ANNUAL Responsive Health System in the New Beginnings!

PERFORMANCE
REPORT 2013 EFY (2020/2021)
ANNUAL Responsive Health System in the New Beginnings!

PERFORMANCE
REPORT 2013 EFY (2020/2021)
CONTENTS

LIST OF TABLES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
LIST OF FIGURES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .VIII
ACRONYMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IX
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XIII
CHAPTER 1: INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CHAPTER 2: PROGRESS OF HSTP-II TRANSFORMATION AGENDAS. . . . . . . . . . . . . . . . . . . . . . . . 4
2.1. Transformation in Quality and Equity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
2.2. Information revolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
2.3. Motivated, Competent and Compassionate (MCC) Health Workforce . . . . . . . . . . . . . . . . . . . . . .6
2.4. Transformation in Health Financing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
2.5. Transformation in Leadership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
CHAPTER 3: HEALTH SERVICE DELIVERY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1. Health Extension Program and Primary Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
3.2. Hygiene and Environmental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.3. Reproductive and Maternal Health and Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.4. Prevention of Mother to Child Transmission of HIV (PMTCT). . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.5. Neonatal, Child, Adolescent and Youth Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5.1. Expanded Program on Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5.2. Neonatal and Child Health Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.5.3. Adolescent and youth Health Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.6. Nutrition Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
3.7. Seqota Declaration implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.8. Prevention and Control of Communicable Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
3.8.1. HIV Prevention and Control Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
3.8.2 Tuberculosis and Leprosy Prevention and Control Program. . . . . . . . . . . . . . . . . . . . . . . 59
3.8.3. Malaria Prevention and Elimination Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.9. Prevention and control of Non-Communicable Diseases and Injuries. . . . . . . . . . . . . . . . . . . . . 71
3.10. Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
3.11. Prevention and control of Neglected Tropical Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.12. Clinical Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
2.13. Emergency and Critical care services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
3.14. Blood Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
3.15. Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
3.16. Health Service Quality and Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
ANNUAL PERFORMANCE REPORT

CHAPTER 4: LEADERSHIP AND GOVERNANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

4.1. Regulatory System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
4.1.1. Food, drug and medicine regulatory functions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
4.1.2. Health and health related institution regulatory functions . . . . . . . . . . . . . . . . . . . . . . 100
4.1.3. Health Professionals’ Competency Assessment and Licensure . . . . . . . . . . . . . . . . . . . 101
4.2. Health Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.3. Gender, Youth and People with Disability Mainstreaming . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
4.4. Policies and Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.5. Health reform and good governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
CHAPTER 5: HUMAN RESOURCE FOR HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
5.1. Capacity building/Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
5.2. Human Resource Management Information system (HRIS). . . . . . . . . . . . . . . . . . . . . . . . . . 109
5.3. Deployment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
5.4. Motivation and retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
5.5. Management of Technical Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
5.6. Distribution of Health workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
5.6.1. Stock of Health workforce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
5.6.2. Distribution of Health workforce by Region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
5.6.3. Health professionals to population Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
CHAPTER 6: Health Information System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
6.1. Evidence based decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
6.2. Use of Technology and Innovations/Digital health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
6.3. Basic and Operational Researches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
CHAPTER 7: PHARMACEUTICALS AND MEDICAL SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
7.1. Pharmaceuticals supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
7.2. Medical equipment and Pharmaceutical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
CHAPTER 8: HEALTH FINANCING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
8.1. Resource Mobilization and utilization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
8.2. Public Budget allocation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
8.3. Health Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
CHAPTER 9: PUBLIC HEALTH EMERGENCY PREPAREDNESS AND RESPONSE . . . . . . . . . . . . . . . . 144
9.1. Epidemic Prevention and Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
9.2. Health Emergency response in conflict affected areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
9.2.1. Health Emergency response in Tigray region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
9.2.2. Emergency Health Response to Other conflict affected areas. . . . . . . . . . . . . . . . . . . . . 148
CHAPTER 10: COVID-19 AND ITS RESPONSE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

IV
2013 EFY (2020/2021)
 MINISTRY OF HEALTH

LIST OF TABLES
Table 1. Distance of Health Posts from supervising Health centers, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Table 2. Number of High Performing PHCU by Region, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Table 3. Summary of the Performance of maternal health indicators, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Table 4. Still birth rate per 1,000 births attended in 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Table 5. Number of maternal deaths notified through MPDS system in 2013 EFY by region. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Table 6. Coverage of maternal health services in Tigray region, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Table 7. Percentage of health posts providing CBNC and iCCM service, 2012-2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Table 8. Proportion of health centers providing IMNCI services by Region, 2012-2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Table 9. Number of stunting cases averted (0-59 months) during the innovation phase of Seqota Declaration. . . . . . . . . . . . . . . . 49
Table 10. Number of lives saved during the innovation phase of Seqota Declaration, by year . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Table 11. Number of people tested for HIV and number of new positives identified (2013 EFY Plan versus achievement), by region. . 51
Table 12. Number and percentage of PLHIV currently on ART disaggregated by age, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . 53
Table 13. 2nd 95 using 81% (first 95 result) of PLHIVs as denominator, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Table 14. Number of Leprosy cases detected, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Table 15. Grade II disability rate among new cases of leprosy by region, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Table 16. Malaria Incidence rate per 1,000 populations at risk and Malaria Deaths per 100,000 populations at risk, 2013 EFY . . . . . . 69
Table 17. Indoor residual spraying coverage and the type of chemical used, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Table 18. Nationally reported mental and neurological illness by sex during 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Table 19. List of blood banks in Ethiopia, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Table 20. Number of functional and under construction Health Posts by Region, EFY 2013. . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Table 21. Number of functional and under construction Health Centers by Region, EFY 2013 . . . . . . . . . . . . . . . . . . . . . . . . . 103
Table 22. Number of functional and under construction Hospitals by Region, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Table 23. Health Workforce Distribution by Region, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Table 24. Selected Health Professionals to Population Ratio by Region, September 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . 114
Table 25. Amount of fund committed and disbursed by development partners, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Table 26. Share of Total health budget (%) from total government budget in 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Table 27. Number of Woredas that started CBHI implementation and services, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Table 28. CBHI membership and fee collection in Woredas that have started CBHI service, 2013 EFY. . . . . . . . . . . . . . . . . . . . . 141
Table 29. Regional distribution of suspected Cholera cases, deaths and CFR in Ethiopia, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . 145
Table 30. Total number of children vaccinated in response to polio outbreaks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Table 31. Measles Outbreak Response from 2017 to 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

LIST OF FIGURES
Figure 1. IR assessment status by period of assessment, June 2021. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Figure 2. Comparison of Quarter IV EHCRIG performance by Chapter: 2012 EFY Vs 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 3. Contraceptive Acceptance Rate: Comparison of baseline, 2013 performance and target by region . . . . . . . . . . . . . . . . . 19
Figure 4. Contraceptive method mix, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Figure 5. Antenatal Care Coverage- four or more visits by Region, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Figure 6. Proportion of pregnant women tested for syphilis, comparison of baseline, 2013 performance and 2013 target. . . . . . . . . 23
Figure 7. Proportion of pregnant women received iron and folic acid supplements at least 90 plus, 2013 EFY. . . . . . . . . . . . . . . . 23
Figure 8. Proportion of births attended by skilled health personnel, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Figure 9. Early PNC coverage by region, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Figure 10. Missed opportunity in pregnancy continuum of care, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Figure 11. Number of maternal deaths reported against the estimated maternal death reported through MPDR surveillance system
(2007-2013 EFY)` . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Figure 12. Percentage of pregnant, Laboring and lactating women who were tested for HIV and who know their results in 2013EFY. . 30
Figure 13. Percentage of HIV-positive pregnant women who received ART to reduce the risk of mother-to child-transmission in
2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Figure 14. Pentavalent 3 vaccination coverage by region, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Figure 15. Measles-1 vaccination coverage (MCV1) by region, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

V
2013 EFY (2020/2021)
ANNUAL PERFORMANCE REPORT

Figure 16. Full vaccination coverage by region, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Figure 17. Dropout Rate (Pentavalent-1 to Measles vaccination), 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Figure 18. Proportion of children under 2 years of age that received GMP service, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Figure 19. Proportion of children aged 6-59 months of age who received two doses of Vitamin A supplementation . . . . . . . . . . . . 44
Figure 20. Proportion of Children aged 24 - 59 months de-wormed, 2012 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Figure 21. Multi-sectoral approach for stunting reduction project (MASREP) approval ceremony in April 2013 EFY. . . . . . . . . . . . . 48
Figure 22. HIV positivity among key and priority population groups, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Figure 23. Trend of TB incidence in Ethiopia, 2015 to 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Figure 24. TB treatment coverage (all forms of TB) by region, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Figure 25. TB Cure rate among bacteriologically confirmed pulmonary TB cases, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Figure 26. Tuberculosis treatment success rate among bacteriologically confirmed new PTB cases, 2013 EFY. . . . . . . . . . . . . . . . 62
Figure 27. Proportion of all forms of TB cases with unsuccessful treatment outcome, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . 62
Figure 28. Proportion of all forms of TB cases with unsuccessful treatment outcome, by type of outcome, 2013 EFY. . . . . . . . . . . . 63
Figure 29. Trend in number of malaria cases, 2009 EFY to 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Figure 30. Number of individuals screened for hypertension and enrollment to care performance, 2012 and 2013 EFY . . . . . . . . . . 73
Figure 31. Number of individuals screened for diabetes and enrollment to care, 2012 and 2013 EFY . . . . . . . . . . . . . . . . . . . . . . 73
Figure 32. Trachomatous Trichiasis screening and Surgery at community level, Photo, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . 78
Figure 33. Annual OPD attendance per capita, 2013EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Figure 34. Annual average length of stay by region, 2013EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Figure 35. Hospital Bed Occupancy Rate (BOR) by region, 2013EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Figure 36. Annual emergency mortality rate by region, 2013EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Figure 37. Annual Intensive care unit (ICU) mortality rate by region, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Figure 38. Proportion of road-traffic injury cases by type, 2013EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Figure 39. World Blood Donor Day Commemoration event at Arbaminch Town; June 14, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . 88
Figure 40. Prevalence of Blood Transfusion Transmissible Infections (TTIs) among Blood Donors tested positive for TTIs, 2013 EFY . . 89
Figure 41. Performance of medical laboratories for SLIPTA in Ethiopia 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Figure 42. Delay for elective surgical admission (in days) by region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Figure 43. Summary of National Health Workforce in 2013EFY (2020/21) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Figure 44. Service Reporting completeness and timeliness, 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Figure 45. Disease Reporting completeness and timeliness, 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Figure 46. Trend of pharmaceuticals procured, amount in Billion Birr (2009 EFY to 2013 EFY) . . . . . . . . . . . . . . . . . . . . . . . . . 128
Figure 47. Trend of pharmaceuticals distributed, amount in Birr (200 EFY-2013 EFY). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Figure 48. Medical Equipment Installation and maintenance campaign. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Figure 49. Number of Medical Equipment Maintained in 2013 EFY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Figure 50. Number of Medical Equipment installed in 2013 EFY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Figure 51. Anthrax outbreak cases in Arbaminch town, SNNPR, May-June 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Figure 52. Measles outbreaks in Ethiopia, by Epi Weeks: Week 01-24, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Figure 53. COVID-19 situation in Ethiopia: Total since the pandemic started versus October 1, 2020 to August 31, 2021 . . . . . . . . . 152
Figure 54. Number of deaths due to COVID-19 by region, from October 1, 2020 to August 31, 2021 . . . . . . . . . . . . . . . . . . . . . . 153
Figure 55. Summary of COVID-19 situation in treatment centers from October 1, 2020 to August 31, 2021. . . . . . . . . . . . . . . . . . 153
Figure 56. Summary of COVID-19 situation in Home based isolation centers: Total since COVID-19 started and October 1, 2020 to
August 31, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Figure 57. Summary of COVID-19 in health care workers, august 31, 2021. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Figure 58. Trend of laboratory test from October 1, 2020 to August 31, 2021 by Epi-weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Figure 59: COVID-19 related events and major activities timeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

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 MINISTRY OF HEALTH

FOREWORD

I am pleased to share with you the 2013 EFY performance report of the health
sector of Ethiopia. It is a detailed report that shows achievements; major
initiatives and activities, and challenges of the health sector in the fiscal year.
The health sector has developed the second health sector transformation
plan (HSTP-II) for the period 2013 EFY-2017 EFY (2020/21-2024/25). The
strategic plan has set a goal of improving the health status of the population,
by accelerating progress towards Universal Health Coverage, protecting
people from emergencies, progressing towards Woreda transformation,
and improving health system responsiveness. This year, 2013 EFY (2020/21),
marks the first year of HSTP-II, when we started our commitment towards
the achievement of HSTP-II objectives and targets. This annual performance
report highlights the progress made in the first year of the HSTP-II period.
As you know, 2013 EFY was a year when the health system is challenged by
the continued COVID-19 pandemic and other emergencies such as conflicts
resulting in many internally displaced people in different parts of the country.
Despite the challenges that we have been through in the fiscal year, the sector
has registered remarkable results in improving access to and utilization of health
H.E. DR. LIA TADESSE services by enhancing the implementation of essential health interventions at
all levels of the health system. The report shows that utilization of maternal
Minister, Ministry of Health, and child health interventions and services have improved; registered
Federal Democratic encouraging results in the prevention and control of major communicable
Republic of Ethiopia diseases such as HIV, tuberculosis and malaria. Moreover, to address the ever-
growing non-communicable diseases (NCD) in Ethiopia, we have strengthened
various NCD prevention and control interventions such as improved screening,
service integration, treatment and management of major NCDs. In addition,
we have been successful in improving health system investments such as
improving the number and mix of health workforce, improving the supply of
pharmaceuticals, and health financing.
In terms of emergencies, we strengthened our responses to the COVID-19
pandemic, including the introduction and expansion of COVID-19 vaccination
enhancing our emergency and critical care treatment capacity. In addition,
emergency preparedness, prevention, response and recovery activities to
other public health emergencies were implemented to protect vulnerable
populations. Through our emergency management efforts, we have learned
lessons to make our health system more resilient and accelerate progress
towards universal health coverage.
In addition to the emergencies mentioned above, shortage of supplies due
to global market constraint, unemployment of our workforce, inadequate
basic amenities at health facilities and inadequate financing were additional
hurdles for the health sector.
The results that we achieved this year are through the determination and hard
work of our health workers and health leaders at all levels of the health system
and the continued partnership and collaborative efforts of all stakeholders.
I would like to commend all the health workers, development partners, and
all the other stakeholders for your commitment towards improving the health
status of the Ethiopian population.
We need to strengthen our commitment and stand in solidarity in efforts that
can improve the health of our people and save thousands of lives. I call upon
all stakeholders to strengthen our collaboration and partnership to a greater
level, work together towards HSTP-II objectives and targets. Working together,
we can achieve what we have envisioned. I believe that, together, we can and
will make a difference, as an ancient Ethiopian proverb says “ድር ቢያብር አንበሳ
ያስር!”.
Lia Tadesse (MD, MHA)
Minister of Health, Ethiopia
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ANNUAL PERFORMANCE REPORT

ACKNOWLEDGEMENTS

This 2013 EFY annual performance report (APR) is coordinated and prepared by a technical team organized
from the Policy, Planning, Monitoring and Evaluation Directorate (PPMED). It is prepared with a continued
support and commitment of experts from PPMED, experts from all directorates of MOH, agencies, Regional
Health Bureaus and development partners. The PPMED would like to extend its appreciation to all those who
supported the preparation of this comprehensive annual performance report.

