Ethiopian Health System Plan 2020/21-2024/25 PDF

DIRE DAWA UNIVERSITY COLLEGE OF MEDICINE AND HEALTH SCIENCES DEPARTMENT OF PUBLIC HEALTH Health policy and management for Medical Laboratory students BY Nigus k. (Bsc, MPH/RH, MBA) OCT, 2024 ...

DIRE DAWA UNIVERSITY COLLEGE OF MEDICINE AND HEALTH SCIENCES DEPARTMENT OF PUBLIC HEALTH Health policy and management for Medical Laboratory students BY Nigus k. (Bsc, MPH/RH, MBA) OCT, 2024  Course Contents Introduction to Health System and Health Policy Health System Management Process (Planning, Organizing, leading communicating and decision making Health service coverage and quality Monitoring and evaluation Health care financing Introduction to Health Economics Health management Information System(HMIS 11/04/24 Nigus K. 2  Course Evaluation Class attendance……………………….…Compulsory Test……………………………………………......... 10% Mid exam…………………………………………... 30% Seminar presentation………………………………20% Final exam………………………………………......40% 11/04/24 Nigus K. 3 Traditional Health care in Ethiopia??? 11/04/24 Nigus K. 4 Midwifery Medhanit awakis (kitel betashs) Holy water/Tsebel/ Zemzem Circumcision  Organization of health services in Ethiopia Session objectives  Recap on traditional health care Evaluate the historical development of health services in Ethiopia Mention some of the health policies & priorities & HSDP of EFDRE Analyze the different levels of health care in Ethiopia. Explain the components of PHC  Basic Concepts of Health System HEALTH: A state of complete physical, mental and social well being and not merely the absence of disease or infirmity (WHO,1948). The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. Health Care: It is the total societal effort, undertaken in the private and public sectors, focuses on pursuing health. Health Services: are specific activities undertaken to maintain or improve health or to prevent decrements of health. 11/04/24 Nigus K. 12  Basic Concepts of Health System… A system - is a group of interacting, interrelated, or interdependent elements forming a complex whole.  Health System: is the sum total of all organizations, people, resources and all activities whose primary ‘purpose’ is to promote, restore or maintain health (WHO, 2007). 11/04/24 Nigus K. 13  Components/Pillars of Health System The WHO framework that describes health systems in terms of six core components or “building blocks”: 1) Service delivery 2) Health workforce 3) Health information systems 4) Medical product, vaccine and technology 5) Financing, and 6) Leadership/governance (stewardship) 11/04/24 Nigus K. 14 11/04/24 Nigus K. 15  What is Health Policy Health policy - refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. “…chooses to do or not to do” A health policy: Defines a vision for the future, Outlines priorities and the expected roles of different groups; and Builds consensus and informs people 11/04/24 Nigus K. 16 11/04/24 Nigus K. 17  Health Service System in Ethiopia  Brief History of the Health Care Organization in Ethiopia  Health Policies and Major Initiatives 11/04/24 Nigus K. 18  Why are health services different from other services? Measuring output is often difficult Work is variable (urgency) and complex Errors lead to serious problems Interdependent activities that need coordination Specialized services and professionalism Management has little control over the most responsible group for the work- physicians Dual lines of relationships 11/04/24 Nigus K. 19 Brief history of Ethiopian health services organization Before Italian occupation During Italian occupation After independence 11/04/24 Nigus K. 20  Before Italian Occupation Joms Bermudes, a surgeon Portuguese diplomatic mission to Lebnedengel in 1520 – 1526 was the 1st documented one. During this time, the practice had been introduced by  Diplomatic visits  Religious visits  Explorers Merchants  But served the ruling class 11/04/24 Nigus K. 21  period of Ethiopianization (1900-35 The reign of Minelik  Vaccine of small pox  The 1st hospital (Russian Red Cross in Addis) following the 1st Ethio-Italian war (1897 – 1906)  Ras Mekonnen Hospital – 1st Ethiopian Sponsored hospital built in 1901 in Harar – run by French Missionaries.  1908- 1st Public Health dep’t was opened under the ministry of interior  1909- 1st Gov’t hospital in Addis (Minelik hospital) established.  