions) is not sufficient. Career development and training opportunities have been frequently cited as major concerns o f healthworkers. The issue o f staff deployment andpossibly staff rotation will needto be seriously considered inorder to create more attractive rural postings. Strategies to ensure that female workers feel safe whenworking inremote rural areas must also be implemented. Thus, the next question is: Aside from developing appropriate safety guidelines and providing adequate protective supplies such as gloves, what additional actions can be taken to address the concern o fprofessionals o f contracting HIV/AIDS in the workplace ifthey decide to work inthe area o f clinical services? 8.13 Positive health outcomes resulting from relatively easy accessto health facilities i s expected inurbanized regions such as Addis Ababa, Dire Dawa and Harari. Tigray's respectable performance interms of several indicators (i.e., immunization coverage, vitaminA supplementation, awareness o f familyplanningmethods, low rate o f female circumcision) should be examined for lessons learned (despite the fact that the region has the highest poverty head count ratio inthe country). Tigray is known for its strong community-based organizations (CBOs), which are used to address the region's high incidence o f ARI and malnutrition inyoung children and mothers. The region also has 96 Actions would also be needed to prevent unwanted pregnancies through increased awareness and use o f family planning methods. -218- the highest number o f FLHW-to-population ratio inthe country. InTigray, staffing and equipment are determinedbased on the location o f a particular facility, (i.e., more surgery-related staff ina remote H C compared to an urban HC). Incontrast, the MOH staffing standard only provides for health officers and general practitioners indistrict hospitals. Based on this experience and those from other regions such as Oromia; this report asks: I s therepotential to modi& national staffing guidelines to be moreflexible, allowing regions to modi& their staffing standards to accommodate local conditions? To what extent could the MOH accommodate such a request, and how would quality assurance be monitored? 8.14 The roles of theprivate sector and NGOs vis-&vis public sector must be addressed. As can be seen from the available data, the private sector plays an important role inthe provision o fhealthcare services, especially inthe form o fpharmacies and drug shops. Most of the larger private facilities such as hospitals andhealth clinics tend to be inurbanareas. There is also clearly arole for thepublic sector inpreventive services, as well as inthe provision o fhealthservices inpoor andremote areas. Interms o f comparative advantage, the public sector should focus principally on the delivery o f the HSEP; while the private sector could be mobilized to play a more significant role in community health promotion (Le., the development o f social marketing activities that maximize local channels to provide clinical/curative services to various segments o fthe population). Indoing so, it will be important to ensure that the poor are not marginalized. One potential strategy is to revise the exemption system inorder to minimize leakages andto increase user fees for those who can afford to pay. 8.15 Non-profit NGOs could alsoprofit from a more enabling environment encouraging them to operate in areas that are unattractive tofor-profit private establishments. The government has expressed its interest andpolicy commitment to increasingly involving NGOs inachieving health sector goals. Legal procedures and guidelines exist for NGO licensing and operation. However, reports indicate that actual progress has been slow and varies across regions. Project formulation, appraisal and final agreement all take time because o fthe organization o fNGO licensing and legal procedures. Lack o f coordination between various stakeholders; procedural differences across regions; humanresource shortages; andbureaucratic red tape further limit NGO activities. 8.16 There is general agreement that Ethiopia's per capita allocation and health care spending is very low. The MBBmakes a strong case for increasing funding to health services. For example, just an increase inUS$1.6 per capita investedincommunity- based healthpromotion activities could reduce U 5 M Rby 27 percent. An augmentation o f US$4.87 to finance health extensiodoutreach, family community-based programs, and clinical services could reduce U5MR by 49 percent and MMRby 37 percent. These favorable outcomes make a compelling case for channeling additional funds to the health sector. 8.17 At the same time, it is important to address the reasons for low budget execution rates inorder to ensure that additional funds earmarked for the sector are spent as planned to meet sectoral objectives. While HSDP data show a few cases (Oromia, Afar and -219- Tigray) o fregions exceeding or fully spending budgeted funds from 1996/97 to 2001/02; there are very few exceptions to the over-all patterno f underspending. What can be done to improve budget execution rates? It has been argued that one possible reason for underspending is the existence o f complicated donor procedures that cause delays in spending. The PER (2003) estimates that about ten to 15 percent o f grants andloans are channeled through government budgets. The average spending rate across all the regions was approximately 44 percent, indicating that even government budgets (i.e. non-donor finds) were not completely disbursed. Another factor potentially responsiblefor underspending inhealth i s the weak capacity for programplanninghudgetingand management at the regional, zonal and woreda levels. The GOE must invest in strengtheningthe capacity for planning, budgetingand implementation at all levels, especially at the woreda level where responsibilities are increasingly being devolved. 