Report writing technical team members

The following individuals are the report preparation members, reviewers and editors of this APR

Reviewers and editors of the report

 Naod Wondrad (BSC, MHA) – Editor-in-Chief

- Director, PPMED, MOH

 Shegaw Mulu (BSC, MPH, MSC)– Reviewer, Editor-in-chief and Coordinator

- Senior Health Information Systems and M&E advisor, PPMED, MOH

 Wubshet Denboba (BSC, MPH) – Reviewer and Editor-in-chief

- Senior Health Information systems and data use specialist, PPMED, MOH

Report-writing team members

 Ayele Teyou (BSC, MPH); Consultant, MOH, PPMED

 Daniel Getachew (BSC, MPH); HIS consultant, MOH, PPMED

 Lemma Gutema (BSC, MPH); HMIS specialist, MOH, PPMED

 Meskerem Abebaw (BSC, MPH); M&E expert, MOH, PPMED

 Shegaw Mulu (BSC,MPH,MSC); Senior Health Information Systems and M&E advisor, PPMED, MOH

 Shemsedin Omer (BSC, MPH); Data use specialist, MOH, PPMED

 Solomon Kassahun (BSC, MPH); M&E expert, MOH, PPMED

 Tsedeke Mathewos (BSC, MPH); M&E technical assistant, MOH, PPMED

 Wubshet Denboba (BSC, MPH); Senior Health Information systems and data use specialist, PPMED,
MOH

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 MINISTRY OF HEALTH

ACRONYMS

AA Addis Ababa
AARHB Addis Ababa Regional Health Bureau
AFRO African Regional Office
AIDS Acquired Immunodeficiency Syndrome
ALOS Average Length of Stay
ANC Antenatal Care
ANC4 Antenatal Care Four visits
APR Annual Performance Report
APTS Auditable Pharmaceutical Transaction and Service
ARM Annual Review Meeting
ART Antiretroviral Therapy
ARV Antiretroviral
AVW African Vaccination Week
BCC Behavior Change Communication
BEmOC Basic Emergency Obstetric Care
BFHI Baby Friendly Hospital Initiative
BMI Body Mass Index
BOR Bed Occupancy Rate
BP Blood Pressure
C/S Caesarean Section
CAR Contraceptive Acceptance Rate
CASH Clean and Safe Health
CBHI Community Based Health Insurance
CBMP Capacity Building and Mentorship Program
CBN Community Based Nutrition
CBNC Community Based New Born Care
CEmOC Comprehensive Emergency Obstetric Care
CFR Case Fatality Rate
CHD Community Health Day
CHIS Community Health Information Center
CPR Contraceptive Prevalence Rate
CRC Compassionate Respectful and Caring
CSA Central Statistical Agency
CVD Cardio Vascular Disease
DALYS Disability Adjusted Life Years
DBS Dry Blood Sample
DHIS2 District Health Information System
DM Diabetes Mellitus
DPs Development Partners
DR TB Drug resistance Tuberculosis
ECD Early Childhood Development
eCHIS Electronic Community Health Information System

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EDHS Ethiopia Demographic and Health Survey

EFY Ethiopian Fiscal Year
EHAQ Ethiopian Hospitals Alliance for Quality
EHCRIG Ethiopian Health Center Reform Implementation Guideline
EHRIG Ethiopian Hospital Reform Implementation Guideline
EHSTG Ethiopian Hospital Services Transformation Guideline
ENBC Essential New-born Care
EOS Enhanced Outreach Strategy
EPI Expanded Program on Immunization
EPSA Ethiopia Pharmaceutical Supply Agency
EPTB Extra pulmonary Tuberculosis
ETB Ethiopian Birr
EU European Union
FHT Family Health team
FMHACA Food, Medicine and Healthcare Administration and Control Authority
FMOH Federal Ministry of Health
GMP Growth Monitoring and Promotion
GOE Government of Ethiopia
HAPCO HIV/AIDS Prevention and Control Office
HCs Health Centers
HCT HIV Counselling and Testing
HDA Health Development Army
HEP Health Extension Program
HEW Health Extension Workers
HIT Health Information Technician
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HPV Human Papilloma Virus
HRH Human Resource for Health
HSTP Health Sector Transformation System
HSTQ Health Service Transformation in Quality
ICCM Integrated Community Case Management
ICD International Classification of Disease
ICMNCI Integrated Community Case Management of New-born & Childhood Illness
ICU Intensive Care Unit
IEC Information, Education & Communication
IESO Integrated Emergency Surgery &Obstetrics
IFMIS Integrated Financial Management Information System
IMNCI Integrated Management of Neonatal and Child Illness
IMR Infant Mortality Rate
IR Information Revolution
IRS Insecticide Residual Spray
IRT Integrated refresher Training
ISS Integrated Supportive Supervision
IUCD Intrauterine Contraceptive Device

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 MINISTRY OF HEALTH

JCCC Joint Core Corrdinating Committee

JCF Joint Consultative Forum
JSC Joint Steering Committee
KPI Key Performance Indicators
LEEP Loop Electro Excision Procedure
LLINs Long-Lasting Insecticidal Net
LQAS Lot Quality Assurance Sampling
M&E Monitoring and Evaluation
MAM Moderate Acute Malnutrition
MARPs Most-At-Risk Population
MCH Maternal and Child Health
MCP Model Community Pharmacy
MDA Mass Drug Administration
MDSR Maternal Death Surveillance and Response
MFR Master Facility Registry
MHM Menstrual Hygiene Management
MMR Maternal Mortality Ratio
MNH Maternal & Newborn Health
MNHQoC Maternal Newborn and child health Quality of Care
MOE Ministry of education
MoF Ministry of Finance and Economic Commission
MOH Ministry Of Health
MPDSR Maternal and Perinatal Death Surveillance and Response
MPH Master of Public Health
MTCT Maternal To Child Transmission
NBC New Born Care
NCDI Non-Communicable Diseases and Injuries
NEQAS National External Quality Assessment Scheme
NICU Neonatal Intensive Care Unit
NNMR Neonatal Mortality Rate
NNP National Nutrition Programme
NTD Neglected Tropical Diseases
ODF Open Defecation Free
OPD Out Patient Department
ORS Oral Rehydration Salt
PCR Polymerase Chain reaction
PCV Pneumococcal Conjugate Vaccine
PHCU Primary Health Care Unit
PHEM Public Health Emergency Management
PIRI Periodic Intensified Routine Immunization
PLHIV People Living with HIV
PMED Pharmaceuticals and Medical Equipments Directorate
PMTCT Prevention of Mother to Child Transmission of HIV
PNC Post Natal Care
PPMED Poliy, Plan, Monitoring and Evaluation Directorate

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PPP Public-Private Partnership

PTB Pulmonary Tuberculosis
QI Quality Improvement
RDQA Routine Data Quality Assessment
RDT Rapid Diagnostic Test
RHBs Regional Health Bureau
RMNCAYH Reproductive, Maternal, Neonatal, Child, Adolescents and Youth Health
RMNCH Reproductive, Maternal, Neonatal and Child Health
SALTS Saving Life through Safe Surgery
SAM Severe Acute Malnutrition
SARA Service Availability and Readiness Assessment
SBCC Social and Behavior Change Communication
SDGs Sustainable Development Goals
SLD Second Line Drug
SNNPR Southern Nations, Nationalities and Peoples’ Region
STH Soil Transmitted Helminthiasis
TB Tuberculosis
TFC Treatment Follow up centers
TICs Treatment Initiating Centers
TOT Training of Trainers
TVET Technical Vocational Educational Training
TWG Technical Working Group
U5MR Under 5 Mortality Rate
UN United Nation
UNFPA United Nations Population Fund
USD United States Dollar
UVP Utrovaginal Prolapse
VAS Vitamin A Supplementation
VPN Virtual Private Network
WASH Water, Sanitation and Hygiene
WDA Women Development Army
WHO World Health Organization
WoHO Woreda Health Office

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 MINISTRY OF HEALTH

EXECUTIVE SUMMARY

This annual performance report details the performance of the health sector in 2013 EFY, the first year of the
HSTP-II period. The report mainly describes the achievements of the sector by comparing performance against
the targets set for 2013 EFY, and includes major initiatives, activities and challenges by program and health
system investment areas. The fiscal year was a time when the health system was challenged by the continued
COVID-19 pandemic and conflicts in different parts of the country resulting in high number of internally
displaced people (IDPs). Despite the emergency challenges that has huge negative impacts on the health
system, the health sector has achieved encouraging results in terms of improving utilization of maternal and
child health services, prevention and control of communicable and non-communicable diseases, emergency
management and response and other health services. However, regional disparity in service utilization was
observed, which denotes designing and implementation of interventions to close the equity gap among the
regions. The achievements of the health sector in the fiscal year were not without challenges. In addition to the
occurrence of emergencies, other challenges and shortcomings, that includes inadequate health workforce
density and mix, inadequate basic amenities at health facilities; inadequate financing; and shortage of
pharmaceutical supplies. The quality of health services was also sub-optimal.

Primary health care and health extension program strengthening activities were performed in the fiscal year.
The health-extension program optimization roadmap was officially launched and implementation started.
Competency based training was provided to 343,832 women development army (WDAs), among which 225,155
were assessed for their competency and 204,000 were found to be competent. In order to advance community
engagement mechanisms in HEP, alternative community engagement approaches were identified and pilot
testing was started in the fiscal year. In the fiscal year, 526 PHCUs were reported as high performing, which
is a 78% increment from the previous yea (from 298). Regarding model Woreda creation, 547 Woredas have
reported their status, among which, 57 were model and 199 were medium performing. In terms of hygiene and
environmental health, Ethiopia has registered significant achievement in reduction of open defecation (OD);
from 92% in 2000 to 17% in 2021, and unimproved latrine coverage has increased from 8% in 2000 to 65% in
2021.

Utilization of maternal health services has shown improvement compared to the previous year. In the fiscal
year, contraceptive acceptance rate was 73%, a 4 percent point increment compared to the baseline. Seventy
percent of pregnant women received four or more ANC visits, 66% women delivered at health facilities and
85% received early PNC service. From ANC attendants, 97% were provided with iron and folic acid but only
72% were screened for syphilis. Still birth rate is decreased from 14 per 1000 births in 2012 EFY to 12 in 2013
EFY. Coverage of immunization services was high with 97% and 93% of under 1 infants received measles 1 and
full immunization services. Regarding child health service uptake, 74.2% of under five children with diarrhea
received ORS & Zinc treatment, while 60.8 % of the same age group with ARI received antibiotics. More than 11
million (86%) children aged 6-59 months received vitamin A, more than 7.7 million (82%) children aged 24-59
months received deworming service.

The health sector has recorded a remarkable improvement in prevention and control of major communicable
diseases (HIV, TB and Malaria). Regarding HIV, more than 7.2 million people were tested, among which 33,988
(0.47%) new HIV positives were identified through implementation of different innovative-targeted HIV testing
strategies. The performance report also shows that Ethiopia has well progressed in achieving the second and
third targets of the 95-95-95 targets of HIV. The first 95 performance in 2013 EFY was 81%, while the second 95
performance was 95% and third 95 performance was 95%. Tuberculosis incidence has consistently decreased
over the years, and reached to 140 cases per 100,000 population in 2020. In terms of detecting and treating
TB patients, TB treatment coverage in 2013 EFY is 76%, which is higher by 5 percent points from the previous
year. Regarding treatment outcome of bacteriologically confirmed TB cases, 95% successfully completed

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treatment. Regarding malaria, 23 malaria cases per 1000 population at risk were reported, which is lower by
five compared to the previous year. Deaths due to malaria has also decreased in the fiscal year.

The burden of non-communicable disease and mental health problems is increasing in Ethiopia. The sector
has designed and implemented NCD prevention and control interventions, including awareness creation,
promotion of healthy lifestyles, and integration of major NCD interventions to primary health care services.
NCD screening, diagnosis, management and follow up care training, as part of the Ethiopian Primary Health
Care Guideline initiative, is provided and the service is being provided in 2086 health centers and all hospitals.
Integration and expansion of mental health services to primary health facilities was also done. Cervical cancer
screening was done for 160,290 women aged 30-49 years.

NTD prevention and control interventions and services were strengthened in the fiscal year. TT surgery was
done for more than 34,077 people with TT, more than 17.7 million people were treated with Ivermectin for
the prevention of onchocerciasis; more than 3.2 million people were treated for lymphatic filariasis, more
than 6.9 million people were treated for soil transmitted helminths, and 1,178 visceral and 1,389 Cutaneous
Leishmaniasis patients received treatment.

The OPD attendance per capita in 2013 EFY was 1.09, a little higher than last year but far below the expected.
Regarding quality improvement and assurance, the second national health care quality and safety strategy
was developed, approved and its implementation started. Different quality improvement initiatives such as
Maternal Newborn and child health Quality of Care initiative, Learning Health Facility initiative, Saving Lives
through Safe Surgery (SaLTS) initiatives were implemented and positive results documented.

Public health infrastructure expansion has been one of the major achievements to make health services
accessible to the population. At the end of 2013 EFY, 367 public hospitals, 3,777 health centers and 17,699
health posts were functional and providing services. Regarding regulation, the sector has performed regulation
of health products, food, facilities and professionals. Accordingly, 79 child foods and 900 different types of food
were registered and post-marketing inspections were undertaken. In addition, 779 pharmaceuticals and 2891
medical equipment licenses were issues. To strengthen evidence based decision-making, data quality and use
improvement initiatives have been conducted. In addition, basic and operational researches were conducted
to strengthen evidence generation and use.

Regarding the health workforce capacity of the sector, 325, 374 health workers (65% of them are health
professionals) are providing health services in public health institutions at the end of the fiscal year. The
health professionals to population ratio is improving over the years. At the end of 2013 EFY, the physician to
population ratio was 1: 8448; nurse to population ratio was 1:1473 and midwives to population ratio was 1:
5053. The health workforce density for physicians/HOs, nurses and midwives was 1.16, which is much lower
than WHO recommendation of 4.45 to achieve SDGs. Though there is an improvement in the number and mix
of health workforce, it still is far below the recommended, calling for improvement in the HRH profile of the
sector.

The sector has strengthened pharmaceuticals supply system through different strategies such as cyclical
procurement, category management system and framework agreements. In 2013 EFY, more than ETB 17.01
Billion worth of pharmaceuticals and medical supplies were procured, an amount more than the previous
years. The availability of vital and essential pharmaceuticals at national level was 85% and 83% respectively.
Pharmacy services and medical equipment maintenance services were strengthened in the fiscal year. APTS is
started in 107 health facilities, adding the total APTS implementing facilities to 324.

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 MINISTRY OF HEALTH

In the fiscal year, various initiatives were implemented to improve health financing. Proactive resource
mobilization was conducted from national and international sources. Accordingly, 13.2% of the total
government budget was allocated to health in 2013 EFY, a higher proportion than the previous years. More
than 388 million USD was mobilized and disbursed from development partners. In addition, implementation
of health care financing reform components were strengthened. Public-Private partnership (PPP) in health is
initiated for three projects. Implementation of CBHI is strengthened, 834 Woredas have started implementing
CBHI and 61% of the eligible households were members.

In 2013 EFY, the health system has been challenged with different emergencies including COVID-19 pandemic
and conflicts that resulted many IDPs in various parts of the country. The health sector has collaboratively
worked with stakeholders to respond to these emergencies. Regarding COVID-19, since the epidemic was
started in March 2020, a total of 319,101 cases and 4830 deaths were reported by the end of August 2021. The
health sector has strengthened the public health epidemic preparedness, prevention and response actions in
the fight against the COVID-19 pandemic. Emergency management actions such as contact tracing, screening,
laboratory testing, expansion of COVID-19 treatment sites and treatment services were some of the major
actions. In addition, the sector has mobilized COVID-19 vaccines and COVID-109 vaccination is being provided
to people aged 18 and above. Health emergency responses and recovery actions were provided to conflict
affected areas in different parts of Ethiopia.

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 CHAPTER

INTRODUCTION
 MINISTRY OF HEALTH

CHAPTER 1: INTRODUCTION

T
he health sector has developed a five-year strategic plan, the second Health Sector Transformation
Plan (HSTP-II) with an overarching objective of improving the health status of the population; and with
four main objectives, namely, accelerating progress towards Universal Health Coverage, protecting
people from health emergencies, achieving Woreda transformation and improving health system
responsiveness. HSTP-II spans for the period 2020/21 to 2024/25 (2013 EFY to 2017 EFY). This fiscal year (2013
EFY) is the first year of HSTP-II period and it is a time when the health system is affected by COVID-19 pandemic
and insecurities in many areas with many internally displace people (IDPs) creating an additional challenge to
the health system.

This is the annual performance report (APR) of the health sector for the 2013 EFY (2020/2021), the first year
of the HSTP-II period. The report mainly include progress of the health sector in achieving the 2013 EFY
annual targets, comparing the annual performance with the annual target. HSTP-II identified five priorities/
transformation agendas, including 1) quality and equity; 2) Motivated, Competent and Compassionate Health
workforce (MCC); 3) information revolution; 4) leadership and 5) health financing. The status and progress of
these transformation agendas are highlighted in the report.

The report details the progress of the different health programs, identifies the major challenges that impede
implementation of the specific programs and recommendations/way forward for the forthcoming fiscal year.
It mainly includes the following areas:

 Health service coverage (utilization of different health services) in 2013 EFY

 Comparison of the performance of 2013 EFY against the target set for the fiscal year
 Trends in performance
 Comparison of performance by region
 Status of implementation of health system investments such as health infrastructure, financing,
governance and leadership, health information, pharmaceuticals
 Emergencies in the fiscal year and major responses performed
 Major initiatives and activities conducted in the fiscal year, for each program area
 Major challenges and the way forward, for each program and investment area

To prepare this performance report, various data sources were used. The main data source for the quantitative
data analysis is the routine HMIS report from DHIS2. In addition, other data sources such as surveillance
information system from EPHI, human resource information system, health-commodity information system,
regulatory system information system, global estimates and other data sources are used. Administrative
data and report from programs are also used. Due to a conflict in the northern part of Ethiopia, there were
no reports from Tigray region for more than 9 months in the fiscal year. Consequently, national coverage
was computed based on population denominators and performance for all regions without Tigray region.
National plan versus target is discussed without Tigray region. The report of Tigray’s 1st quarter performance
is dealt separately under each program area. In addition, a separate section is also included for all the major
emergency responses provided in Tigray region. The report includes quantitative data represented in the form
of tables and graphs that represent comparisons across regions and trends over time for selected indicators.

