Ethiopian Health Care Delivery System PDF

THE ETHIOPIAN HEALTH CARE DELIVERY SYSTEM 12/20/2024 1  Session objectives At the end of this session students will be able to: o Explain historical development of Ethiopian healthcare delivery system o Describe six tier healthcare...

THE ETHIOPIAN HEALTH CARE DELIVERY SYSTEM 12/20/2024 1  Session objectives At the end of this session students will be able to: o Explain historical development of Ethiopian healthcare delivery system o Describe six tier healthcare delivery system o Discuss10 year health plan o Describe priorities of current Ethiopian health policy 12/20/2024 2  Brainstorming  Have you ever heard about 6, 4, 3 tiered health delivery system? 12/20/2024 3  Historical development Ethiopia is the second most populous country in Africa Has poor health outcomes even by sub-Saharan Africa’s standards Characterized by many decades without a national health policy Weak healthcare system infrastructure and low government spending 12/20/2024 4  Cont … In spite of its ancient civilizations and freedom from colonization, Ethiopia today is one of the least developed countries 12/20/2024 5  Cont … Modern medicine was introduced to Ethiopia in the 16th century during the regime of Emperor Libne Dingel (1508–1540) Then it was enthusiastically promoted during the reigns of Emperor Menelik II (1889–1913) and Emperor Haile Selassie (1930–1974) 12/20/2024 6  Cont … Emperor Menelik invited travellers, missionaries and members of diplomatic missions to introduce medicines and provide medical services, mostly in Addis Ababa The first hospital was established in 1906 12/20/2024 7  Cont … The foundation for formalized health service began when the gov’t instituted Ministry of Interior in 1908 12/20/2024 8  Cont … Emperor Haile Selassie established the Ministry of Public Health in 1947 In 1960 gov’t begun to develop basic health services with health center as its backbone 12/20/2024 9  Cont … Gondar College of P.H established to train Health Officers, Sanitarians And Community Nurses to staff rural health centers in 1962 In 1963 Ministry of Public Health formulated national policy and strategy for definite health services The first medical school in Addis Ababa was opened in 1966 12/20/2024 10  Cont … The monarchial gov’t had planned and executed three round 5 years’ plans The fourth round (1974-1979) was planned focusing on increasing health service coverage from 15 to 30% but not implemented b/c the gov’t was sacked 12/20/2024 11  Cont … In 1974 Dergue gov’t begun ruling the country 12/20/2024 12  Cont … When the Military Junta took over the power there were: – 6474 health personnel of all categories – 650 health stations – 93 health centers – 84 hospitals with 8624 beds, and Health service coverage was 15% 12/20/2024 13  Cont … The socialist gov’t: – Declared National Democratic Revolutionary Programme (NDRP) in 1976 NDRP states: o " To ensure full and meaningful life for the broad-masses, all the necessary effort will be under taken to provide adequate health services." 12/20/2024 14  Cont … – Revised health policy o Gave emphasis to PHC & rural health services o Prevention and control of communicable diseases 12/20/2024 15  Cont … o Promotion of self reliance and community involvement in health activities In 1978 it had adopted Alma-Ata Declaration of PHC as strategy to achieve Health for All (HFA) by the year 2000 12/20/2024 16  Cont … Specific priorities of socialist gov’t health policy: Community involvement in development activities including health Coordinate efforts of development sectors having direct or indirect bearing on health promotion The gradual integration of special programme and specialized health institutions 12/20/2024 17  Cont … The delivery of essential health care at the cost affordable by the community Development of a 6 tiered health service with levels of increasing technical complexity to facilitate management, referral support, and training 12/20/2024 18  Cont … The six-tiered national health care system consists of: – Community health services (Health Posts) – Health stations (Clinics) – Health centers – Rural hospitals – Regional hospitals and – Central referral and teaching hospitals 12/20/2024 19  Cont … A. Community Health Service (health post) – 1/1000 popn – Community Health Agent & Traditional Birth Attendant – Performing PHC programmes – Referring unresolved matters – Reporting, registration of birth & death – Participating in studies 12/20/2024 20  Cont … B. Health Station (Clinic) – 1/10,000 popn – 3 Health Assistants – Performing PHC programmes – Supporting and supervising HPs – Minor laboratory services – Referring unresolved matters 12/20/2024 21  Cont … – Participating in training – Collecting and reporting health information – Participating in Studies C. Health Center – 