8.18 The need to achieve an adequate balance between expansion and maintenance of adequate service delivery standards has been discussed extensively in different HSDP reviews. Coverage levels inEthiopia remain low, and giventhe needs ofthe population, the expansion targets are not overly ambitious. Yet it will be important to ensure that recurrent spending keeps pace with facility expansion. Discussions with RHB staff duringfield visits indicate that two factors have contributed significantly to the flawed financing o f HSDP I(outside o f the intra-sectoralpriorities set out inthe program): (1) HSDP's inadequate integration o fplanning andbudgeting processes;97and (2) a costing system that is based on historical expendituretrends rather thanthe strategic directions outlined inHSDP. Movingforward: this reports ash: How does the government plan to address these issues? 8.19 While decentralizationi s intended to foster local ownership and management o f government services, there are practical challenges that are inherent inEthiopia's implementation o f its decentralization policy. These encompass, but also go beyond, the health sector, and ways to motivate the woredas to focus their attention on health priorities must be identified. At present, as the system i s still intransition, woredas still greatly depend on the regional and central levels for many health system functions, including the recruitment and allocation o f health personnel and the procurement and distribution o f supplies. However, woredas are expected to decrease their reliance over time on the higher administrative levels. As this transition occurs, it will be is essential to monitor the process to ensure that health sector development objectives continue to be met. The following questions also must be addressed: What mechanisms can be usedto motivate and influence local planning and implementation? Will performance-based agreements andmatching grants be feasible? (SNNPR, for example, has started piloting performance-based contracts with its woreda officers. The experiences from this region could provide guidance as other regions transition.) 97The health budget has been developed using four separate processes: recurrent budget; capital budget financed through treasury resources; capital budget financed through loans and extemal assistance; and off-budget resources. It has been difficult to relate annual HSDP outputs and budgets with these three processes, especially since the budget process has generally been focused more on incremental increases, which are based on historical requirements, rather than on sufficient analysis o fresource requirements. The overall FDREbudget process is also usually based on a one- year time frame, while HSDP is planned over a five-year period (HSDP Review 2003). -220- 8.20 As part o fits strategy to address landdegradation, growing populationpressure, and increasingly smaller farm sizes, the government plansto resettle 2.2 million vulnerable people inareas with low population densities over a three-year period (2002- 2005) through a voluntary program. People are resettled only within their administrative regions, and resettlers have the right o freturn to their region o f origin ifthey are dissatisfied with conditions inthe resettled area. About 170,000 people were resettled in the Amhara, Oromiya, Southern Nations and Tigray regions in2003, and an additional 200,000 people hadbeen resettled as o f March 2004. An assessment of resettlement conditions in 2004 indicates thatpositive conditions existed in areas where adequate planning, preparation and resources were available. However, other areas (especially inOromiya where the mostresettlement has takenplace) faced inadequate food and water supplies as well as a lack o f health care to address problems requiring urgent action. 8.21 Past experience has shown that despite plannedimprovements to improve sector efficiency, the health sector improvements under SDPRP objectives along will not achieve the child andmaternalmortality MDGs. This report finds a strong correlation between a mother's level o f education (as well as improvedknowledge gathered through other sources such as the media), infant mortality rates and a child's nutritional status. , Additionally, a mother's educational level is indicative o fthe likelihood that she will avail herself o f health services such as immunization, antenatal care and family planning services. 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The poverty index reflects variations in food consumption and food insecurity and hence the expenditure requirements for the agricultural sector. Index is derived fiom 1995/96HICES and 1996 WMS. However, these surveys excluded non-sedentary populations in the predominantly pastoralist Afar and Somali regions, thereby underestimatingthe poverty level inthese areas. The Development index is comprised o f two sets o f variables. First set is comprised of sectoral indicators reflecting the level o f development; and second set uses unit expenditure variables reflecting different expenditure needs. It also includes administrative cost based on area and number of woreda. While this index tries to strike a balance between level o f development and expenditure needs, it i s also complex and non-transparent. A better alternative would be regional per capita income but this would have to wait for more accurate and statistically robust regional income estimates. 6 + N o r - o b m b O d - m - o - N - N m N m m o m w N N o v , w r - rc, O b d I h