The preparation of the report is coordinated by a technical team represented from the Policy, Planning,
monitoring and Evaluation Directorate (PPMED) of MOH. It was prepared in close collaboration and consultation
with directors and program experts from the different directorates and agencies of MOH were consulted during
the preparation of the report.

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This Annual Performance Report is divided into ten chapters:

Chapter 1 [Introduction] - is an introduction that covers the background about the preparation of the Annual
Performance Report

Chapter 2 [Progress of transformation agenda of HSTP-II] - Highlights the progress and current status of the
five priorities/transformation agendas of HSTP-II

Chapter 3 [Health Service Delivery] – This chapter covers the performance the different health programs of the
health sector, including, health extension program/Primary health care, hygiene and environmental health;
reproductive, maternal, neonatal, child and adolescent health, nutrition and Disease prevention and Control
programs, clinical services and others

Chapter 4 [Leadership and governance] – deals about the major governance and leadership areas such as
regulatory activities, health infrastructure, policies and strategies; and health reform and governance related
activities

Chapter 5 [Human Resource for Health] – describes about human resource development and management
such as the distribution and mix of health workforce

Chapter 6 [Health Information System] – covers about evidence based decision making in the health sector,
use of technology and innovations and basic and operational researches

Chapter 7 [Pharmaceuticals and medical supplies] – covers about pharmaceutical supply management,
medical devices and pharmacy services

Chapter 8 [Health Financing] – Covers about resource mobilization and utilization, public health budget
allocation and liquidation and implementation of health insurance

Chapter 9 [Public Health Emergency preparedness and response] – deals about public health emergencies
such as disease epidemics and response, and emergency responses in conflict areas

Chapter 10 [COVID-19 and its response] - This section highlights about the status of COVID-19 pandemic and
its responses in Ethiopia.

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 CHAPTER

PROGRESS OF HSTP-II
TRANSFORMATION AGENDAS
ANNUAL PERFORMANCE REPORT

CHAPTER 2: PROGRESS OF HSTP-II TRANSFORMATION

AGENDAS

2.1. Transformation in Quality and Equity

Q
uality and equity of health services is one of the five priorities/transformation agendas of HSTP-II.
It refers to ensuring delivery of quality health care (reliable, patient-centered and efficient) to all
in need in an equitable and timely manner. It is about ensuring availability of the best care to all,
so that the quality of care provided does not differ by any personal characteristics including age,
gender, socioeconomic status or place of residence, or disability status. It at improving both the demand and
supply side of quality and equitable health services.

In 2013 EFY, various interventions and activities were implemented to achieve the objectives of this
transformation agenda. The second National Health Care Quality and Safety Strategy (2021-2025) is developed
and disseminated to various stakeholders. In addition, other essential documents such as the national quality-
coaching guide, clinical audit tool for health centers and the revised clinical audit tool for hospitals were
developed to guide the provision of quality health services. Quality improvement initiatives that were proven
effective in the first HSTP have been continued in this year as well. The QI projects include the Saving Lives
through Safe Surgery (SaLTs) and the Maternal and Newborn Quality of Care (MNH QoC) initiatives. National
health care quality hubs are identified and financial and technical support was provided to the hubs. These
hubs will serve as center of excellence for quality improvement in the health sector.

With regard to equity, the Ministry of Health has identified and designed interventions to address five types of
disparities namely, geographic, demographic, socioeconomic, gender and people with special needs. Such
disparities in the community not only resulted poor health outcomes but also harm the society and economy in
general. Reducing health inequities is a social and moral imperative that needs an agile and responsive health
system, which provides equitable access to comprehensive and quality health care. This often requires strong
political commitment and multi-sectoral collaboration and interventions. In response to such disparities in
service availability, utilization and outcome, health equity interventions have been implemented in the fiscal
year. Health Systems Strengthening and Special Support directorate along with all the relevant stakeholders
has prepared the national health equity strategy through an extensive participation and consultations of
stakeholders. As equity requires contextual intervention, this strategy is being customized by all regions and
city administrations. Moreover, regional level advocacy is being entertained to ensure of leadership at all
level. The other vital activity started in 2013EFY was the comprehensive national health equity analysis. All
the preparatory activities have been finalized and the analysis result will be released in the 2014 fiscal year.
The Health System Strengthening Monitoring and Evaluation guideline has also been developed with the aim
of strengthening and ensuring system level follow up and use of trustable data for evidence-based decision-
making. In the fiscal year, technical and financial support was provide to regions and zones that require special
support. In addition, capacity building trainings were conducted to these regions and zones.

2.2. Information revolution

Information revolution (IR), which was introduced during HSTP-I implementation period, remains one of the
transformation agenda in HSTP II. The overall goal of the IR is to improve the capability of the health system
to generate and use high-quality data for evidence-based decision-making and advance towards better health
systems performance. It is not only about changing the techniques of data and information management;
rather it is also about bringing fundamental cultural and attitudinal change regarding perceived value and
practical use of information. During HSTP-II, efforts will focus on the three pillars of the information revolution:

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transforming a culture of high-quality data use; digitization of the health information system (HIS); and
improving HIS governance. The major accomplishment of 2013 fiscal years is described below (for further
detail refer the section on health information system).

Transforming a culture of data use

To improve data recording and availability, routine HMIS indicators and data recording tools were revised
to respond to additional data requirements. Similarly rapid assessment on morbidity and mortality data
recording was conducted to inform the revision process of existing national classification of disease (NCoD).
Capacity building training on data quality, data use and DHIS2 was given for health workers working at all level
of health system. Furthermore, monthly and quarterly data analytics which was initiated during the 2012 EFY
was institutionalized.

Assessing the status of HIS structure and resources, data quality, and data use domains using the

IR model Woreda measurement tool, which has been used at few woreda before 2013 EFY, is institutionalized
and scaled-up. In 2012 EFY, only 255 sites (38 WoHOs, 181 HCs, and 36 hospitals) were conducting self-
assessment using the IR measurement tool. In 2013 EFY, it was scaled up to 1,503 sites (208 WoHOs, 862 HCs,
88 hospitals, and 345 health posts).

An interactive dashboard was developed to track and monitor IR implementation status of connected Woredas
across regions regarding HIS structure and resource, data quality, information use indicators, and facilities’
IR pathway (categorizing facilities as Model, Candidate, and Emerging based on the three indicators).This
dashboard is updated regularly every six months following IR woreda assessment result. In January 2021,
the assessment result of 1364 health facilities was obtained and 14%(197) of the sites were reported to have
reached IR model status while out of 770 self-assessed result in June 2021, 33% (253) are reported model.

The average HIS structure and resources score measured out of a score of 30 increased from 15.4 (self-
assessment result from 250 sites in 2018) to 24.5 (self-assessment result from 700 sites), recording about a
nine-point change. Similarly, the average scores for data quality out of a score of 30 and information use out of
a score of 40 also increased from 14.4 and 18.5 in 2018 to 26.4 and 30 in June 2021, respectively. In both cases,
the average change is greater than ten points. In general, the overall IR score out of 100 score, increased from
48.3 in 2018 to 80.8 in June 2021. To date four woreda are verified to reach IR model status.

Figure 1. IR assessment status by period of assessment, June 2021

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Digitization

Lack of standards to guide the development of electronic medical recording systems was one of the challenges
in HSTP-I implementation period. Cognizant of this, standards for electronic health recording system was
developed to set standards for the development and implementation of an EHR system in the country that
will streamline the standardized health data collection, transmission, analysis and use for clinical and public
health decision making. The development of digital health blue print, which certainly goes beyond IR agenda,
can be considered as an opportunity in facilitating this agenda implementation. Electronic community based
information system (eCHIS) implementation was scaled up from four region to eight and the number of health
posts implementing it was also increased from 1,193 of 2012 baseline to 6,320. To date, more than 2.8 million
households and more than 12 million family members were registered in the HPs that started implementing
eCHIS.

HIS governance

HIS governance is considered as a foundation for IR agenda implementation. In this reporting period HIS
governance framework was revised by including national advisory group (NAG) as the HIS governance structure;
merging of the various types of related, but redundant TWGs into three groups, revising the frequency of
meetings of the HIS steering committee, NAG, and HIS Governance TWG; and clearly defining the relationship
of national and regional HIS structure. By the end of 2013 EFY 7 out of 12 region have customized the HIS
framework to their regional context. Furthermore, the five year national HIS strategic plan (2020/21-2024/25) is
developed to improve evidence-based decision-making.

2.3. Motivated, Competent and Compassionate (MCC) Health

Workforce
Transformation in Health Workforce is among the key priority area of HSTP II, directed towards ensuring
the availability of adequate number and mix of quality health workforce that are Motivated, Competent and
Compassionate (MCC) to provide quality health service. Adequate number and mix of quality health workforce
is a critical element of a health system. To achieve holistic health system compassion at all levels, a concerted
and parallel effort is required to increase the motivation and competency of all players, including leadership,
health care professionals, and support staff, by strengthening existing strategies and implementing new
policies, regulations, and practices.

To ensure the presence of MCC and committed health professionals in the health system, a national Motivated,
Competent and Compassionate Health Services Implementation Strategy (2020/21-2024/25) was developed.
In the strategic plan, a new theory of change was developed by incorporating best experiences from previous
initiatives as input and initiated a new direction towards strengthen health workforce and health systems for
compassionate health service. Additionally, MCC implementation manual was developed and put into effect.
Guidelines on Ethical Health Service, MCC-Model health institutions, passion/attribute based student selection
and health- sector volunteerism implementation were developed and put in place.

To enhance the implementation of MCC, implementation researches in 6 thematic areas were conducted in
collaboration with development partners. A baseline assessment was also conducted on MCC and Ethical
health care practices, through intensive consultation with key stakeholders. Moreover, Human Resource
Management related Laws, directives and guidelines are compiled into a document of 700 pages, which is
organized into 256 volumes to make it suitable for use.

Regarding strengthening the quality of professional standards and curriculum development, several activities
were executed at different levels, some of which as follows:

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• Enabled health facilities to create conducive environment for practical training in medical and health
sciences education
• Introduced innovative and technological products to medical and health science students
• Coordinated the enrollment of medical specialization program
• Facilitated long-term educational opportunities for the Ministry of health staff
• Prepared guideline on health education quality assurance
• Coordinated the enrolment of trainees for field epidemiology training program,
• Developed and followed up the implementation of field epidemiology training program quality
assurance monitoring guide
• Prepared Clinical Practice Guideline for medical and health science students
• Developed 8 qualification standards for degree programs and 16 occupational standards for TVET
programs
• Developed Draft scope of practice for 126 health professionals
• Developed and put in place Continuous Professional Development (CPD) platforms all over the nation

With active involvement of about 302 volunteers across the country, it was also possible to provide a variety
of voluntary services to more than 1, 393, 084 patients in hospitals and health centers. In addition, volunteers
were actively engaged in establishing surgical services in health facilities through renovation and capacity-
building activities in 5 federal hospitals and selected health centers from 11 regions. Currently, voluntary
services are being implemented in all regions in collaboration with health professional association consortium
and Addis Ababa youth and volunteer service coordinating office. These compassionate-sparking activities
will inspire health system leaders and health workforce to have a sympathetic attitude toward clients, which
will be further expanded across all health-care facilities.

As part of coordinating relevant stakeholders for MCC, a series of consultations and discussions were held with
relevant stakeholders and inputs were gathered to establish Health Professionals Council. A draft proclamation
for the Council of Health Professionals was also prepared through coordinating various forums where key
stakeholders including Attorney General participated.

2.4. Transformation in Health Financing

Health financing is one of the five priorities/transformation agendas of HSTP-II, with the objective of mobilizing
sufficient and sustainable health financing to health and improving efficiency by reforming the financing
and management system of the health system. It aims to address finance-related barriers to health service
utilization through major interventions such as proactively mobilizing adequate resources from domestic and
international sources, reforming resource allocation & prioritization, optimizing the health insurance system,
forming public-private partnership, reforming cost recovery mechanisms, implementing performance-based
financing, and designing and implementing strategies for efficient use of resources and capacities.

In 2013 EFY, the health sector has implemented various health financing interventions and encouraging
achievements were documented. Resource was mobilized proactively both from national and international
sources. In the fiscal year, 13.2% of the total government budget was allocated to health. This is an increment
by 1.2% from the previous year, and the highest proportion in the past five years. More than 388.25 million USD
was mobilized and disbursed from development partners (DPs) in 2013 EFY, a little more than the previous
year’s disbursed amount. A proactive resource mobilization (both in cash and in kind) was also conducted for
COVID-19 pandemic response. In this regard, more than 411.6 Million USD was mobilized from the government,
development partners, civil society organizations, and from the private sector.

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Health care reform implementation was strengthened in the fiscal year, with more than 96% of health centers
and 99% of public hospitals implementing the reform components. Exempted health service and fee waiver
system are implemented at public health facilities to ensure equity of health services and enable the poor
to access health services without financial hardship. Outsourcing of non-clinical health services have been
implemented in 135 hospitals. In order to make user fees to reflect the cost of delivering health services, fee
setting and revision exercise is started in some regions. User fee for federal hospitals and university hospitals
was set and endorsed by the council of Ministers.

Public-private partnership (PPP) implementation was initiated to improve engagement of the private sector
with the public health sector. PPP feasibility study was done for two projects; medical Gas Plant Placement
and Diagnostic services (laboratory, Pathology, and Imaging services). In addition, a pre-feasibility study on
oncology service was conducted. The PPP projects are registers and are on follow up for full approval and
implementation.

Community based health insurance (CBHI) implementation is one of the health financing strategies that have
been conducted in the health sector for the past few years. In this year, CBHI implementation was strengthened
and expanded to cover more than 834 Woredas throughout Ethiopia (All regions except Tigray). About 61% of
eligible households in CBHI implementing Woredas become members of CBHI, this is a 12% increment from
the previous year. More than 2.02 billion ETB was collected from paying CBHI members. For indigent CBHI
members, more than 137.5 ETB was paid by the government. The sector has planned to initiate implementation
of social health insurance system for the formal sector employees in the next fiscal year.

2.5. Transformation in Leadership

Leadership is a crucial pillar of a health system and exerts direct influence on the performance of the health
system. In HSTP-II, Transformation in leadership is identified as one of the top priorities of the health sector.
It is about enhancing the leadership and governance system at all levels of the health system to drive
attainment of the strategic objectives set in HSTP-II. The agenda aims to implement different initiatives and
major interventions to transform the leadership and governance system of the health system, including
redesigning & restructuring the health system, institutionalizing accountability mechanisms, strengthening
clinical governance, ensuring regulatory system, strengthening stakeholder engagement and partnership,
building leadership capacity at all levels, and incorporating the Health in All Policies approach throughout the
government. In 2013 EFY, the health sector has achieved various results in terms of improving the governance
ad leadership system of the health system.

Health policy: The revision of the health policy of Ethiopia, which was initiated some years back, was finalized
in 2013 EFY and submitted to council of Ministers for approval after comments were incorporated from the
General Attorney. During the revision, a series of consultative meetings were held with different stakeholders
such as RHBs, house of peoples’ representatives (HPN), different sectors, academia, civil society organizations
(CSOs), development partners (DPs), and with the public at large. Feedbacks from the consultative meetings
were used to enrich and finalize the health policy.

Strategic plans: The health sector has developed; approved and disseminated ten years strategic plan that
shows the sector’s directions, priorities and targets for the next 10 years. In addition, a five years Health sector
Transformation plan (HSTP-II), for the period 2020/21-2024/25, was finalized, approved and disseminated. The
leadership led the development process, with extensive consultations with various stakeholders. Following the
development of HSTP-II, different sub-strategies for the different programs of the health sector were developed
and approved by the senior leadership of the sector.

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Health legislation: A draft Health Act is developed, in consultation with various stakeholders. The draft
Health Act was submitted to General Attorney, from which feedback were received and used for document
enrichment. The Health Act will be submitted to council of Ministers for approval.

Advocacy: The leadership has conducted various advocacy activities to mobilize resources for the health
sector, to create awareness on HSTP-II to different national and international stakeholders and to improve
partnership between MOH and stakeholders.

Harmonization and Alignment: In order to improve the health sector’s planning, budgeting and
implementation of HSTP-II, revision of health harmonization and alignment manual (HHM) was finalized in the
fiscal year. It was endorsed by the MOH-donor committee (Joint Consultative forum /JCF) and approved. The
document will be indispensable to improve planning, budgeting, systematic implementation and coordination
in the health sector.