1/50-100,000 popn – GP (2), Nurse (3), MCH nurse (2) Sanitarian (2), Lab. Technician (1), Health Assistant (6) – Planning and implementing PHC programmes 12/20/2024 22  Cont … – Participating in training – Supporting ‘A’ and ‘B’ – Compiling health information and reporting – Medium level laboratory services – Referring unresolved matters – Participating in research and studies 12/20/2024 23  Cont.. D. Rural Hospital – 1/50-100,000 popn – Increased number of professionals in HC + Surgeon, Pharmacists, Anesthetist Nurse, Dental Hygienist, Ophthalmic Assistants, X-ray experts – Planning and implementing PHC programmes – Participating in training – Improve laboratory and X-ray services – Supporting "A" "B" and "C" and participating in supervision 12/20/2024 24  Cont … – Handle Surgical Emergencies – Compiling and analysis of health information – Referring unresolved matters – Participating in research and studies E. Regional Hospital – 1/1.6-3 mln popn 12/20/2024 25  Cont … Increased number of professionals in rural hospital + Internist, Pediatrician, Gyn-Ob, Ophthalmologist, Radiologist, Physiotherapist, Optometrist…. – Performing PHC programmes – Participating in training – Improved laboratory and x-ray services – Major speciality services – Supporting ‘A’, ‘B’, ‘C’, and ‘D’ and Participating in supervision 12/20/2024 26  Cont … – Compiling and analysis of health information – Collaborating with Regional Health Department in monitoring and evaluation of health services – Conducting research and studies – Referring unresolved matters F. Central Hospital – Increased number of professionals in RH + dentist, psychiatrist, and other medical specialties 12/20/2024 27  Cont … o Performing, strengthening and giving strong support to PHC programmes o Complete laboratory, x-ray and other examinations o Seeking solutions to major health problem o Supporting evaluating and participating in the supervision of health institutions o Conducting serious research and studies 12/20/2024 28  Cont … – Providing various trainings – Compiling, analysing and disseminating health information – Reporting 12/20/2024 29  Cont … Assessment of 6 tier HCDS indicated that: o Management is very centralized and lacks professionalism o Participation of the community and the private sector is minimal o Undesirable impact on efficiency and resource allocation 12/20/2024 30  Cont … o Health service institutions are clustered around their immediate points of supervision (Awraja and regional towns) o Overlapping services around a minor segment of the population 12/20/2024 31  Cont … Annual campaigns (1979-1985) Aimed at overcoming urgent problems in all sectors including health esp. in rural areas Implemented by high school and university students Outcomes have been encouraging in solving the urgent social and economic problems Construction of thousands of wells and latrines 12/20/2024 32  Cont … o Community health services (HPs) introduced in more than 5000 localities o Health station tripled from 650 to 1950 o Health centers increased from 93 in 1974 to 145 in 1985 12/20/2024 33  Cont … The Ten Year Health Sector Plan (1985-1994) It was the part of the over all process to achieve the goal of health for all by the year 2000 based on the principles of PHC through: o Promotion of health o Prevention of disease and o Reduction of morbidity and mortality 12/20/2024 34  Cont … Objectives of 10 year plan To foster full and active community involvement in health activities To ensure multi-sectoral collaboration and coordination in all health actions Extend health services to where the broad masses live and work Put under control all major communicable diseases 12/20/2024 35  Cont … Expand EPI services to ensure a wide coverage of the population Ensure provision of HS to mothers, children, students, under privileged nationalities, workers etc To extend medical service to 80% of the population 12/20/2024 36  Cont … Main targets of the plan o Reduction of infant mortality (IMR) from 155/1000 to 95/1000 o Reduction of child mortality rate from 247/1000 to 95/1000 o Improvement of life expectancy at birth from 42 years to 55 years 12/20/2024 37  Cont … To achieve the targets the gov’t set intermediate actions: – Training of health workers for all levels of health services – Development of supportive institutions, such as the MCH center – Improving resource capacity – Improving of property management skills 12/20/2024 38  Cont … – Maintenance and construction capacity for buildings, medical equipment, vehicles – Organizing and strengthening traditional medicine – Expanding EPI, nutrition education, medical screening, school health service – Control and prevention of communicable diseases. 