1910- More private hosp, clinic, pharmacies etc.  1930- 1st medical legislation to regulate the work of medical practitioners and pharmacies 11/04/24 Nigus K. 22  During occupation  All the health facilities were taken over by the Italians  Red cross missions (Sweden, Britain, Egypt, Holland, Norway and Finland) came to Ethiopia but soon closed because of the war.  The period was also marked by the development and expansion of services (e.g. 22 hospitals with bed capacity of 20,000 – 22,000).  Italian medical contingency force (2484 doctors, 188 pharmacy officers, 384 nurses, 16139 hospital attendants). 11/04/24 Nigus K. 23  After Independence Before 1948 Some of the facilities were destroyed by the British Ethiopia had little service after the war The health services were not coordinated and were in Fragmented way There was no line /sector Minster of Health The diplomatic entry had significant roles in health 1947 issues on health appeared Heath law (Public Health Proclamation) Health Directorate under Ministry of Interior was established 11/04/24 Nigus K. 24 Organization of Health care between 1953- 1974 (the Basic Health Services period) 1948 Ministry of Public Health was established and took the responsibilities and mandates of Health Medical practitioners registration proclamation 1951/1952 – the Basic Health Services Policy was launched Basic health services (Basic Health Services Team) approach: Expansion of Health Center and Health Stations 11/04/24 Nigus K. 25  The Basic Health Services period… The chart of the Ministry of Public Health at the time included: Ministery of Health Boards (Advisors) Task offices Main departments of services Departments Sections 11/04/24 Nigus K. 26  The Basic Health Services period… 1941 -1953 was the reconstruction period. 1954- Establishment of the Gondar Public Health Training Center.  [An important land mark in the Ethiopian Health Training and Public Health Services (HO, Community Nurse and Sanitarian)]. 11/04/24 Nigus K. 27  1974 -1991 The Ethiopian Revolution erupted in 1974 Dergue Period – Socialist Regime Sometimes called the Primary Health Care Period The National Democratic Revolution Program was launched in 1976 11/04/24 Nigus K. 28 Policy focus of the socialist regime Emphasis on disease prevention and control Priority to rural health services and their expansion Promotion of self-reliance and community involvement in health activities 11/04/24 Nigus K. 29  Limitations of the policy The policies and strategies lacked implementation guidelines for specific issues Regions and institutions had limited awareness of the polices Lack of clarity of the policy in the regions (poor dissemination) Poor international support (particularly from the developed nations) Almost no private input 11/04/24 Nigus K. 30 The Primary Health Care Strategy Comprehensive Primary Health Care Strategy: Comprehensive approach to Preventive, Promotive, Rehabilitative and Curative health care particularly for developing countries 11/04/24 Nigus K. 31  Background for PHC Most programs in developing countries were vertical programs – piecemeal, wastage of resources, lack of efficiency  period of cold war (Western and Eastern block) Experience from missionaries, NGOs, International organizations Experience from china 11/04/24 Nigus K. 32 Background… Least developed countries (independence) faced with major challenges of the copied model (Hospital-based) Equity was on the agenda: the need for alternative approach was high on the agenda 11/04/24 Nigus K. 33  Primary Health Care (PHC) Definition:  PHC is Essential Health Care made Universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that that the Community and country can afford.  It forms an integral part both of country's health system of which it is the nucleus and of the overall social and economic development of the Community. 11/04/24 Nigus K. 34  Key words in PHC Essential Health Care Universally accessible Accessible to individuals and families in the community Acceptable to the Community Full participation of Community Affordable Integral part of the health System 11/04/24 Nigus K. 35 PHC 1977: “Health for all by the year 2000” was proclaimed and the strategy was Primary Health Care. 1978: Primary Health Care Approach was declared at Alma-Ata (WHO/UNICEF) and was considered as the strategy to meet…”health for all…” 11/04/24 Nigus K. 36 Principles of PHC Inter-sectoral Collaboration Community Participation Appropriate technology Equity Focus on Health promotion and prevention Decentralization 11/04/24 Nigus K. 37 Components of PHC Health Additional Education Oral Health Food supply Provision of Mental Health And Nutrition Essential Traditional medicine Drugs Occupational health HIV/AIDS ARI Communicable Disease PHC Immunization Control Adequate Rx of common Supply of safe Diseases Water injuries sanitation MCH/FP 11/04/24 Nigus K. 38 PHC activates in Ethiopia, which formally began in 1980s, include the following: 1. Education on the prevailing health problems and methods of preventing and controlling them. 2. Locally endemic diseases prevention and control. 