Governance platforms and coordination: In 2013 EFY, the senior management of MOH and RHB heads have
conducted regular meetings to review the performance of HSTP-II implementation. In the fiscal year, additional
frequent forums were conducted through virtual meetings in order to discuss, follow and set directions for
COVID-19 response.

In the fiscal year, coordination mechanism between MOH and development partners was strengthened through
regular, uninterrupted Joint Core Coordinating Committee (JCCC) meetings with health-population-nutrition
(HPN) partners. During the JCCC meetings, important health sector priorities and issues were discussed and
action points were jointly identified and implemented.

Leadership Capacity Building: In order to build the capacity of the health sector’s leaders, a leadership
incubation program (LIP) is designed and potential future leaders are selected and trainings are being provided.
In 2013 EFY, 33 health sector leaders are selected for the LIP and started the training program. In addition, the
senior management of MOH were trained on different leadership technical trainings.

International engagement: Ethiopia has participated in the 73rd World Health Assembly (WHA), during
which Ethiopia has transmitted messages that are valuable to the health system of Ethiopia. In addition,
Ethiopia has developed a resolution on local manufacturing of pharmaceuticals and it was endorsed by
the WHA. Ethiopian health sector leaders were also engaged in different WHO-AFRO meetings, during which
Ethiopia reflected its country priorities. Ethiopia has also shared its experiences for delegates from different
countries such as Burkina Faso, Central African Republic, during which the leadership shared best practices for
the African counterparts.

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HEALTH SERVICE DELIVERY

 MINISTRY OF HEALTH

CHAPTER 3: HEALTH SERVICE DELIVERY

3.1. Health Extension Program and Primary Health Care

E
thiopia has achieved substantial progress in improving health outcomes during the past two decades.
These achievements were mainly realized after the expansion of primary health care services to
households and communities through the implementation of the Health Extension Program (HEP).
The program was launched in 2003 (1997 EFY) in agrarian regions and was later tailored to the
pastoral and agro-pastoral contexts in 2006 and to urban areas in 2009. This section of the report covers the
accomplishments related to health extension program, health education and promotion, implementation of
different reforms to strengthen the provision of primary health care service and accomplishment related with
Woreda transformation.

Community Engagement: Competency Based Training

The Ethiopian health sector has registered a tremendous achievement since the launching of the HEP. The
health extension workers have been using women development army (WDA) as a platform to engage with the
community members. The introduction of WDA facilitates the scaling up of best practices in implementing the
Health Extension Program (HEP) to all households, mainly through organized women. A Competency Based
Training (CBT), that was designed and implemented through an organized and tailored practical training
approach, with some theoretical courses build the capacity of WDA leaders’ knowledge and skills to make
them model and serve as a change agents to play pivotal role in influencing their family, network members
and their neighbors at large. In 2013 EFY, 343,832 WDAs completed their CBT and among these 225,155 were
assessed for their competency and 204,000 were found to be competent.

Community Engagement Options Pilot

The MOH envisioned advancing community engagement through designing and implementing alternative
community engagement approaches to achieve universal health coverage (UHC). In 2013 EFY the ministry
has designed inclusive community engagement approaches. These include, optimizing the existing WDA
platform, Men Development ARM (MDA), youth engagement, other social structures and re-inventing community
engagement strategy through producing village health leaders (VHLs), to realize meaningful community
engagement. Motivation mechanisms are also included as one intervention to encourage and motivate
individuals and teams engaged in this endeavor.

So far, to test it in small scale, four woredas (Ada’a from East Shoa Zone of Oromia Region, Dembecha from West
Gojjam Zone of Amhara Region and Damote Woyede and Hulbareg from SNNP Region) were selected as pilot
sites. A series of national, regional and Woreda level consultative workshops were organized; implementation
manual was developed and 255 selected VHLs from the four aforementioned Woreda have received capacity
building training. Following the training, regular follow up visits, performance review meetings and experience
sharing sessions have been conducted.

Health Extension Program Optimization (HEPO)

During the last two years of the previous HSTP-I implementation period, MOH has undertaken multiple activities
aimed at optimizing HEP and finally developed a new 15 years (2020-2035) roadmap to guide Ethiopia’s efforts
to optimize the HEP. The overall goal of the HEP optimization roadmap is to accelerate the realization of UHC
through which all Ethiopians will have access to needed health services, including prevention, promotion,
treatment, rehabilitation and palliative care. In 2013 the following key milestone were accomplished.

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Nationally, the roadmap was officially launched on March 3, 2021 by H. E. Demeke Mekonnen (deputy Prime
minister) in the presence of high-level government officials, including Ministers, Presidents of Regional
States, heads of Regional Health Bureau; directors of MoH and allied Agencies; representatives of donors
and implementing partners; Ambassadors of selected countries and professionals from several media
outlets. Likewise, Regional level launching workshop was also organized at Gambella, Sidama and Somali
in the presence of respective regional presidents and key partners. At Oromia Region, a one-day orientation
was provided to the senior management team of the RHB followed by a series of cascade training for zonal
structures were conducted.

According to HEPO road map, health posts (HPs) are classified into three based on their relative distance from
the supervising health center (HC) or primary hospital (PH). HPs that are located in kebeles where there is
a HC or PH will be merged with the HC or PH and become a unit in the facility. Those within a reasonably
short distance (one-hour distance) from a HC or PH will continue providing basic packages. Those located in
kebeles far from HC (longer than one-hour distance) will provide comprehensive HEP packages. HPs mapping
was done using geo spatial data from CSA and different previous assessments data sources to inform the
suggested restructuring process. A total of 17,600 health posts and health centers with attribute data were
reconciled from different secondary data sources and distance analysis of 9,455 HPs is completed. The result
of the mapping showed that the average distance is 11.9km and average travel time on foot is 2.3hours. As
depicted in table below there is a wide variation across regions.

Table 1. Distance of Health Posts from supervising Health centers, 2013 EFY

Travel time ( on foot (in hours)

Regions <= 0.5 hour 0.5-1 hour 1-1.5 hour 1.5-2 hour > 2 hour  
No.  % No.  % No.  % No.  % No.  % Total
Tigray 83 21.3 34 8.7 64 16.5 50 12.9 158 40.6 389
Afar 5 3.3 13 8.6 14 9.3 11 7.3 108 71.5 151
Amhara 407 23.1 230 13.0 282 16.0 224 12.7 623 35.3 1766
Oromia 651 16.9 671 17.4 718 18.6 572 14.8 1245 32.3 3857
BG 39 17.6 23 10.4 29 13.1 21 9.5 110 49.6 222
Gambella 11 20.4 4 7.4 7 13.0 3 5.6 29 53.7 54
Sidama 103 27.8 105 28.4 63 17.0 38 10.3 61 16.5 370
SNNPR 371 19.7 485 25.8 410 21.8 220 11.7 393 20.9 1879
Somali 11 1.4 26 3.4 55 7.2 52 6.8 623 81.2 767
Total/Average 1,681 17.8 1,591 16.8 1,642 17.4 1,191 12.6 3,350 35.4 9,455

Health Education and Health Promotion

Health education and promotion is considered as a part of primary health care ever since 1978 Alma Ata
Declaration. In the previous fiscal year (2012 EFY), a total of 1026 health workers from 474 health facilities were
trained on facility based health education manual. As a continuation of this initiative in 2013 EFY, additional
816 health-workers from 351 health facilities have received a similar training. Currently 728 health facilities
have started implementing facility based health education implementation manual.

Emerging global pandemics and frequent public health emergencies such as COVID-19, malaria resurgence,
zoonotic diseases and increasing burden of NCD and the HEPO road map, which calls for revision of social
and behavioral communication strategy, necessitate shifts in strategic approaches of health promotion.
Accordingly, the National Health Promotion strategy (NHPS 2021-2025) was developed in participatory
approach to respond to the MOH policy framework.

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Now a day, digital platforms are increasingly being used to disseminate and exchange health information
for the public. In order to increase accessibility and ensure the equity issues, the family health guide mobile
application was developed for people who live in cities and own smartphones. To ensure this app utilization
a text message has been prepared and sent to all mobile users through Ethio-telecom. An animated spot has
been developed with the collaboration of volunteers, TV and radio spot message transmitted and a message
was also disseminated through MOH’s website.

To strengthen risk communication and community engagement (RCCE), technical support on how to develop
key message on COVID-19 was given to Somali, Amhara, Benishangul and Tigray regions. Social mobilization
activities were done to 2,582 various religious leaders in six regions. Furthermore, RCCE training was given for
670 HEWs and key message developed and transmitted on cholera vaccine campaign for Tigray region.

Primary Health Care Related Reform

To strengthen health service delivery at primary health care level, MOH has been implementing a number of
initiatives such as designing and implementation of Ethiopian health-center reform implementation guideline
(EHCRIG), primary health care clinical guideline implementation and redefining primary health care delivery in
urban context. Major accomplishments in 2013 EFY are described as below.

The implementation status of Ethiopian Health center Reform Implementation Guideline (EHCRIG) is monitored
through DHIS2 on a quarterly basis. The report completeness was improved from 76% in quarter IV of 2012 EFY
to 78% in 2013 EFY of the corresponding quarter. Similarly, timeliness was improved from 43% to 61% during
same reporting period.

The analysis of EHCRIG quarter IV performance by chapters reveals that performance monitoring and quality
improvement, leadership and governance, medical record and health center - health post linkage are 83.3%,
82.6% 80.6% and 80.3% respectively. Patient flow performance (53.4%) is the lowest of all while medical
equipment management and laboratory service chapters performance are also low compared with other
chapters. Overall, there is an improvement from last year’s same period performance.

72.2%
Overall Average 75.6%
Performance monitoring and quality improvement 80.6%
83.2%
Human resource management 75.1%
78.8%
61.5%
Medical equipment and facility management 66.6%

CASH-IPPS 75.3%
79.6%

Laboratory service 62.8%

66.7%

Pharmacy service 77.2%

79.3%

Medical record 77.3%

80.6%

Patient flow 50.7%

53.3%
76.8%
Health center-Health post linkage 80.3%

Leadership and Governance 79.7%

82.5%

Quarter IV: 2012 Quarter IV: 2013

Figure 2. Comparison of Quarter IV EHCRIG performance by Chapter: 2012 EFY Vs 2013 EFY

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Generally, the major challenge in ensuring proper implementation and reporting of the EHCRIG are weak
follow-up, suboptimal technical support and verification of reports at every level. Considering the ever-
changing environment, the current guideline is revised and its chapter is increased to 13. Training on the new
guideline is expected to be conducted in 2014 EFY.

A primary health care unit (PHCU) is considered as high performing when the composite index of model kebele
performance, EHCRIG performance and key performance indicators (KPI) performance average score is greater
than 85%. Except Tigray and Addis Ababa, the PHCU report status were reported by all region with varied
report rate across region as stated in the below table. In the current fiscal year, the total number of high
performing PHCU are 526 which shows an increment by about 77% from 298 of 2012 EFY . Overall, of the 2,468
health centers that reported their status, 21% have reached high performing PHCU status.

Table 2. Number of High Performing PHCU by Region, 2013 EFY

No. of health centers that re- High Performing PHCUs

Region
ported their status
Number %
Afar 30 4 13%
Amhara 846 184 22%
BG 23 10 43%
DD 12 0 0%
Gambela 6 0 0%
Harari 8 3 38%
Oromia 856 162 19%
Sidama 134 41 31%
SNNP 524 122 23%
Somali 29 0 0%
Total 2,468 526 21%

Ethiopian Primary health care clinical guideline (EPHCG), an integrated symptom-based algorithmic approach
to address the common presenting symptoms and priority chronic conditions in the country, is a standard
tool to be utilized at the health centre level. Its implementation is believed to contribute in ensuring equitable
access to quality of care. In 2013 EFY a total number of 1,482 health centers were successfully trained and
started its implementation increasing the cumulative number of health center implementing EPHCG to 2,054
(about 55% of total health centers in the country). To enhance its accessibility and for easy facilitation of
periodic update interactive android application was developed and made it available on the play store.

The urban primary health care reform (UPHCR) was introduced during the HSTP-I period to address the Ethiopian
urban population health need. In 2013 EFY, MOH planned to further expand the reform implementation to 131
health centers found in 72 towns. Financial and technical support was provided to regions on implementation
of the plan. In 2013 EFY, the number of health centers implementing UPHCR are increased from 145 to 271 and
currently 99 towns are implementing this reform. From the service provision side, 213,468 households and 653
schools were visited and 739,314 clients had received the service from family health team.

Woreda Transformation

Woreda transformation is one of the overarching objectives of HSTP-II. It is an aspiration to see transformed
Ethiopia at each Woreda. It promotes transforming all households from the level they are now to the next
socially acceptable level in a manner that does not slide back. It is also a means to cascade SDG to sub national
level so that no one is left behind by tailoring/customizing national programs to local context and creating

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ample space for local wisdom and ownership. Two approaches were outlined for its implementation: sector
specific and multi-sectoral woreda transformation.

In EFY 2013, MOH has planned to ensure the 25 model woreda reported in EFY 2012 remain model, create
additional 15 model Woredas and work to bring 110 Woreda to medium performance. Various activities such
as capacity building training, supportive supervision and financial support to RHB and regular monitoring
including verification were accomplished to realize this plan. Out of the 547 Woredas that reported their status
this year, 57 (10.4%) are model, 199 (32%) medium and the remaining 291 are either low or very low performer.
Of the 57 woredas reported as model, 22 were from the SNNPR, 22 from Amhara, and 13 are from Oromia.
However verification carried out by the ZHD, RHBs and MoH at 23 self-reported model Woredas, reveals that
21 were found to be model while the rest performance were below 85%.

The implementation of the multi-sectoral Woreda transformation agenda that was launched in Gumbichu
Woreda has been reactivated. Multi-sectoral plan was developed by the technical working group and MOH
has undertaken advocacy workshop, capacity building training, documented baseline and supported
implementation of eCHIS. Other sectors were involved in the multi-sectoral Woreda transformation and the
major accomplishments are as follows.

• Ministry of Labor and Social Affairs (MoLSA): recruited and deployed integrated social workers for
all kebeles (37)
• Water & electricity: CIFF private philanthropy has entered into a three-year project agreement with
MoWIE, MoE & MoH.
• Ministry of Agriculture (MoA): MoA has delivered a multipurpose tractor/machine with accessories,
and Agricultural Management Information System (AGMIS) designed and training was provided to
agriculture development agents and experts drawn from Gimbichu Woreda and East Shewa Zone
Agriculture Office. Furthermore, 68 tablets were provided to the kebeles (2 tablets per kebele).
• Transport: construction of Bishoftu–Chefe Donsa–Sendafa 55 Km asphalt road (project amount Birr
915.00 million) is in progress (17%) in two directions.

Challenges (HEP and PHC program)

 Health education and promotion structure not addressed at all level

 Weak sectoral and multi-sectoral collaborations and coordination
 High attrition and turnover of staff and leaderships
 Delay of SDG budget release

Way forward

 Increasing the coverage of implementing facility based health education

 Increase the coverage of second generation HEP implementation
 Consolidate and align multiple health centers reform initiatives
 Work toward fulfilling the basic amenities and required medical equipment to health centers
 Advocate for the implementation of national health promotion strategy

3.2. Hygiene and Environmental Health

Hygiene and environmental health focuses on impacting environmental determinants of health and thereby
promoting health, preventing diseases and other conditions and improving quality of health services. It
encompasses implementation of multi-dimensional interventions to ensure adequate and safe sanitation;

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personal hygiene; water safety and quality; food hygiene and safety; indoor air quality; healthy living
environment; occupational health safety; and liquid and solid waste management. It also includes contributing
to building climate-resilient health system and water, sanitation and hygiene (WaSH) in institutions including
health care facilities and emergencies situation that requires concerted efforts of various sectors. In this
section, the major hygiene and environmental health activities and achievements in 2013 EFY are described.

Basic Sanitation Services

Ethiopia has registered significant achievement in reduction of open defecation (OD). According to joint
monitoring program (JMP), open defecation has been reduced from 92% in 2000 to 17% in 2021, and
unimproved latrine coverage has increased from 8% in 2000 to 65% in 2021. On the other hand, the coverage
of basic latrine increased slowly from zero in 2008 to 18 % in 2021.

One of the key initiatives, which have been implemented towards improving the sanitation status was
strengthening of market based sanitation at Woreda level. In 2013 EFY, 191 new sanitation marketing centers
have been established through by providing financial and technical support to Woredas. In parallel to this,
194,555 household constructed/upgraded their latrines to improved standard through intensive community
mobilization and demand creation activities at the community level. Additionally, 573 kebeles become Open
Defication Free (ODF) through intensive community mobilization conducted at kebele level.