12/20/2024 39  Cont … – Provision of environmental health services and clean water to include 80% of the rural popn – To increase health awareness of the population-through continuous HIE 12/20/2024 40  Example of plan for training health professionals Type of Medical Available in 1984 Plan for 1994 Personnel GP 721 2,000 Specialists 349 819 Nurses (All types) 1,960 5,498 Sanitarians 298 1,962 Lab. Tech. 425 1,209 12/20/2024 41  Cont … X-ray Tech. 138 183 Pharmacy Attendants 150 646 Health Assistants 6,991 13,500 CHA 31,500 TBA-trained 33,000 12/20/2024 42  Cont … The 10 year health plan had several shortcomings: o Unrealistic goals o Under funding o Inefficient utilization of resources o Unsuitable organizational structures o The plan remained unattended as the government was primarily pre- occupied by political conflicts and war 12/20/2024 43 Health policy of Transitional Government of Ethiopia 12/20/2024 44  Group discussion W hat is p olicy? Its imp ortan ce? W hat are the p riorities of curren t E thiop ian health p olicy? 12/20/2024 45  Cont … o A policy is a deliberate plan of action to guide decisions and achieve rational outcome(s). o It is a predetermined course of action established as a guide toward accepted organizational strategies & objectives o It is a general guideline that regulates different activities o In 1993 Ethiopian transitional government has endorsed the health policy for the country 12/20/2024 46  Cont … Priority areas of the 1993 TGE health policy o Information, Education and Communication (I.E.C) of health to enhance self-responsibility among people o Emphasis on: Control of communicable diseases, epidemics, malnutrition Promotion of occupational health & safety Development of env’tal health, health infrastructure, HSM system 12/20/2024 47  Cont … o Appropriate support shall be given to the curative and rehabilitative components of health including mental health o Due attention shall be given to the development of the beneficial aspects of Traditional Medicine including related research and its gradual integration into Modern Medicine. o Applied health research addressing the major health problems shall be emphasized 12/20/2024 48  Cont … o Provision of essential medicines, medical supplies and equipment shall be strengthened o Development of human resources with emphasis on expansion of the number of frontline and middle level health professionals with community based, task oriented training shall be undertaken 12/20/2024 49  Cont … o Special attention shall be given to the health needs of:- – The family particularly women and children – Those in the forefront of productivity – Most neglected regions and segments of the population (rural population, pastoralists, the urban poor and national minorities) – Victims of man-made and natural disasters 12/20/2024 50  Reading assignment  Strategies of TGE health policy 12/20/2024 51 Health sector develop men t p rog ram (HS D P ) 12/20/2024 52  Session objectives At the end of this session students will be able to: o Describe components of HSDP o Describe four tier healthcare delivery system o List HSDP achievements o Discuss health service extension program o Describe 3 tier health system o Describe HSTP pillars 12/20/2024 53  HSDP HSDP was launched in 1997/1998 (1990 EFY) – To respond to prevailing and newly emerging health problems – In recognition of weaknesses in the existing health delivery system – Health needs of the rural population (85%) Based on strong government commitment to democracy and decentralization 12/20/2024 54  Cont … It proposes long-term goals for the sector Has series of phased & medium-term plans Health systems management (PIE) was one of the critical elements for HSDP 12/20/2024 55  Cont … HSDP vision To see healthy, productive and prosperous Ethiopians HSDP mission To reduce morbidity, mortality and disability, and improve the health status of the Ethiopian people through providing a comprehensive package of preventive, promotive, rehabilitative and basic curative health services via a decentralized and democratized health system in collaboration with all stakeholders 12/20/2024 56  Cont … Values of HSDP o Focus on promotive, preventive and basic curative aspects of health care o Deliver integrated, efficient, quality, equitable and pro-poor health service o Efficient use of resources and application of appropriate technology o Involve the community on health care decision-making process 12/20/2024 57  Cont … o Promote transparent, result oriented and democratic working culture o Abide by professional ethics o Sense of urgency for the national development o Enhance teamwork, partnership and multisectoral approach o Be gender sensitive o Be ready for continuous change 12/20/2024 58  Cont … HSDP components: – Health service delivery and quality of care To increase the coverage and quality of promotive, preventive and curative activities – Health facility