3. Expanded program on immunization 4. Maternal and child health including family planning 5. Essential drugs provision 6. Nutrition promotion of food supply 7. Treatment of common diseases an injuries 8. Sanitation and safe water supply.  MAJOR PROBLEMS IN THE IMPLEMENTATION OF PHC IN ETHIOPIA 1. Absence of infrastructure at the district level. 2. Difficulty in achieving inter-sectoral collaboration. 3.Inadequate health service coverage and mal-distribution for available health services. 4. Inadequate resource allocation. 5. Absence of clear guidelines or directives on how to implement PHC. 6.Presence of harmful traditional practices or unscientific beliefs and practices in Ethiopia. 7. Absence of sound legal rules to support environmental health activities. 8. Weak community involvement in health Review of PHC (1985)- Lessons Question on the level of quality of services (?equity) There were not significant resources to implement PHC including for expanding health centers, training health personnel, improving nutrition, water supply, sanitation… Not cheap: Required financial inputs which most of the developing countries could not afford. Goals were very ambitious and broad Tension between medical doctors and the concept of the strategy Lack of political commitment and instability 11/04/24 Nigus K. 41 Review of PHC (1985)- Lessons Expansion of health services to the broad mass (health stations) Expansion of immunization programs Increasing number of medical and paramedical personnel Increased health propaganda Established PHC committees at different levels 11/04/24 Nigus K. 42  Limitations of selective PHC The focus was narrow and gains were short lived Ignores the intimacy between health and development Most of the interventions are donor driven Maintained the vertical program approach: little coordination Surviving from one disease does not guarantee surviving from the other Lacked focus on Alma-Ata’s basic causes for PHC i.e. ensuring social equity and health systems development 11/04/24 Nigus K. 43 “Some argue that comprehensive primary health care is an experiment that failed; others contend that it was never truly tested” 11/04/24 Nigus K. 44 The 6 tier health care delivery system. Central hospital Regional hospital 1: 1.6-3 million Rural hospital 1: 50-100,000 people Health center (HC) 1: 50 -100,000 people Health Station (HS) 1: 10,000 people Com. health services 1: 1000 people The 6 tier health care delivery system It is very centralized and lacks professionalism  Undesirable impacts on efficiency and resource allocation  Health service institutions clustered around immediate points of supervision.  Overlapping services around a minor segment of the population In conclusion, the dev’t of health services in Ethiopia since the revolution has been relatively rapid, particularly in rural areas, but hindered by economic and political problems. The Sector-wide Approach Period (1991-?) The Ethiopian Health Policy – 1993 (Transitional Government of Ethiopia) 11/04/24 Nigus K. 47  Previous policy (Socialist Regime) More elaborated than the Emperor Haileselassie’s Focused on rural population/disadvantaged Primary Health Care strategies and activities Implementation was severely affected by the then political system: Totalitarian government 11/04/24 Nigus K. 48  Health Policy of the TGE The health policy followed the fall of the Socialist regime; Ideological shift from socialist economy to market economy (composition of global partnership also changed); Ethiopia was war ravaged including collapse of infrastructures and management in health; Poor economy, high population growth, dominantly rural populations (access) … 11/04/24 Nigus K. 49  Health Policy of FDRE General policy 1. Democratization/ Decentralization 2. Comprehensive health care (Prev., Prom. & Curative) 3. Equitable/Acceptable health service for all 4. Intersectoral collaboration 5. National self reliance in health development 6. Accessibility 7. Work closely with neighboring, regional and international organizations 8. Capacity building (need