In the fiscal year, preparatory activities for the TSEDU Ethiopia (ፅዱ ኢትዮጵያ) five years campaign have been
done including development of logo/brand, program implementation guide, SBCC strategy, advocacy guide,
capacity gap assessment, sanitation infrastructure catalog and monitoring and evaluation.

Water and food safety

In 2013 EFY, experts from 52 woredas have been trained on water quality monitoring and surveillance. The
woredas have been supported financially for establishing strong and regular water quality monitoring and
surveillance system. Regarding food hygiene, an assessment of the school feeding program was conducted in
15 schools from Oromia, Amhara and Addis Ababa and feedback was provided for improvement.

Hygiene

Hand Hygiene: A one-month mobilization has been carried out on hand hygiene in all regions through which
wide range of advocacy and promotion interventions. Promotion was carried out at different levels through
Mainstream Medias, print Medias, social Medias, audio visuals and so on. In addition to the one-month
campaign, key messages on hand hygiene have been continuously broadcasted on social and mass media.

Menstrual Hygiene Management (MHM): Advocacy has been done both at federal and regional level for
better investment and action on Menstrual hygiene management. Additionally, experts from all regions have
been trained on MHM for improved implementation. Moreover, 40,000 soaps; 60,200 sanitary pads, and 10,000
under wears were distributed to school-girls.

Institutional WASH and Environmental Health

Institutional WASH and environmental health is one of the key intervention areas for infection prevention and
control, and ensuring safe facilities. In the fiscal year, 110 (82 new and 32 rehabilitation) water points, 314 (253
new and 61 rehabilitation) improved latrine, 197 incinerators and 124 placenta pit were constructed at health
centers and health posts.

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A national Health Care WASH guideline and health care waste management manual have been developed.
Moreover, an assessment has been conducted in 20 religious institutions, in three industry parks and six federal
prisons to identify and jointly address environmental health gaps.

Reducing the impact of Climate Change on public health

Emergency WASH and Environmental Health Guideline, Climate Resilient Health System toolkit, air quality and
Health Guideline, and Health Impact Assessment Guideline have been developed and familiarized to regional
health bureaus staffs, sector offices and other partners. Key messages on air pollution and health have been
produced and broadcasted on Mass Medias to improve public awareness.

Challenges

 Gaps in affordability of sanitation services by the population

 Shortages of test kits for performing water quality test
 Inadequate WASH interventions in health care facilities and limited partner’s engagement.
 Gaps in WASH services in institutions and public areas
 Lack of dedicated government budget for sanitation and hygiene programs
 Absence of monitoring platform for environmental health programs
 Absence of strong sector coordination platform for environmental health with accountability
framework

Way forward

 Establish different financing mechanism for sanitation and hygiene to ensure provision of the services
to all
 Ensure availability of water quality monitoring test kits in all Woredas
 Consider WASH in health care facilities through government and donors funding as a short-term
strategy and ensure inclusion of WASH services in design and construction of new health facilities
 Strong regulation of WASH services in institutions as part of licensing and re-licensing process.
 Advocate for government funding for sanitation and hygiene programs.
 Advocate towards establishment of a high-level sector coordination platform for environmental health
with accountability framework.
 Establish monitoring platform for hygiene and environmental health program

3.3. Reproductive and Maternal Health and Services

In the second health sector transformation plan (HSTP-II), improving the health status of women, neonates,
children and young people is prioritized to be one of the sub-strategic directions under the strategic direction
“Enhance provision of equitable and quality comprehensive health services”.

Under this section, the 2013 EFY annual performance of major reproductive and maternal health indicators
are discussed mainly by comparing with baseline and target of the fiscal year, and when appropriate, data
disaggregated by age and geography is presented. Moreover, major activities accomplished in the fiscal year,
the major challenges faced and the way forward are discussed for each program area.

The following table summarizes the performance of selected key reproductive and maternal health indicators.
The performance of each indicator in this fiscal year will be discussed individually then after.

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Table 3. Summary of the Performance of maternal health indicators, 2013 EFY

Performance
Indicator Baseline
in 2013 EFY
Contraceptive acceptance rate 69% 73%
Antenatal care 4+ coverage 69% 70%
Percentage of deliveries attended by skilled health personnel 63% 66%
Early postnatal care coverage 83% 85%
Cesarean section rate as a proportion of all births 4.3% 4.6%
Percentage of pregnant women counseled and tested for PMTCT 84% 90%
Percentage of pregnant and lactating women who received ART to
84% 79%
prevent mother to child transmission of HIV

Contraceptive Acceptance Rate (CAR)

Ministry of Health, through its national standards for improving quality of family planning services guide, has
renewed its focus on family planning service quality, the provision of quality family planning services that can
increase uptake, and continuation of contraception as part of this family planning program. This National
Guidelines is intended to provide explicit directives on the minimum acceptable levels of performance
and expectations for service delivery and program implementation in Ethiopia. The National standards for
improving quality of family planning services embraced 12 standards. In addition, family planning service
integration guideline was prepared which informed implementation issues encompassing family planning
(FP) service integration in HIV/ART, PMTCT, ANC, Labor and delivery, PNC, EPI, child health care and adult OPD
areas. It also outlines the importance of linkage of other reproductive health (RH) services for clients coming
for FP service in general.

During the current fiscal year, 14,008,577 (73%) women in the reproductive age group have received a modern
contraceptive method. Compared with last year’s performance, it has showed a 4% point increase. However, it
is 9% less than the target set for the fiscal year.

Looking the data disaggregated by region; the highest CAR performance was observed in Sidama (90%)
followed by Oromia (86%) and Amhara (83%) while the lowest performance was recorded in Somali (11%)
and Afar (22%). Two regions, namely Somali and Benishangul Gumuz, performed below their last year’s
performance while the remaining regions performed better than their baseline. The highest increment was
in Harari (11%) followed by Addis Ababa (by 9%). All regions are unable to achieve their target set for the year
and seven regions have a target to performance difference of 10% or more. The biggest gap is observed in Dire
Dawa (36%) followed by Benishangul Gumuz (31%) and Afar (28%).

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Contraceptive Acceptance Rate: comparison of baseline, 2013

performance and target by Region
100% 90%
83% 86%
80% 74% 73%
65%
60%
42% 39%
36%
40%
22% 25%
20% 11%

0%
Dire Addis
Afar Amhara Oromia Somali B/Gumuz SNNP Sidama Gambella Harari National
Dawa Ababa
Baseline 16% 83% 78% 16% 49% 72% 90% 17% 54% 35% 27% 69%
EFY 2013 Performance 22% 83% 86% 11% 42% 74% 90% 25% 65% 39% 36% 73%
EFY 2013 Target 50% 85% 90% 25% 73% 91% 97% 44% 70% 75% 55% 82%

Baseline EFY 2013 Performance EFY 2013 Target

Figure 3. Contraceptive Acceptance Rate: Comparison of baseline, 2013 performance and target by region

Modern Contraceptive Method Mix

As depicted in the chart below, Injectable (58%) account for the biggest share of contraceptive methods used
by clients in the fiscal year followed by implants (27%) and oral contraceptive pills (11%). Compared with last
year, the share of use of oral contraceptive pills from the total users increased by 2% points while injectable
and implants usage decreased by 1% and 2% respectively. Moreover, IUCD utilization remained the same.

Contraceptive Method Mix, 2013 EFY

3% 2%

11%

27%

58%

Oral contraceptives Injectables Implants IUCD Others

Figure 4. Contraceptive method mix, 2013 EFY

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Immediate post-partum Contraceptive Acceptance

The immediate pot partum period is a great opportunity to provide mothers with family planning service,
which is crucial for ensuring the health, human rights and well-being of women and their babies. Efforts were
exerted to increase immediate postpartum family planning (IPPFP) service coverage mainly through scaling up
the service in facilities with no experience of providing IPPFP service for years. The scale up process required
enormous capacity building training for service providers and making the necessary commodities available. In
EFY 2013, only 7% of women who delivered in a health facility by skilled attendant received immediate post-
partum contraceptive. All of the regions performed less than 10% except Sidama (15%), Afar (11%) and Dire
Dawa (10%).

Premature removal of long acting family planning

Long-acting reversible methods of family planning methods are assumed safe and highly effective and it
serves the need of the users for a long period. In Ethiopia, despite the huge investment being incurred in
these commodities by the government and partners, a premature removal of the Long-acting Reversible
Contraceptives (PR-LARC) method has been increasing or not decreasing as expected. The number of clients
who prematurely remove long acting family planning within 6 months of insertion (79,882) showed a slight
decrease (by 1,576) in the current fiscal year compared with last year’s value.

During the fiscal year, a study to explore the reasons and contributing factors for the premature removal of the
Long-acting reversible methods of family planning (LARFP) methods in Ethiopia was conducted. The study
pointed out that side effects, husband’s imposition, desire to get pregnant, misconceptions and myths about
LARC methods, pressure from friends and close family members, and being divorced were the main reasons
for premature removal of LARC methods. The study also revealed poor quality counselling service, provider
bias, and intolerance for the early phase of the side effects by the clients and low attention by the responsible
bodies as some of the contributing factors that are associated with the premature removal of LARFP methods.

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Family Planning in 2013 EFY

Major activities performed in 2013 EFY

 Spot messages and talk shows targeted to COVID-19 pandemic was broadcasted for three consecutive
months to ensure continuity of Sexual and reproductive health (SRH) services
 In collaboration with implementing partners, dedicated postpartum intrauterine device (PPIUD)
insertion (a specially designed inserter aims at facilitating IUD insertion) have been piloted in 200
health facilities with high delivery load
 Community sensitization programs aimed at improving male involvement in family planning
conducted in Afambo & Itang woreda in Afar & Gambella region respectively
 Developed mobile application to support the delivery of quality contraception services by enabling
frontline health workers to counsel clients about family planning and contraceptive options
 Prepared a five-year Reproductive Health Commodity Security strategic plan (RHCS) to ensure
access to reproductive health commodities
 Provided training on FP-methods counseling and PPFP clinical skills as part of service expansion
Efforts are strengthened to make more domestic funding available for family planning program
and to this end an advocacy guide was prepared and communicated with regional health bureau
heads to allocate budget for FP

Challenges

 Budget allocated for family planning from the treasury remain very low
 Lack of adequate budget for FP commodity procurement
Way forward
 Establish model family planning health facilities: Implement family planning quality standards in
selected health centers to improve family planning counseling and service uptake. These health
facilities could serve as a gold standard and the health facilities will remain under the supervision
of regional health bureau and FMOH
 Strengthening family planning service integration with maternal health, newborn health,
childhood immunization, and prevention of mother-to-child transmission of HIV services at all
health delivery point and across all levels of health facilities
 Increase contraceptive acceptance rate and reach an additional 5.2 million new women and
adolescent girls with FP services

Antenatal Care Coverage-ANC 4 or more visits

Antenatal care, a preventive health care, is essential for protecting the health of women and their unborn
fetus. It is an opportunity whereby women learn about healthy behaviors during pregnancy, better understand
warning signs during pregnancy and childbirth, and receive social, emotional and psychological support at
this critical time in their lives, access micronutrient supplementation and vaccinations, and get diagnostic and
treatment services for major diseases such as hypertension, HIV, malaria etc.

The annual coverage of ANC-1 during the fiscal year is 100%. However, the timing of the first antenatal visit
during the pregnancy period plays important role in risk identification and action.

Out of the total first ANC visits, only 31% of them got the care within the 16 weeks of gestation. Huge majority
of the pregnant mothers come for first antenatal care late in the pregnancy period. Continuation ANC to four
or more visits facilitates the provision of essential evidence based interventions creating promises life-saving
potentials for both the mother and the newborn. It is also a platform for counselling and informing the mother

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about delivering in a health facility, and healthy behaviors such as breastfeeding, early postnatal care, and
planning for optimal pregnancy spacing.

During the current year, a total 2,303,562 (70%) pregnant women attended four or more antenatal care visits.
This year’s performance is better by 1% than last year’s performance; however, it is less by 22% from the target
of the year.

Antenatal Care Coverage- four or more visits by Region, 2013 EFY

100%
100% 91%
81%
80% 69% 70%
66% 68%
61%
60%
46% 48%
42%
40%
25%

20%

0%
Addis
Afar Amhara Oromia Somali B/Gumuz SNNP Sidama Gambella Harari Dire Dawa National
Ababa
Baseline 48% 60% 65% 71% 53% 98% 82% 25% 50% 44% 100% 69%
EFY 2013 Performance 46% 61% 66% 69% 42% 81% 91% 25% 68% 48% 100% 70%
EFY 2013 Target 70% 93% 90% 81% 64% 97% 99% 68% 85% 90% 100% 92%

Baseline EFY 2013 Performance EFY 2013 Target

Figure 5. Antenatal Care Coverage- four or more visits by Region, 2013 EFY

When disaggregated by regions, the ANC4+ coverage ranged from 25% to 100%, which demonstrates the
presence of huge geographic inequity. All regions except Addis Ababa performed lower than their target.
The biggest target-performance difference is in Gambella and Dire Dawa (Both by 42%), followed by Amhara
(33%). Four regions (Afar, Somali, Benishangul-Gumuz and SNNP) performed lower than their baseline. Biggest
reduction was observed in SNNP (by 17%) followed by Benishangul Gumuz (by 10%). The other regions
recorded a performance greater than or equal to their baseline. Biggest increase in Harari (by 17%) followed
by Sidama (by 9%).

Syphilis testing for pregnant women

All pregnant women should be screened for syphilis to reduce the risk of congenital Syphilis for their newborns.
Syphilis screening is a major component of the focused antenatal package. During 2013 EFY, a total of 2,344,722
(72%) pregnant women were tested for syphilis during pregnancy which shows a 6% increment from the
baseline and 15% of shy of the target set for the year. Out of the total tests, 1.4% turned out to be reactive for
syphilis and 89% of those pregnant mothers who tested positive for syphilis received treatment.

When disaggregated by regions, the syphilis testing among pregnant women ranged from as low as 40% in
Somali followed by 49% in Afar and Benishangul Gumuz to as high as 100% in Addis Ababa and Harari. All
regions except Benishangul Gumuz performed better than their baseline. However, all regions except Afar,
Harari and Addis Ababa are unable to achieve their targets. In fact, there is a 20% or more difference between
the current year performance and the target in six regions, namely Sidama, SNNP, Benishnagul-Gumuz,
Amhara, Gambella and Somali.

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Proportion of pregnant women tested for syphilis, 2013 EFY

100% 100%
100% 95%

80% 69%
73% 71% 72%
63%
60% 49% 49% 52%
40%
40%

20%

0%
Addis
Afar Amhara Oromia Somali B/Gumuz SNNP Sidama Gambella Harari Dire Dawa National
Ababa
Baseline 45% 66% 63% 32% 50% 67% 52% 39% 88% 85% 100% 66%
EFY 2013 Perf 49% 69% 73% 40% 49% 71% 63% 52% 100% 95% 100% 72%
EFY 2013 Target 15% 91% 86% 60% 73% 95% 98% 74% 98% 98% 100% 87%

Baseline EFY 2013 Perf EFY 2013 Target

Figure 6. Proportion of pregnant women tested for syphilis, comparison of baseline, 2013 performance and 2013 target

Iron folate supplementation during pregnancy

Iron and folic acid supplements at least 90+ reduces the risk of iron deficiency and anemia in pregnant women
and also prevents the newborn from congenital anomalies because of its role in fetal development.

In 2013 EFY, 3,185,607 (97%) of pregnant women have received iron and folic acid supplement at least 90+. This
performance is less by 1% from both last year’s achievement and the target set for the year.

When looked at from regional perspective, the lowest performance was reported from Somali region (53%)
followed by Gambella (66%) and Afar (69%). The highest performance at 100% was five regions (Oromia,
Sidama, SNNP, Harari and Addis Ababa).

Proportion of pregnant women received iron and folic acid supplements at least 90 plus, 2013
EFY
100% 100% 100% 100% 97% 100% 97%
100%
84%
80% 69% 71%
66%
60% 53%

40%

20%

0%
Dire Addis
Afar Amhara Oromia Somali B/Gumuz SNNP Sidama Gambella Harari National
Dawa Ababa
Baseline 56% 83% 100% 53% 79% 100% 100% 46% 100% 79% 100% 98%
EFY 2013 Performance 69% 84% 100% 53% 71% 100% 100% 66% 100% 97% 100% 97%
EFY 2013 Target 100% 100% 100% 76% 98% 98% 99% 94% 96% 98% 100% 98%

Baseline EFY 2013 Performance EFY 2013 Target

Figure 7. Proportion of pregnant women received iron and folic acid supplements at least 90 plus, 2013 EFY

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Skilled Birth Attendance

In 2013 EFY, 2,167,475 (66%) pregnant women received delivery service by a skilled birth attendant. The current
year performance is greater than last year’s by 3% point but compared with the target set for the year (89%), the
performance showed a 23% deficit.