rehabilitation and expansion To increase the access to and to improve the quality of health services through the rehabilitation of the existing facilities and construction of new facilities 12/20/2024 59  Cont … – Human resource development To rationalise the categories of personnel, increase the supply of manpower, and improve the productivity of staff – Strengthening pharmaceutical services To ensure a regular and adequate supply of effective, safe and affordable essential drugs of high quality in both the public and private sector 12/20/2024 60  Cont … – Information, Education and Communication o To support the development and implementation of a national IEC strategy – Health management and information systems To improve skills in the areas of policy formulation, planning and budgeting, financial management, programme implementation, and monitoring and evaluation for staff of the FMOH and the regions 12/20/2024 61  Cont … – Health care financing To improve public sector efficiency and to generate additional and new sources of revenue – Monitoring and evaluation To monitor improvements in services delivery, quality and financial performance, and to evaluate the impact, effectiveness and cost- effectiveness of HSDP’s components 12/20/2024 62  Cont … HSDP I o Implemented from 1997/1998 to 2001/2002 (EFY 1990 – 1994) o Introduced four tier HSO o PHCU – one HC & five satellite HPs --Serve 25, 000 people o District hospital – 250, 000 people o Zonal hospital – 1 million people o Specialized referral hospital – 5 million people 12/20/2024 63  Cont … Table: Health Facility to Population Ratio of Ethiopia in 2000 (Source: HSDP II) HF type Number Ratio Hospitals 110 1 : 594,036 Health centers 382 1 : 171,057 Clinics 3,463 1 : 18,869 Health posts 1,023 1 : 63,875 Hospital beds 10,736 1: 6,086 12/20/2024 64  Cont … Some achievements of HSDP I o National standards set for HFs o Modest increase of HS utilization o ANC visit inc. 30.4% - 34.7% b/n 1997 & 2001 o FP (CPR) inc. 9.8% - 18.7% b/n 1997 & 2001 o No of zones providing DOTS Rx of TB increased o Increased no of HFs 12/20/2024 65  Cont … o National AIDS Council & National AIDS Secretariat were established o A lot of IEC activities have been undertaken to tackle HIV/AIDS o Taskforce for blindness prevention & control 12/20/2024 66  Cont … o 14, 062 (HWs) were trained far higher than plan of 9,579 o Training institutions increased from 15 to 30 o Drug Administration and Control Authority (DACA) established 12/20/2024 67  Cont … o Health Education Center (HEC) founded under auspices of FMOH o Steering committee est. at central & regional levels for M & E Lessons learnt o Need of balance b/n new HFs & recurrent budget o More structured and comprehensive approach to strengthening community-based health services 12/20/2024 68  Cont … o Integration of HSDP into general government planning and monitoring processes o Improved monitoring of health sector performance o Strengthening partnership with donors and its process 12/20/2024 69  Cont … HSDP II Implemented from 2002/03–2004/05 (EFY 1995–1997) Introduced innovative community-based approach; the Health Extension Package (HEP) 12/20/2024 70  Cont … HEP objective: – To increase access and equity to preventive essential health interventions through community/kebele based health services with strong focus on sustained preventive health actions and increased general health awareness 12/20/2024 71  Cont … Some achievements – HRD – 16, 782 HCWs (before HSDP I), 37, 233 (HSDP I), 45, 860 (in 2004) – In 2004/05 - 2, 800 health extension workers (HEWs) trained & deployed 7, 138 admitted for HEP training – DPT3 – 51.5% to 70.1% – ANC – 30% to 41.5% – TT2 for pregnants – 27% to 43.3% 12/20/2024 72  Cont … National Reproductive Health Taskforce was formed IMCI was expanded & C-IMCI initiated Integrated Disease Surveillance & Reporting (IDSR) strategy established Training of primary health care workers was 133% Number of trainings and workshops were conducted using IEC for BCC 12/20/2024 73  Cont … Table: Number of health facilities in Ethiopia (Source: HSDP III) HF type 1996 2001 2004 Hospitals 86 110 131 Health centers 243 412 600 Health posts 76 1, 192 4, 211 12/20/2024 74  Cont … Reading assignment Key achievements of: HSDP III Implemented from 2005/6-2009/10 HSDP IV Executed from 2010/11 – 2014/15 12/20/2024 75  Cont... Health sector transformation plan (HSTP) 2015/16 - 2019/20 (2008-2012 EFY) In past 20 years Government of Ethiopia has invested heavily in health system strengthening MDG-4 achieved with a 67 percent drop in under-five mortality from the 1990 estimate Average life expectancy at birth increased from 45 in 1990 to 64 in 2014 12/20/2024 76  Cont … Maternal mortality decreased from 1400 to 420 per 100, 000 live births Total fertility rate from 7.7 in the 1990s to 