based) 9. Pay/Free service 10.Private sector & NGO participation  Health policy… The health policy - formulated within the context of the state politics/system. General policy: Democratization and decentralization Development of the preventive and Promotive components Equitable and accessible health care 11/04/24 Nigus K. 51 General policy… –Promoting inter-sectoral activities –Promoting national self- reliance (mobilizing internal and external sources) –Assurance of accessibility of services –Working closely with neighboring, regional and international organizations 11/04/24 Nigus K. 52  General… Development of appropriate national capacity Provision of health care for the population with a scheme of payment according to ability Promotion of the participation of the private sector 11/04/24 Nigus K. 53  Priorities of the Health Policy 1. Information Education Communication (IEC) 2. Emphasis: Communicable dis., occupational health and safety, environmental health, rehabilitation of infrastructure, health service management system 3. Appropriate support to curative and rehabilitative components including mental health 11/04/24 Nigus K. 54  Priorities… 4. Attention to the beneficial aspects of traditional medicine and related research 5. Applied health research on major problems 6. Provision of essential medicine, medical supplies and equipment 7. Special attention MCH; productive force; neglected regions and populations: rural, pastoralists, urban poor and national minorities; victims of man-made and natural disasters. 11/04/24 Nigus K. 55 General (guiding) strategies for the health policy Democratization Decentralization Inter-sectoral collaboration Health education Promotive and preventive Human resource development 11/04/24 Nigus K. 56 Strategies… Availability of drugs, supplies and equipment Traditional medicine Health systems research Referral system 11/04/24 Nigus K. 57 Strategies… Diagnostic and supportive services for health Health legislation Health service organization Administration and management 11/04/24 Nigus K. 58  Strategies… Democratization within the system shall be implemented by establishing health councils with strong community representation at all levels and health committees at grass-root levels to participate in identifying major health problems, budgeting planning, implementation, monitoring and evaluating health activities. 11/04/24 Nigus K. 59  Strategies… Decentralization shall be realized through transfer of the major parts of decision making, health care organization, capacity building, planning, implementation and monitoring to the regions with clear definition of roles. 11/04/24 Nigus K. 60  Context, Challenges and Opportunities 11/04/24 Nigus K. 61  Context of the Health Policy Rapid spread of HIV infection and AIDS demanding more resources for prevention, treatment and care Natural disasters including drought, flooding, … Diversity of population, poor infrastructure (road, communication) Decentralization and severe shortage of human resources 11/04/24 Nigus K. 62 Challenges Chronic illnesses are on the rise HIV/AIDS epidemic and its consequences Decentralization and acute shortage of human resources Financing the health care system 11/04/24 Nigus K. 63  Governments in developing countries face well documented challenges Heavy burden of high cost curative care Inadequate funding of public health activities Inadequate budget in relation to the physical needs of the population and large package of services governments hope to deliver Inadequate levels and quality of inputs 11/04/24 Nigus K. 64 Opportunities  The Health Extension Program – strengthening the weakened health facility – community links through house- to-house visit (community-based health services)  The Health Reform – Business Process Reengineering  Good external support & increasing donor interest  Supportive sectoral policies  Increasing number of higher learning institutions 11/04/24 Nigus K. 65  TWENTY-YEAR HSDP (1996-2015 GC) The focus was on preventive and Promotive aspects of care with: Health Education, Reproductive Health Care, Immunization, Better Nutrition Environmental Health and Sanitation receiving prominence.  