When analyzed by region, the performance for this indicator ranged from 29% (in Afar) to 100% (in Addis Ababa
and Harari) signifying the inequity across regions. All regions, except Afar and Benishangul Gumuz (both by 1%)
recorded a performance either equal or greater than their baseline. Moreover, only two regions (Addis Ababa
and Harari) both at 100% were able to achieve their target. The remaining regions performed lower than their
targets of the year. In fact, the target-performance difference in these regions is greater than 20%. The biggest
target-performance difference is in Amhara (36%) followed by Afar (31%).

Proportion of births attended by skilled health personnel,

2013 EFY
100% 100%
100%

80% 75% 74%

68% 69% 66%

60% 55%
42% 42% 44%
40%
28%

20%

0%
Dire Addis
Afar Amhara Oromia Somali B/Gumuz SNNP Sidama Gambella Harari National
Dawa Ababa
Baseline 29% 54% 61% 37% 43% 73% 70% 41% 100% 59% 100% 63%
EFY 2013 Performance 28% 55% 68% 42% 42% 75% 74% 44% 100% 69% 100% 66%
EFY 2013 Target 59% 91% 89% 62% 69% 95% 96% 64% 100% 91% 100% 89%

Baseline EFY 2013 Performance EFY 2013 Target

Figure 8. Proportion of births attended by skilled health personnel, 2013 EFY

Caesarean Section (C/S) service

According to WHO estimation, 5% to 15% of pregnant women develop severe complications that requires
caesarean section intervention. The caesarean section rate in the current fiscal year is 4.6%, which is better by
0.3% compared with last year’s performance.

In general, all regions except Gambella, showed improvement in C/S rate. The highest C/S rate was reported in
Addis Ababa (49%) followed by Harari (28%) and Dire Dawa (13%). All the remaining regions have a C/S rate of
less than 5%, which requires investigation and appropriate action such as expansion of BEmOC and CEmOC
services. The lowest C/S rate among these regions was recorded in Somali (1%) followed by Gambella and Afar
both at 2%. Compared with their baseline, Dire Dawa (by 1.7%) and Addis Ababa (by 1.6%) showed the biggest
changes.

Early Postnatal Care Service (PNC)

The postnatal period, the first six weeks after birth is the most vulnerable time for both is during the hours and
days after birth for the survival of the mother and her newborn. Shortage of care in this period may result in
disability or death as well as missed opportunities to promote healthy behaviors, affecting women, newborns,
and children. Vast majority of maternal and newborn deaths occur during the early antenatal period, which is
within seven days after birth.

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During the current fiscal year, a total of 2,766,314 (85%) women received PNC within seven days after delivery.
This has shown an increase of 2% points compared with the baseline and a deficit of 10% from the target. Out
of the total early PNC users, 62% of the care was given within 24 hours after delivery.

When disaggregated by regions, the early postnatal coverage ranged from 41% to 100%. The highest coverage
was recorded in Addis Ababa, Harari and Sidama all at 100% while the lowest was reported from Afar (41%)
followed by Gambella (44%) and Somali (45%). All regions except Benishangul Gumuz (less by 18%), Somali
(less by 13%), Afar (less by 6%) and SNNP (less by 1%) performed better than their baseline. The biggest
increase was in Dire Dawa (by 12%), followed by Harari (by 9%) and Oromia (by 7%).

Addis Ababa, Harari and Sidama achieved their target of the year while the remaining regions could not. The
biggest target-performance difference was in Benishangul Gumuz and Somali (both by 29%) followed by
Gambella region (by 27%).

Early PNC Coveragel, 2013 EFY

100% 100% 100%
100% 92% 93%
85%
80% 71% 73%

60% 47%
45% 44%
41%
40%

20%

0%
Dire Addis
Afar Amhara Oromia Somali B/Gumuz SNNP Sidama Gambella Harari National
Dawa Ababa
Baseline 48% 71% 85% 58% 65% 94% 97% 44% 91% 61% 100% 83%
EFY 2013 Performance 41% 71% 92% 45% 47% 93% 100% 44% 100% 73% 100% 85%
EFY 2013 Target 68% 96% 97% 74% 76% 100% 99% 70% 95% 95% 100% 95%

Baseline EFY 2013 Performance EFY 2013 Target

Figure 9. Early PNC coverage by region, 2013 EFY

Missed Opportunities in pregnancy continuum of care

Early initiation of ANC and continuation of the care to four or more visits providing essential evidence based
interventions such as syphilis screening, hepatitis testing, HIV testing supplementation of micronutrients such
as iron folate, provides women and babies with life-saving potentials. In the continuum of the care, ANC also
creates opportunity for delivery by skilled attendant, early postnatal care and other services essential for the
women and the newborn.

During the reporting period, 100% of pregnant women got at least one antenatal care visit by HEWs or other
health care providers. However, the continuity and the content of the care still lags behind the expectation.
About 34% (more than 1.1 million) pregnant mothers who had one ANC visit either delivered at home or not
assisted by a skilled personnel. Besides, close to a million did not receive four or more visits. In relative terms,
pregnant women who got testing for HIV and those who received iron folate showed minor gaps.

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EFY 2013: MISSED OPPORTUNITY IN PREGNANCY CONTINIUM OF CARE

3,500,000

3,000,000 - 82,953 313,056 502,246 964,998 923,838 1,101,085

2,500,000

2,000,000

1,500,000

1,000,000

500,000
3,268,560 3,185,607 2,955,504 2,766,314 2,303,562 2,344,722 2,167,475
0
ANC at least Iron Folate PMTCT Testing Early PNC ANC 4+ Syphilis Delivery by
One visit screening skilled
Performance Gap Series3 attendant

Figure 10. Missed opportunity in pregnancy continuum of care, 2013 EFY

Abortion Service

Comprehensive abortion care (safe abortion care service and post-abortion care services) for the needy in
accordance with the legislation of the country is a high impact intervention that saves millions of maternal
deaths.

During 2013 EFY, a total of 247,226 women received a comprehensive abortion care service which is less by about
14 thousand compared with last year. From the total number of women who received comprehensive abortion
care, 136,792 (56%) were safe abortion care service and 107,412 (44%) were post abortion care services. There
is a huge tendency to get comprehensive abortion service in the first trimester (<12weeks of gestation) which
accounts for 80%. However still, 20% of them come late which may increase the risk of complications.

Disaggregated by age, the majority (38%) of them fall under the age group 20-24 years, which is followed by 25-
29 years, which constitute for 28% of the share. Teenagers account for 27,705(206%) the clients who received
abortion service.

Still Birth Rate

By definition, a stillbirth is birth of a baby born with no signs of life at or after 28 weeks of gestation. Still
birth rate, which is calculated as the proportion of stillbirths from total births attended usually serves as a
proxy indicator for the quality of obstetric care.

In 2013 EFY, the national still birth rate was 12 per 1,000 births which is lower than last year’s still birth rate
of 14 per 1,000. There is a huge disparity among regions ranging from 6 per 1,000 births in Sidama to 52 per
1,000 in Harari region. Addis Ababa, Oromia, Somali and Gambella regions exhibited reduction in still birth rate
compared with last year baseline.

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Table 4. Still birth rate per 1,000 births attended in 2013 EFY

Still Birth rate (Per 1,000 births attended)

Region
2012 EFY 2013 EFY
Afar 18 20
Amhara 17 17
Oromia 14 11
Somali 23 17
B/Gumuz 17 18
SNNP 8 8
Sidama 7 6
Gambela 26 23
Harari 49 52
Dire Dawa 24 29
Addis Ababa 19 14
National 14 12

Maternal and perinatal death Surveillance and Response (MPDSR)

In the current five-year health sector transformation plan (HSTP-II) and reproductive health strategy, reduction
of maternal and perinatal deaths is included as a top priority. MPDSR is one of the strategies designed for
providing essential information needed to stimulate and guide actions to prevent future maternal and
perinatal deaths. MPDSR is a form of continuous surveillance linking the health information system and quality
improvement process from local to national levels.

Based on the WHO and World Bank 2017 estimate, about 13,946 maternal deaths were estimated to happen
in 2013 EFY. In general, the number of maternal deaths notified through the surveillance system was low, with
only 1,027 (7.4%) maternal deaths were notified from the total estimated deaths in 2013 EFY. From the total
notified deaths, 670 (65%) were case-based reports, which were subsequently investigated, reviewed, and
reported. Despite the presence of improvement in the verification of the notified death, the surveillance is
not yet well representing the national figure of maternal death. However, the trend in the number of maternal
deaths notification has shown a constant pattern over the years.

Maternal deaths notified

1400

1200 1010 1162 1025

972 1027
1000
#MD NOTIFIED

10% 9% 7%
6% 8%
800 590
600
335 4%
400

200 1%
0
2007 2008 2009 2010 2011 2012 2013
EFY

Figure 11. Number of maternal deaths reported against the estimated maternal death reported through MPDR surveillance
system (2007-2013 EFY)`

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Regarding regional variation in maternal death notification, the highest percentage of maternal deaths from
the estimated maternal deaths was notified in Harari region (69%) followed by Addis Ababa (17%) and the
lowest notification rate was in Sidama region (1.4%) followed by Gambella (4%).

Table 5. Number of maternal deaths notified through MPDS system in 2013 EFY by region

Number of notified Percent of notified maternal

Estimated no. of maternal deaths deaths
Region
maternal deaths
2012EFY 2013EFY 2012EFY 2013EFY
Afar 229 16 34 7% 14.8%
Amhara 3050 280 262 9% 8.6%
Oromia 5441 401 417 8% 7.7%
Somali 807 39 45 5% 5.6%
Benishangul Gumuz 163 32 21 21% 12.9%
SNNPR 2292 96 104 3% 4.5%
Sidama 635 _ 9 _ 1.4%
Gambella 100 9 4 15% 4.0%
Harari 34 36 23 110% 68.5%
Dire Dawa 61 17 10 26% 16.4%
Addis Ababa 355 50 61 15% 17.2%
National 13946 1025 1027 8% 7.4%
**MMR of 401 per 100,000 live births (WHO and World Bank) used to proportionate to the regions

Regarding case-based reporting among the regions; all regions implemented case-based reporting in 2013
EFY. On the other hand, the performance of death review was varied across the regions, the lowest rate of
review of death was observed in Benishangul and SNNP in which only 24% and 25% of death were reviewed
respectively. The remaining regions reviewed more than 50% of the reported deaths.

Causes of notified maternal deaths

The trend in causes of maternal death since the MDSR is started showed that Obstetric hemorrhage, anemia,
hypertensive disorders during pregnancy, and sepsis have persisted as the major causes of the 670 maternal
deaths reviewed in 2013 EFY. Out of these maternal deaths, 219 (82.2%) were due to direct causes, while the
remaining 17.8% were due to indirect causes. Obstetric hemorrhage was the leading cause of maternal deaths
accounting for 52.4% of the total maternal deaths followed by anemia (20%), hypertensive disorders during
pregnancy (13.1%), and sepsis (10%) of total maternal deaths Abortion contributed to only 3% of maternal
deaths in the 2013 EFY.

Perinatal death

In 2013EFY, 7042 perinatal deaths were notified which is 6% of the estimated perinatal death according to
EDHS 2016 and from notified death 1,650(23%) were reviewed and reported via case-based reporting which is
the highest Perinatal death review since the implementation started in 2009 EFY. Most of the perinatal death
review was reported from the Amhara region (56%) followed by Addis Ababa (23%) and Oromia (7%).

Regarding the cause of perinatal death, the leading cause was prematurity, which contributed 577 (35%),
followed by Asphyxia (31%) and Sepsis, Pneumonia & meningitis altogether contributing 13% of the deaths.

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Maternal Health services in 2013 EFY

Major activities
 Enhanced implementation of initiatives such as early ANC initiation and Post-natal 24 hour care
and stay, maternity waiting home, establishment of obstetric referral networking with in & out of
catchment area
 Social mobilization and awareness creation activities to strengthen ANC, institutional delivery
and PNC (Safe motherhood month initiative, Pregnant women conference and other SBCC
interventions etc)
 Capacity building on Catchment based clinical mentorship so far reach 265 hospitals & 530
health centers were mentored
 Efforts made to establish mini blood bank
 Strengthen MPDSR system & develop new initiative such as confidentiality enquiry
 Develop Call to action document & implement activities
 Conducted capacity building for health care providers on comprehensive an abortion care
service
 Advocacy on elimination of obstetric fistula on international fistula day , In addition integrating
obstetric fistula surveillance and response with in PHEM system
 Sensitization workshop done for Gimbichu Woreda transformation
 Support conflict affected areas technically and by mobilizing resources

Challenges
 Shortage of budget & delayed approval and release
 Shortage of maternal health commodities
 Delayed procurement process of Mini Blood Bank equipment
 COVID-19 pandemic
 Lack of consistency of local mentoring fee for catchment based clinical mentorship.
 Shortage of ambulance and misuse
 Security problem

Way forward
 Improve maternal health commodity budget and overall budget allocation for maternal health
programs
 Finalize reimbursement protocols to initiate reimbursement of MH commodities
 Planning and close monitoring of procurement to establish a mini blood bank in 77 hospitals
 Institute uniform mentorship payment system
 Improve ambulance management, secure budget for maintenance & buy additional
ambulances
 Address maternal health service in the midst of humanitarian setting
 Strengthen the diagnosis and treatment of obstetric fistula
 Support implementation of Reproductive Health strategic plan, national obstetric fistula
elimination strategy, Obstetric protocols, and ANC and Catchment Based Clinical Mentorship
guidelines

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3.4. Prevention of Mother to Child Transmission of HIV (PMTCT)

Testing for PMTCT

Testing pregnant woman for HIV is the key entry point to PMTCT and other HIV care and treatment services.
During the performance year, a total of 2,955,504 (90%) pregnant women were tested for HIV and know their
status which exceeds last year’s performance by 6% points and is only 4% shy of the target. Vast majority (79%)
of the tests were conducted during pregnancy while the remaining 18% and 2% testing happens during labor
and delivery, and postpartum period respectively.

The regional performance ranges from as low as 33% in Somali followed by 55% in Afar to as high as 100% in
Addis Ababa, Sidama, Dire Dawa and Harari. Three regions; namely Afar, Benishangul Gumuz and Gambella
performed lower than their last year performance while the remaining regions performed either equal to
greater than their baseline. The biggest increment was recorded in Sidama region (by 16%). Six regions are
unable to achieve their target with the biggest target-performance gap observed in Afar (by 45%) Benishangul-
Gumuz (29%) and Somali (19%).

Percentage of pregnant, Laboring and lactating women who were

tested for HIV and who know their results: EFY 2013
100% 100% 100%
100% 99% 100% 90%
84% 86%
80% 69% 70%
55%
60%

40% 33%

20%

0%
Dire Addis
Afar Amhara Oromia Somali B/Gumuz SNNP Sidama Gambella Harari National
Dawa Ababa
Baseline 56% 79% 90% 24% 75% 81% 84% 73% 100% 97% 100% 84%
EFY 2013 Performance 55% 84% 99% 33% 69% 86% 100% 70% 100% 100% 100% 90%
EFY 2013 Target 100% 100% 94% 52% 98% 95% 97% 86% 100% 100% 100% 94%

Baseline EFY 2013 Performance EFY 2013 Target

Figure 12. Percentage of pregnant, Laboring and lactating women who were tested for HIV and who know their results in
2013EFY

Percentage of HIV-positive pregnant women who received ART to reduce the risk of mother-to child
transmission

Based on the recent (April 2021) HIV Related Estimates and Projections in Ethiopia, there are an estimated
18,677 HIV positive pregnant and lactating women who are in need of PMTCT. In 2013 EFY, a total of 13,064
(79%) pregnant and lactating women received ART for the prevention of mother to child transmission of HIV.
Out of the total pregnant and lactating women who received ART, 62% (8,359) were known HIV-positive women
who get pregnant while on ART and linked while the remaining 38% (5,201) were newly identified positives
during ANC (30%), labour and delivery (6%) and PNC (3%) for the first time and linked to PMTCT.

When analyzed by region, the performance for this indicator ranged from 29% (in Sidama) followed by Afar
58%) to 100% (in Dire Dawa). Four regions (Sidama, Afar, Oromia and Harari) performed lower than their
baseline. Moreover, there was no region that achieved the target set for the year with four regions having a
target-performance gap of 20% or more; Sidama (by 66%), Afar (by 42%), Oromia (by 25%) and Benishangul-
Gumuz (by 24%).