4.1 in 2014 16,440 health posts, 3,547 health centers and 311 hospitals have been constructed 12/20/2024 77  Cont … HSTP pillars of excellence: o Excellence in health service delivery o Excellence in quality improvement and assurance o Excellence in leadership and governance o Excellence in health system capacity 12/20/2024 78  Cont … Some targets By 2020 to reduce: o Maternal MR to 199/100,000LB o Under five-year MR to 30/ 1,000 LB o Infant MR to 20/ 1,000 LB o Neonatal MR to 10/1,000 LB 12/20/2024 79  Cont … Reduce HIV incidence by at least 60% compared with 2010 Achieve zero new HIV infections among children Reduce malaria case incidence and mortality by at least 40% each compared with 2015 Reduction in number of TB deaths and incidence rate by 35% and 20% respectively compared with 2015 12/20/2024 80  Cont … o Since HSDP IV which was began in 2010/2011, three tier health system was implemented Primary level health care- PHCU/District health system (primary hospital, HCs, HPs) –HP- 3,000-5000 people –Urban HC- 40,000 –Rural HC- 15,000-25,000 –Primary hospital- 60,000-100,000 12/20/2024 81  Cont … Secondary level health care- General Hospital expected to serve 1-1.5 million people Tertiary level health care- Specialized Hospital serves 3.5-5 million people 12/20/2024 82  Cont … PHCU Household 1 to 5 network HDA 12/20/2024 83  Cont … o HPs are expected to implement health extension programme (HEP) o HEP is a community based strategy to deliver health promotion, disease prevention and selected curative health services at the community level o HPs are staffed by two health extension workers 12/20/2024 84  What curative services do you think/know provided by HEWs?? 12/20/2024 85  Cont … o A HC is staffed with an average of 20 staff. o It provides both preventive and curative services. o It serves as a referral center and practical training institution for HEWs. o A HC has an inpatient capacity of 5 beds. o A primary hospital provides inpatient and ambulatory services to an average population of 100,000. 12/20/2024 86  Cont … o In addition to what a HC can provide, a primary hospital provides emergency surgical services, including cesarean sections and gives access to blood transfusion service. o It also serves as a referral center for HCs under its catchment areas, a practical training center for nurses and other paramedical health professionals. o A primary hospital has an inpatient capacity of 25-50 beds and is staffed by an average number of 53 persons. 12/20/2024 87  Cont … o A General Hospital provides inpatient and ambulatory services to an average of 1,000,000 people. o It serves as a referral center for primary hospitals. o It serves as a training center for health officers, nurses and emergency surgeons categories of health workers. o It is staffed by an average of 234 professionals. 12/20/2024 88  Cont … o A Specialized Hospital serves an average of five million people. o It is staffed by an average of 440 professionals. o It serves as a referral center for general hospitals. 12/20/2024 89  HSTP-II pillars 20/12/2024 90  Reading assignment  Federal min istry of health. HS T P II (2 0 2 0 /2 1 -2 0 2 4/2 5 )  How E thiop ia achieved M illen n ium D evelop men t G oal 4 throug h multisectoral in terven tion s: a C oun tdow n to 2 0 1 5 case study 12/20/2024 91  Summary Historical dev’t of healthcare delivery from Menelik II through Dergue regime Six tier healthcare delivery system Ten year health plan Priorities of TGE health policy HSDP components HSTP pillars 4 tier health system 3 tier health system 12/20/2024 92  References Chali Jira. Amsalu Feleke, Getnet Mitike. HSM lecture note. 2003 Health policy of TGE. 1993 HSDP II HSDP III HSDP IV HSTP I & II 12/20/2024 93  Questions What were the priorities of Ethiopian monarchical government health policy? How much was the health service coverage during Haile Selassie gov’t? What were the major accomplishments in health sector at the Menilik II gov’t? Compare the global primary health care strategy and socialist government health policy. What are the outcomes of six years’ annual campaigns for the health sector? What are the strategies of the TGE health policy? Explain the priorities of TGE health policy. 12/21/2024 94  Questions What were the major motivations for launching the health sector development program? Describe some major achievements of the four HSDPs. Describe the difference b/n health promotion and disease prevention. Identify b/n rehabilitative and palliative care? Explain how Ethiopia achieved the fourth MDG. Explain the primary level healthcare beginning from household. Explain why Ethiopia failed to meet the MDG five. Compare the maternal mortality reduction plan in HSTP I & HSTP II, then explain their difference that seems paradoxical. 12/21/2024 95  Thank you!! 12/20/2024 96