Components of HSDP 1. Service Delivery and Quality of Care 2. Health Facility Rehabilitation and Expansion 3. Human Resource Development 4. Pharmaceutical Services 5. Information Education & Communication (IEC) 6. Health Sector Management & MIS 7. Monitoring and Evaluation 8. Health Care Financing  Phases of HSDP HSDP I -1997/8-2002 HSDP II -2002/3-2005 HSDPIII –July 2005-June 2010 HSDP IV –June 2010-2015  HSDP IV (2010-2015) National Policies and Strategies National Health Policy and other national policies and strategies have been taken into account in the design of HSDP IV. Development of the preventive and promotive components of the health service; Ensuring accessibility of health care by all population; Promoting inter-sectoral collaboration, involvement of the NGOs and the private sector; and Promoting and enhancing national self- reliance in health development by mobilizing and efficiently utilizing internal and external resource HSDP IV (2010-2015) Having the national health policy as an umbrella for the development of HSDP IV, other health and health related policies and strategies have been considered. These include: Policy and Strategy for Prevention and Control of HIV/AIDS The National Drug Policy The National Population Policy The National Policy on Women Child Survival Strategy  HSDP…  National Nutrition Program  National Strategy for the prevention, control and elimination of malaria  National TB prevention and control strategy  Development and Transformation Plan (DTP)  Rural Development Policy and Strategy Reproductive Health Strategy Health Extension program The Capacity Building Strategy and Program Targets: 1. Decrease maternal mortality ratio from 673 per 100,000 live births to 267/100,000 2. Decrease institutional maternal mortality rate to less than one. 3. Increase family planning service from 32% to 66% 4. Reduce teenage pregnancy from 17% to 5% 5. Increase Focused ANC 1+ from 68% to 90% and ANC 4+ from 31% to 86% 6. Increase Deliveries attended by skilled birth attendants from 18.4% to 62% 7. Increase postnatal care coverage from 34% to 78%. 8. Increase proportion of deliveries of HIV+ women that receive full course of ARV prophylaxis from 8% to 77% Targets… 9. Decrease under five mortality rate from 101 to 68 per 1000 live births 10. Decrease infant mortality rate from 77 per1000 live births to 31/1,000 11. Increase Protection at Birth (PAB) against Neonatal tetanus from 42% to 86% 12. Increase Pentavalent 3, Measles, Full immunization, Rotavirus and Pneumococcal immunization coverage from 82%, 76.6%, 65.6%, 0%, and 0%, to 96%, 90%, 90%, 96% and 96% respectively. Recent Health System Structural Changes  Ethiopia recently introduced a three-tier health care delivery system. Level (Tier ) One - Primary Level Level (Tier) Two - Secondary Level Level (Tier) Three - Tertiary Level Health tire system of Ethiopian 3 tier system  Level (Tier) One - Primary Level  The woreda (district) includes:  a primary hospital (with population coverage of 100,000 – 150,000 people),  health centers (25-40,000 people for rural, and 40,000 people for urban) , and  their satellite health posts (3-5,000 people) connected to each other by a referral system.  Health centers and health posts form a primary health care unit with each health center having five satellite health posts.  Level (Tier) Two - Secondary Level  a general hospital with population coverage of 1-1.5 million people. Level (Tier) Three - Tertiary Level  a specialized hospital that covers a population of 3.5- 5 million.  Private-for-Profit and NGO  The rapid expansion of the private-for-profit and nongovernmental organization (NGO) sectors is playing a significant role in expanding health service coverage and utilization of the Ethiopian Health care System,  Thus enhancing the public/private/NGO partnerships in the delivery of health care services in the country. Decision-making Processes, Powers, and Duties  Offices at different levels of the health sector, from the Federal Ministry of Health (FMoH) to RHBs and woreda health offices, share decision-making processes, powers, and duties:  where FMoH and the RHBs focus more on policy matters and technical support  while woreda health offices focus on managing and coordinating the operation of a district health system that includes a primary hospital, health centers, and health posts under the woreda’s jurisdiction. Decision-making Processes, Powers, and Duties…  Regions and districts have RHBs and district health offices to manage public health services at their levels.  The devolution of power to regional governments has resulted in a shift of public service delivery, including health care, largely under the authority of the regions. Global Initiatives - MDGs  MDGs – Millennium Development Goals.  Period covers 1990 – 2015.  Comprehensive goals and development focused.  