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Percentage of HIV-positive pregnant women who

received ART
100% 97% 100% 99%
100% 89% 93% 92%
87% 90% 91%
83%80% 82% 83%
79% 79%
80% 75%
71% 74%77%

58%
60% 52%

40% 29%
22%
20%
0%

a
ia

l
i

lla
NP
ar

ba
ri
uz
ra

na
al

w
am

ra
om
Af

ha

be
m

um

ba
SN

Da

tio
Ha
So

Sid
Am

sA
Or

Na
re
Ga
B/

di
Di

Ad
Baseline EFY 2013 Performance

Figure 13. Percentage of HIV-positive pregnant women who received ART to reduce the risk of mother-to child-transmission
in 2013 EFY

HIV testing of partners of pregnant, laboring and lactating women is a major component of the PMTCT service.
In 2013 EFY, a total of 288,744 partners were tested for HIV out of whom 1,758 (0.6%) were tested positive for
HIV.

During the fiscal year, a total of number of 10,300 (62%) HIV exposed infants received virological test result
within 12 months, out of which 68% were tested within two months after birth. Out of the total tests, 309 (3%)
turned positive. Confirmatory test (antibody test) for HIV exposed infants by 18 months was done to a total of
8,799 HIV exposed infants out of which 1.4% had a positive result.

Regarding antiretroviral (ARV) prophylaxis, 6,570 (35%) HIV exposed infants received antiretroviral (ARV)
prophylaxis for 12 weeks for prevention of Women-to-child transmission (PMTCT). With regard to co-trimoxazole
prophylaxis use within two months of birth, 9,100 (49%) infants born to HIV positive women out of the total
estimated were started on cotrimoxazole prophylaxis.

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Prevention of mother to child transmission of HIV in 2013 EFY

Major activities performed:

 Dual HIV and Syphilis test was piloted at four regions in order to strengthen HIV and Syphilis
testing for pregnant women
 EMTCT validation committee prepared validation report based on the WHO EMTCT validation
report
 Focuses on improving quality of MNCH/PMTCT/EID services (PMTCT mentorship implementation)
 Implementation of Dual prophylaxis for all HEI
 Strengthening implementation of PMTCT Cohort Monitoring
 MSG for adherence counseling and tracing of lost to follow ups (LTFU)

Challenges:
 Insecurity and displacement at different regions
 Budget shortage and less attention to MSG groups
 Data quality problem and major performance discrepancies between regions
 Supply interruption for HIV commodities

Way forward:
 Strengthening Effective supportive supervision and mentorship by utilizing CQI and DASH board
 Bringing MSGs in the government system or mobilizing resource for them to maintain the service
they are providing
 Strengthening the supply chain management at the national level & regional level
 Expansion of POC sites for the service quality and coverage of PMTCT services

Maternal health services in Tigray region

Due to the existing political situation in Tigray region, health services are interrupted in some areas and it is
extremely difficult to get accurate data on actual service uptake status of maternal health services in the region.
The following table summarizes the number women who are reported to have received essential services in
the region.

Table 6. Coverage of maternal health services in Tigray region, 2013 EFY

Base- Performance   Target

Indicator Eligible
line # % in %
Contraceptive acceptance rate 1,131,486  81%  170,345   15% 80% 
Antenatal care 4+ coverage 194,033   96% 28,733  15%   100%
Percentage of deliveries attended by skilled health person-
194,033   98% 31,103  16%   100%
nel
Early postnatal care coverage 194,033   99% 35,723  18%  100% 
Percentage of pregnant women counseled and tested for
194,033   99% 41,517  21%  98% 
PMTCT
Percentage of pregnant and lactating women who received
2, 079   100% 496   24% 95% 
ART to prevent mother to child transmission of HIV

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3.5. Neonatal, Child, Adolescent and Youth Health

To realize the child health targets set of HSTP-II, Ministry of Health has designed and been implementing high
impact interventions at facility and community levels. In the HSTP II period, some of the major neonatal and
childhood interventions include implementation of ; New-born corners, Advanced neonatal care, expansion of
Neonatal Intensive Care Units (NICU), Kangaroo mother care (KMC), community and facility based Integrated
Management of Neonatal and Childhood Illnesses (IMNCI), implementation of Early childhood development
(ECD) interventions, strengthening the immunization program and other high impact interventions. In this
section, summary of key achievements, challenges and way forward are discussed.

3.5.1. Expanded Program on Immunization

According to the routine health information system data in 2013 EFY, the national pentavalent-3, measles,
and fully vaccination coverages were 100%, 97% and 93% respectively. The performance of these EPI key
performance indicators show that the coverage is almost similar to the previous year’s performance, despite
challenges of immunization services interruptions due to conflicts in different part of the country causing
health emergencies and presences of COVID 19 pandemic affecting the health system. The detail national and
regional performance is described below.

Pentavalent-3 vaccination coverage

In 2013 EFY, about 3,131,041 (100%) infants under 1 year of age were vaccinated with pentavalent third dose.
However, there is regional disparity among regions, ranging as low as 77% in Benishangul Gumuz and Afar
regions respectively to more than 100% in Oromia, Harari, SNNPR, SIdama and Addis Ababa. Except B. Gumuz
and Somali Regions, all regions showed slight increment from their baseline performance.

Pentavalent 3 coverage, 2013 EFY

96% 100% 100% 100% 100%
100% 93%
88%
90% 80%
78% 77%
80%
70%
60%
Percent

50%
40%
30%
20%
10%
0%
Dire Addis
Afar Amhara Oromia Somali B/Gumuz SNNPR Sidama Gambella Harari National
Dawa Ababa
Baseline 76% 92% 100% 100% 92% 97% 100% 86% 100% 77% 100% 99%
Performance 78% 93% 110% 96% 77% 100% 105% 88% 100% 80% 100% 100%
Target 91% 100% 100% 100% 99% 100% 100% 98% 100% 86% 100% 100%

Figure 14. Pentavalent 3 vaccination coverage by region, 2013 EFY

Note about Tigray region – Performance report is received for the first quarter of 2013 EFY only. In the
first quarter of 2013 EFY, 43,142 (24%) infants received pentavalent 3 vaccine in Tigray region.

Measles-1 Vaccination Coverage

The national Measles-1 vaccination coverage (MCV1) in 2013 EFY is 97%, with the regional performance
ranging from 71% in Gambella and B. Gumuz region to 100% in Oromia, Sidama, Harari and Addis Ababa city
administration. Except Afar, Gambella, and B. Gumuz, all regions showed slight increment from their baseline
performance. Oromia, Sidama, Harari and Addis Ababa performed above the national average.

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Regarding the second dose of measles vaccine (MCV2), 2,313,704 (72%) children received the second dose of
Measles in 2013 EFY. However, regions such as Afar(46%), Benishangul Gumuze (52%), Gambella(48%), and
Somlai(60%) achieved relatively lower coverage of MCV2 vaccination coverage.

Measles-1 coverage, 2013 EFY

120%
102% 100% 100%
94% 97%
100% 88% 85% 71%
71% 79%
80% 72%
Percent

60%

40%

20%

0%
Dire Addis
Afar Amhara Oromia Somali B/Gumuz SNNPR Sidama Gambella Harari National
Dawa Ababa
Baseline 82% 88% 99% 92% 85% 93% 97% 70% 98% 73% 100% 95%
Performance 71% 88% 103% 85% 71% 94% 102% 79% 100% 72% 100% 97%
Target 94% 100% 100% 95% 94% 100% 99% 98% 100% 100% 100% 99%

Figure 15. Measles-1 vaccination coverage (MCV1) by region, 2013 EFY

Note about Tigray region – Performance report is received for the first quarter of 2013 EFY only. In the
first quarter of 2013 EFY, 38,090 (21%) infants received Measles-1 vaccine in Tigray region.

Full vaccination coverage

Nationally 2,815,320 (93%) under one infants received all types of basic antigens in before celebrating their
first-year birthday. Looking into the regional data the performance ranges from 58% in Afar region to 100% in
Harari, Addis Ababa and Oromia. All regions showed slight performance increment from their baseline except
Afar, Benishangul Gumuz and Somali regions.

Full vaccination coverage, 2013 EFY

120%
103%
100% 99% 100%
100% 91% 93% 93%
87%

80% 71% 69% 68%

62%
Percent

58%
60%

40%

20%

0%
Dire Addis
Afar Amhara Oromia Somali B/Gumuz SNNPR Sidama Gambella Harari National National
Dawa Ababa
Baseline 61% 86% 94% 74% 81% 90% 94% 61% 90% 70% 100% 90% 90%
Performance 58% 87% 100% 71% 69% 91% 99% 62% 103% 68% 100% 93% 93%
Target 93% 100% 96% 86% 93% 100% 99% 92% 100% 91% 100% 97% 97%

Figure 16. Full vaccination coverage by region, 2013 EFY

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 MINISTRY OF HEALTH

Note about Tigray region – Performance report is received for the first quarter of 2013 EFY only. In the
first quarter of 2013 EFY, 37,305 (20.5%) infants received Measles-1 vaccine in Tigray region.

Dropout Rate (Pentavalent-1 to Measles vaccination)

In 2013 EFY, the national pentavalent-1 to measles dropout rate is 11%, which is higher than the acceptable
range. Only three regions have a dropout rate less than 10% (Addis Ababa, Amhara and Sidama). The highest
penta-1 to MCV1 dropout rate was observed in Dire Dawa (34%) followed by Gambella (23%) and Somali (21%)
regions.

Somali region 21%, followed by Afar 20% and the lowest dropout rate was registered in AA city administration
(3.8%).

Dropout Rate (Pentavalent-1 to Measles vaccination), 2013 EFY

40%
34%
35%
30%
25% 23%
21%
20%
20%
15% 11% 12% 11% 11%
10%
10% 8%
7%
4%
5%
0%
Benishang Addis
Afar Amhara Oromia Somali SNNP Sidama Gambella Harari Dire Dawa National
ul Gumuz Ababa
2012 EFY 17% 8% 13% 23% 15% 9% 8% 26% 15% 15% 7% 12%
2013 EFY 20% 8% 11% 21% 12% 11% 7% 23% 10% 34% 4% 11%

Figure 17. Dropout Rate (Pentavalent-1 to Measles vaccination), 2013 EFY

Other major Immunization activities conducted in the fiscal year

 Vaccinated more than 14.5 million children aged 9-59 month for measles all over the country
 Switch from TT to Td and PCV10 to PCV13
 HepB birth dose pilot implementation underway in Afar, Addis Ababa, Amhara & Tigray
 Financial support was provided to regions for the implementation of periodic  intensification of
routine immunization (PIRI) health system strengthening activity
 HPV vaccination: 1,384,517 (92%) for the 1st dose of 2020 cohort and 1,244,467 2nd dose of HPV 2019
cohort were vaccinated with human papilloma virus (HPV) vaccine
 Conducted Cold chain equipment inventory
 Panel discussion on world polio day about Polio eradication and COVID-19 vaccine was conducted
 COVID 19 vaccine introduction
 Measles 5 dose pilot implementation in Amhara and Oromia region
 TV and radio spot messages transmitted at national and regional medias to celebrate African
vaccination week

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Challenges

 Global COVID 19 Pandemic

 School closure in some areas affected HPV vaccination
 Insecurity /Local unrest in some parts of the country
 Shortage of cold chain equipment and other supplies
 Emergence of circulating vaccine derived polio virus type 2 (cVDPV2), diverting attention and resources
of government and partners
 Inadequate government budget allocation for immunization at service delivery points
 Sub-optimal reporting of adverse effects following immunization (AEFI)
 Delayed shipment of additional doses of Vaccine-uncertainties in vaccine logistics system

Way forward

 Strengthen commitment & engagement of leadership at all level

 Continue advocacy and communication for COVID 19 vaccination uptake
 Strengthen and expand vaccination delivery services access and utilization to address the zero dose
and under-vaccinated children (PIRI and RED)
 Implement data quality activity (digitalization, data triangulation)
 Strengthen public private partnership and domestic resource mobilization
 Continuous monitoring and supervisory activities, at each level
 Enhance Advocacy, communication, and social mobilization activities at all level

3.5.2. Neonatal and Child Health Services

In the effort to reach the goal of universal access to essential high impact neonatal and child health services, the
health sector has achieved remarkable results during the HSTP-I period. The results have been strengthened
in the first year of HSTP-II. In respect to service expansion, the proportion of health facilities that provide IMNCI
services and the proportion of woreda that provide iCCM services as per the standard increased from 89% (2007
EFY) to 96%(2013 EFY) and from 74% (2007 EFY) to 97.7 % (2013 EFY), respectively. The proportion of health
posts providing CBNC also increased from 58% (2007 EFY) to 93% (2013 EFY). Moreover, the percentage of
health centers with a Newborn corner increased from 69.6% (2007 EFY) to 78% in (2013 EFY) while the number
of hospitals with NICU increased from just 30 (2007 EFY) to 196 in (2013 EFY).

With regard to service uptake, in EFY 2013, 74.2% of under five children with diarrhea received ORS & Zinc
treatment, while 60.8 % of the same age group with ARI received antibiotics. In addition, 100% of asphyxiated
newborns were resuscitated and 41.8% of newborns with neonatal sepsis received routine treatment. During
the year, 62.4% of very low birth weight (VLBW) newborns received Kangaroo method care (KMC).

In 2013 EFY, various initiatives have been implemented to improve the health and development status and
reduce morbidity & mortality among newborns. The major initiatives that have been implemented include
Expansion & Strengthening of Community Based New-Born Care (CBNC), implementation of Integrated
Community Case Management of New-born & Childhood Illness (iCMNCI), Integrated Management of Newborn
and Childhood illnesses (IMNCI), expansion of NICU services, Expansion of Essential New-born Care (ENBC),
and initiation and implementation of Early Childhood Development (ECD) intervention. COVID-19 Pediatric
management protocol and child-health mitigation plan was developed, published and distributed to health
facilities. Its implementation has been monitored on a weekly basis.

Performance of different neonatal and child health interventions is described below:

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Community Based New-Born Care (CBNC) and Integrated Community Case Management of
Newborn & Childhood Illness (ICMNCI)

In the fiscal year, more focus was provided to expansion of CBNC and iCMNCI services to more health posts in
pastoralist regions.

Major activities related to CBNC include:

 Mobilized resource and sent for the three pastoralist regions to launch Community Based Newborn Care
(CBNC) program in 36 districts ( 24 in Somali, 9 in Afar, and 3 in Gambella)
 CBNC program post-training follow-up has been provided to 103 health posts in Somali region
 Performance review and Clinical mentoring meeting (PRCMM) was conducted in 5 Woredas of Gambella,
6 Woredas of Afar, 2 Woredas of Benishangul Gumuz and 6 Woredas of Somali

Major activities related to iCMNCI include:

 Provided ICMNCI training to 152 Woreda and Zone Health Office experts in woredas where the Integrated
Community Case Management for Newborn and Childhood Illness (iCMNCI) program was already
launched
 Performance review and Clinical mentoring meeting (PRCMM) training was given for 20 professionals
from the four pastoral regions
 one-day orientation workshop was held with 20 pastoralist regions regional health bureau child health
experts on Contextualized iCMNCI implementation guide
 To strengthen implementation of multi-sectoral woreda transformation, iCMNCI training was provided to
30 HEWs in Gimbichu Woreda
 Provided technical support while implementing Possible Serious Bacterial Infection (PSBI) implantation
research in two selected districts
 Initiated pilot implementation of eCHIS- ICCM/CBNC modules in one district of Oromia region

Table 7. Percentage of health posts providing CBNC and iCCM service, 2012-2013 EFY

Proportion of health posts implementing CBNC Proportion of health posts implementing

Region iCCM
2012 EFY 2013 EFY 2012 EFY 2013 EFY
Afar 74.0% 95.9% 100% 100.0%
Amhara 100% 95.0% 100% 96.0%
Oromia 98% 94.9% 98% 97.2%
Somali 47% 57.4% 98% 99.4%
Benishangul-Gumuz 94% 99.3% 100% 99.5%
SNNP 98% 99.4% 98% 99.5%
Sidama 94.5% 95.6%
Gambella 69% 89.9% 97% 94.9%
Harari 0% 56.3% 100% 93.8%
Dire Dawa 0% 0.0% 100% 94.4%
Addis Ababa NA NA  NA  NA
National 94% 93% 99% 97.7%

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Integrated Management of Newborn and Childhood Illnesses (IMNCI)

Strengthening the implementation of Integrated Management of Newborn and Childhood Illnesses (IMNCI) at
health facilities has been one of the major initiatives in 2013 EFY. The major activities performed include:

 Provided IMNCI training for 25 & 27 health professionals from Somalia and Afar regions respectively
 IMNCI training materials were revised to include recent global and national recommendations
 Orientation on major changes of the revised IMNCI guide was given for 22 Child Health Officers from all
regions
 Printed and distributed 1,665 IMNCI registers
 Conducted IMNCI and ICMNCI program based supportive supervision in selected 8 woredas, 8 Health
centers and 16 health posts in four agrarian regions and also conducted the feedback dissemination
workshop

Table 8. Proportion of health centers providing IMNCI services by Region, 2012-2013 EFY