There are 8 goals with 21 targets and 60 indicators.  Out of the eight goals three are on heath. 11/04/24 Nigus K. 83  MDGs The Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 that respond to the world's main development challenges. The MDGs are drawn from the actions and targets contained in the Millennium Declaration that was adopted by 189 nations-and signed by 147 heads of state and governments during the UN Millennium Summit in September 2000. 11/04/24 Nigus K. 84 The eight MDGs break down into 21 quantifiable targets that are measured by 60 indicators.  Goal 1: Eradicate extreme poverty and hunger  Goal 2: Achieve universal primary education  Goal 3: Promote gender equality and empower women  Goal 4: Reduce child mortality  Goal 5: Improve maternal health  Goal 6: Combat HIV/AIDS, malaria and other diseases  Goal 7: Ensure environmental sustainability  Goal 8: Develop a Global Partnership for Development 11/04/24 Nigus K. 85 Goal 1: Eradicate extreme poverty and hunger Target 1: Halve, between 1990 and 2015, the proportion of people whose income is less than $ 1 a day. Target 2: Halve, between 1990 and 2015, the proportion of people who suffer from hunger. 11/04/24 Nigus K. 86 Why is goal number 1 relevant to health goals? 11/04/24 Nigus K. 87 Goal 2: Achieve Universal Primary Education Target 3: Ensure that, by 2015, children everywhere, boys and girls, will be able to complete a full course of primary schooling 11/04/24 Nigus K. 88  What is the implication of goal number 2 on health goals? 11/04/24 Nigus K. 89 Goal 3: Promote Gender Equality and Empower Women Target 4: Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015. 11/04/24 Nigus K. 90 What is the implication of goal number 3 on health goals? 11/04/24 Nigus K. 91 Goal 4: Reduce Child Mortality Target 5: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate. Indicators Under-five mortality rate Infant mortality rate Proportion of 1 year-old children immunized against measles 11/04/24 Nigus K. 92 Goal 5: Improve Maternal Health Target 6:  Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Indicators  Maternal mortality ratio  Proportion of births attended by skilled health personnel  Contraceptive prevalence rate  Adolescent birth rate  Antenatal care coverage (at least one visit and at least four visits)  Unmet need for family planning 11/04/24 Nigus K. 93 Goal 6: Combat HIV/AIDS, Malaria and other diseases Target 7: Have halted by 2015 and begun to reveres the spread of HIV/AIDS Target 8: Have halted by 2015 and begun to reveres the incidence of malaria and other major diseases 11/04/24 Nigus K. 94 Indicators HIV prevalence among population aged 15-24 years Condom use at last high-risk sex Proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years Proportion of population with advanced HIV infection with access to antiretroviral drugs 11/04/24 Nigus K. 95 Incidence and death rates associated with malaria Proportion of children under 5 sleeping under insecticide-treated bednets Proportion of children under 5 with fever who are treated with appropriate anti-malarial drugs Incidence, prevalence and death rates associated with tuberculosis 11/04/24 Nigus K. 96 Goal 7: Ensure Environmental Sustainability Target 9:  Integrate the principles of sustainable development into country polices and programs and reverse the loss of environmental resources. Target 10:  Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. Target 11:  Have achieved by 2020 a significant improvement in the lives of at least 100million slum dwellers. 11/04/24 Nigus K. 97 Goal 8: Develop a Global Partnership for Development Target 12: Target 13: Target 14: Target 15: Target 16: Target 17: Target 18: 11/04/24 Nigus K. 98  SDG (Sustainable development Goal 11/04/24 Nigus K. 99  In September 2015, the era of the MDGs came to an end, the 2030 agenda for SDGs have been seated by the united nation which integrate these dimensions of sustainable development for -people, - planet, -prosperity, - peace -partnerships. 11/04/24 100  SDGs has 17 goals and 169 targets. Goal three is directly associated with health that has 13 targets. Target 3.1 indicate maternal mortality reduction It contribute for the global well-being of women, newborns, families, communities, nations, and the global community (UN 2015) 11/04/24 101 11/04/24 Nigus K. 102 11/04/24 Nigus K. 103 11/04/24 Nigus K. 104 11/04/24 Nigus K. 105 ETHIOPIA HEALTH SECTOR TRANSFORMATION PLAN (2020/21-2024/25) 11/04/24 Nigus K. 106