Proportion of health centers implementing IMNCI

Region
2012 EFY 2013 EFY
Tigray 100% No update data
Afar 90% 92.8%
Amhara 91% 95.5%
Oromia 97% 99.4%
Somali 87% 85.6%
Benishangul- Gumuz 93% 94.8%
SNNP 98% 94.6%
Sidama - 94.1%
Gambella 86% 89.7%
Harari 100% 100%
Dire Dawa 100% 100%
Addis Ababa 100.0% 94.9%
National 95% 96%

Essential Newborn Care (ENBC)

The following activities have been performed in 2013 EFY to improve essential care to newborns

 Trainings organized and provided to health care providers across all regions
 ENBC service quality monitoring activity was integrated into the catchment-based mentorship program
 Helping baby breath training was provided for 32 health care providers from Oromia and Addis Ababa

Neonatal Intensive Care Unit (NICU) Service

Expansion of advanced NICU service in hospitals was one of the major activities undertaken in 2013EFY. The
following major activities and achievements were documented regarding NICU service

 At the end of 2013 EFY, 79 hospitals were equipped with Level III NICU equipment and made ready for
level III NICU service. Supportive supervision was conducted for hospitals that received equipment for
NICU level III service

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 NICU Clinical mentorship conducted in 45 hospitals in Amhara Oromia, SNNPR Sidama Afar Benishangul
Gumuz regions.
 gap filling training was provided for 233 NICU nurses.
 NICU KMC and L&D Clinical mentorship was conducted in 56 selected hospitals from Sidama, Amhara,
Oromia SNNP Regions
 National assessment was conducted on NICU level III equipment and preventive and curative maintenance
is planned per the result of the finding s
 NICU trainings were organized and provided to NICU nurses and other health care providers
 A virtual consultative meeting was conducted on NICU quality service improvement with 52 hospital
CEOs, 33 NICU heads and 19 are MCH directors and child health focal persons
 Formative assessment on NICU, KMC L&D was conducted in 27 hospitals in Oromia, 18 hospitals in
Sidama and SNNPR, 19 hospitals in Amhara and 10 hospitals in Tigray regions. Based on the findings of
the assessment, procurement was ordered on the following medical equipment:- Digital weigh scale,
neonate Oxygen nasal Prongs, Pulse oximeter and Oxygen concentrator and KMC wrap, gown and
reclining chair Television
 Consultative workshop conducted on validation of Minimum care packages on NICU L&D and KMC
 Clinical mentorship TOT has been provided on NICU, KMC L& D Quality improvement for 176 Health care
workers (48 SNNPR and Sidama, 47 Tigray, 52 Oromia, 29 Amhara regions)
 Conducted high level advocacy on world prematurity day celebration and documentary film developed
radio and television spot message prepared and awareness creation activity conducted

Early Childhood Development (ECD) Intervention

Early childhood development is a multi-sectoral initiative that was initiated in 2011 EFY with the objective of
providing young children with good health, adequate nutrition, security and safety, responsive caregiving, and
the opportunity for early learning and development. It is to ensure that every child of Ethiopia relishes early
childhood care, growth, development and education to be responsible, healthy, and productive citizens of
good character.

The following are the main activities accomplished in 2013 EFY

 ECDE policy framework was revised in collaboration with MoLSA, MoWCYA and Ministry of Education
(MoE)
 ECD content was integrated into the revised integrated refresher training (IRT) manual and in the
preservice training curriculum of health care providers
 Advocacy on ECD was conducted using different opportunities such as review meetings and annual
conferences
 A Five-year (2021-2025) sector specific strategic plan for health sector was developed
 A total of 12,000 ECD Job aids (counselling cards, key messages, and developmental milestone checklists)
were developed, translated in to local languages and disseminated
 Contextualized Care for Child Development (CCD) training package was developed and technical
assistance was provided for other sectors to contextualize the respective sector specific training package.
Moreover, CCD trainings conducted for more than 200 health workers and 40 experts from other sectors
i.e. education, women, children and youth affairs
 Technical supports for on job training and supportive supervision were provided for the Addis Ababa ECD
project, which is led by the Addis Ababa mayor’s office/AA city administration

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 Media campaign in the form of TV and radio spots were conducted to improve awareness of the public
on dealing with kids during pandemics; spend time with children at home and coping stress in kids and
caregivers;
 Child Play corners were established in health facilities
 ECD is integrated in IMNCI, ECD messages integrated in mHealth platforms
 The ECD/NC implementation of Ethiopia has been documented and shared with the global communities
via presentation and publication
 High level ECDE policy framework review and the Addis ECD project launch was conducted on 27th
March, 2021

Documents, medical Supplies & Commodities for child health

 Even though adequate specification on the quality of amoxaciline DT was not obtained from the supplier
to be purchased as per the 2013 FY quantification, an agreement was reached to extend the contract and
order the purchase. On the ther hand, due to the delay in the purchase of ORS Zinc co pack by EPSA, an
agreement was reached with NI to avail emergency supply. Additional budget allocated for the purchase
of Zinc, ORS, TTC and A,oxacillin DT (250mg) was transferred to EPSA
 Child Health 2030 Roadmap final version was prepared and submitted for approval
 To complete contextualization guideline on ICMNCI for pastoralist regions and areas and its launching
workshop was organized in collaboration with THDR project for a day
 Availed personal protective equipment (PPE) in under 5 OPD and paediatrics wards to maintain the
essential child health services and demand generating activities.
 KMC wrap, KMC reclining chair kMC gown were procured and distributed to 74 hospitals
 Pulse oximetry, oxygen concentrator, infusion pumper, digitized weighing scale procured

Challenges

The following are some of neonatal and child health program-related challenges in 2013 EFY:

 The COVID-19 pandemic has negatively impacted the provision of Neonatal and child health services and
on care-seeking for sick infants and children,
 Inadequate resource to fully rollout CBNC in all pastoralist regions and cascade the revised ICMNCI
training
 Stagnant neonatal mortality despite the implementation of high impact community and facility-based
interventions and the low attention given for neonatal mortality by the leadership
 Competing priority activities and untimely release of budget
 Shortage of human resource for newborn and child health program at all levels
 High turnover of trained health professionals
 Unavailability of some health workers on their duty during working hours
 Low uptake/utilization of some child health commodities e.g. Amoxicillin DT for newborn & childhood
infections, Zinc DT for diarrheal diseases and Chlorhexidine gel for umbilical cord care
 Lack of sustainable domestic financing for child health program commodities
 An increasing trend in incidence of congenital anomalies such as neural tube defects
 Purchase of substandard/poor quality newborn and child health medical supplies, and lack of spare
parts and no timely maintenance
 Shortage of essential child health drugs and sub optimal quality of services at some health facilities
 Lack of attention to newborn health activities at pastoralist areas

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 Lack of local incidence data on newborn and childhood illnesses like Birth asphyxia, neonatal infections
(PSBI), diarrhea and pneumonia
 Gap in availing quality health services for all newborns in many health facilities. Neonatal ICUs are also
inadequately equipped and have yet to expand. The limited competency of midwives& nurses in the
provision of emergency new born care services, lack of a separate newborn corner, absence of a neonatal
unit in some health facilities; and low coverage of skilled delivery and newborn care are some of the
challenges related to newborn care

Way forward

 Maintain provision of essential health service during the COVID-19 pandemic

 Strengthen the continuum of care in the life course approach for women and children
 Implement integrated ECD to make the newborn and child health interventions developmentally sensitive
and address child health issues beyond survival.
 Strengthen integration of child-health training packages such as IMNCI in to pre-service curricula of
health sciences colleges.
 Revision of basic newborn and child-health training packages such as NICU and IMNCI
 Conduct/strengthen program based and Integrated supportive supervisions
 Expansion of CBNC in Woredas that have not not yet initiated CBNC such as in Afar, Gambella and Somali
regions
 Integrate implementation of child health focused catchment-based mentorship with the existing
RMNCAYHN platform
 Strengthen evidence generation by research advisory committee (RAC) teams to support evidence-based
decision making of Child Health program
 Continue capacity building activities in the form of trainings and mentorship(PRCMM) focusing on
community & facility child health initiative (ICMNCI, IMNCI, ENC, NICU)
 Address the gap in capacity among health care providers in effectively utilizing new child-friendly
formulations and commodities
 Ensure sustainable domestic funding for child health commodities
 Strengthen program ownership & sustainability at all levels.
 Strengthen the Supply chain management system for newborn and child health
 Improve supportive supervision and performance review meeting to ensure access to quality and equity
services on newborn, infant and child health

3.5.3. Adolescent and youth Health Services

The proportion of health facilities providing Youth friendly services has increased to 46% in the reporting
period. The teenage pregnancy rate among all those tested positive for pregnancy has decreased from 23%
to 19.8%. This year, a five-year adolescent and youth health strategy (2021-2025) has been drafted and costed.
A roadmap for Integrating Smart Start in Ethiopia (RISE) was launched in five regions (Amara, Oromia, SNNP,
Afar and Somali). Besides, a youth and adolescence training Manual (e-learning) was developed and a 13
session module was converted to the learning Management system platform. A pilot training was also given
to staff in the Human Resource Development Directorate. Moreover, a mobile app has also been developed
and translated into six languages ​​to make health information accessible to adolescent and youth population.

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During the fiscal year, Adolescent and Youth forum was conducted under the theme “Let’s work together for
youth health” with presence of Honorable President Sahlework Zewde and higher official of Ministry of health
and more than 1000 youth attended the forum. The forum was the first of its kind for the Ministry of Health and
its partners as well as the youth to discuss the national efforts to improve the health of youth and adolescents.

In collaboration with key stakeholders, Adolescents Health Service Barrier Assessment (AHSBA) was conducted
in five regions of Ethiopia.

Other Major activities of adolescent and youth Health

 MoH held a high-level consultation meeting with Industrial Parks Development Corporation (IDPC) on
health service delivery & promotion to the youth employed under them
 Efforts have been made to improve the provision of quality youth and adolescent health services at youth
centers. Supplies (such as weighing scale, first aid kits, wireless microphones & contraceptives) have been
provided for youth centers clinics
 The Yene Tab Mobile App has been developed and made available in different languages ​​(Amharic, English,
Afan oromo, Tigrigna, Afar and Somali).
 In collaboration with the Ethiopian Institute of Public Health, more than 2,000 dignity kits and RH kits have
been donated for people displaced for various reasons.
 A one-minute spot message on AY friendly health services has been broadcasted to the public twice a
week on radio and television.
 In the year, 36 professionals working in 952 call centers, 24 female leaders selected from universities and
more than 198 professionals were trained on youth and adolescent health.
 A review meeting and integrated supportive supervision on the implementation of the Youth and
Adolescent Health Program was held

Challenges

 High turnover of trained AYH service providers at different health institutions

 COVID-19 affected the provision of youth friendly health service provision
 Shortage of budget for AYH program planning and implementation
 Weak structural organization at regional health bureaus which induce low accountability mechanism and
collaboration
 Not including reproductive health issues/ information in the education curriculum design process

Way forward

 Strengthening the adolescent and youth health structures at all levels of the system
 Mobilizing and allocating adequate budget for AY health program implementation
 Strengthen inter-sectoral collaboration mainly with the Ministry of Education
 Enhancing conducive environment for adolescent and youth to access quality health-education and
information
 Increase the number of facilities providing youth friendly health service to 48%.
 Strengthening and supporting youth and adolescent health services in industrial parks and development
corridors
 Develop and expand best practices, capacity building of health professionals etc

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3.6. Nutrition Program

In the past decade, Ethiopia has implemented the first and second national nutrition programs (NNPI and
NNP II). With the implementation of the first and second NNPs, nutrition indicators showed improvement over
the years. The prevalence of stunting, wasting and underweight in under 5 children has decreased over time.
Stunting has decreased from 58% in 2000 to 37% in 2019. The prevalence of wasting and underweight has also
been reduced from 12% and 41% in 2000 to 7% and 21% in 2019 respectively. Even though malnutrition has
decreased over time in Ethiopia, the problem is still high. This shows that more effort is required to reduce
malnutrition by implementing evidence based and effective nutrition interventions in the HSTP-II period.

Following the second NNP, Ethiopia has developed and endorsed food and nutrition policy in 2018 and
developed a food and nutrition strategy, which will span for the period 2021-2030. The food and nutrition
strategy aims to attain optimal nutritional status of the population at all stages of the life span and conditions
to a level that is consistent with quality of life, productivity and longevity. It mainly focuses on implementation
of high impact multi-sectoral nutrition interventions, through multi-sectoral collaborative activities tackling
both nutrition specific and nutrition-sensitive challenges.

In this section, major nutrition-specific interventions and achievements in 2013 EFY, performed mainly by the
health sector are described.

Implementation status of nutrition interventions

The health sector has implemented different nutrition interventions to prevent malnutrition, especially in
pregnant and lactating women, and children specifically focusing on the first 1000 days nutrition. The major
nutrition related interventions include growth monitoring and promotion and counselling services for all
children under 2 years of age, vitamin A supplementation for children aged 6-59 months, deworming service for
children aged 24-59 months of age, nutrition screening and treatment of malnutrition among under 5 children
and PLW, iron and folic acid supplementation and other nutrition specific services. The major achievements
and activities conducted in 2013 EFY are described below.

Growth Monitoring and Promotion

Growth monitoring and promotion service for children under 2 years is provided with the aim to identify
inadequate growth early enough and reverse the problem with appropriate nutritional interventions. It focuses
on children under 2 years of age when catch-up growth is possible if intervened for a growth problem. It uses
regular community dialogue to engage community members to assess the overall nutritional status of children
in their community, to understand the barriers and potential supports for improved nutrition, and to develop
consensus on plans of action to make a difference.

In 2013 EFY, more than 2.5 million (51%) of children under 2 years of age received growth monitoring and
promotion service. This performance is lower than the baseline and much lower than the target for 2013 EFY
(target was 97%). The performance of GMP is the lowest in Afar, Somali, and Gambella regions, where GMP
coverage is below 10%. Compared to the target set for 2013 EFY, no region has achieved the 2013 target.

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Proportion of children under 2 years of age GMP, EFY 2013

120%

100%

80%

53% 57% 54% 56%

60% 51%
49%

40%
29% 28%

20% 15%
4% 4% 3%
0%
Dire Addis
Tigray Afar Amhara Oromia Somali B/Gumuz SNNPR Sidama Gambella Harari National
Dawa Ababa
Baseline 4% 49% 44% 4% 31% 50% 63% 4% 27% 11% 34% 45%
Performance 4% 53% 57% 4% 29% 54% 56% 3% 49% 15% 28% 51%
Target 72% 100% 100% 57% 98% 96% 93% 88% 84% 99% 100% 97%

Figure 18. Proportion of children under 2 years of age that received GMP service, 2013 EFY

Vitamin A Supplementation

Supplementation of children aged 6-59 months of age with two doses of vitamin A every year is one of the
key nutrition interventions to eliminate Vitamin A deficiency and its consequences. In 2013 EFY, more than 11
million (86%) children aged 6-59 months received two doses of vitamin A. This performance is higher than the
previous year’s performance (79%) but lower than the target for 2013 EFY (97%). There is a regional disparity in
Vitamin A supplementation, ranging from 27% in Benishangul Gumuz region to 100% in Harari and Dire Dawa.

Proportion of children aged 6-59 months of age who received

two doses of Vitamin A supplementation, 2013 EFY
120%
97% 100% 100% 88%
100% 95%
84% 86%
77% 81%
80%

60%

40% 30% 34%

27%
20%

0%
Ben.Gum Dire Addis
Tigray Afar Amhara Oromia Somali SNNPR Sidama Gambela Harari National
uz Dawa Ababa
Baseline 35% 77% 96% 16% 83% 65% 62% 20% 92% 60% 100% 79%
Performance 30% 77% 97% 95% 27% 81% 84% 34% 100% 100% 88% 86%
Target 87% 98% 97% 69% 100% 91% 92% 99% 100% 97% 100% 95%

Figure 19. Proportion of children aged 6-59 months of age who received two doses of Vitamin A supplementation

Deworming service

Deworming children aged 24-59 months of age with Albendazole twice a year is one of the nutrition interventions
implemented in Ethiopia. In 2013 EFY, more than 7.7 million (82%) children aged 24-59 months received bi-
annual deworming service. This performance is higher than the previous year’s performance (74%) but lower

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than the target for the fiscal year (96%). The lowest performance is reported in all the four special support
regions; Somali (15%), Benishangul Gumuz region (23%), Afar (25%) and Gambella region (35%).

Proportion of Children aged 24 - 59 months de-wormed, 2013 EFY

120%

98% 100%
100% 93%
89%
81% 84% 82%
80%

60% 55%

40% 35%
25% 23%
20% 15%

0%
Addis
Tigray Afar Amhara Oromia Somali Ben.Gumuz SNNPR Sidama Gambela Harari Dire Dawa National
Ababa
Baseline 20% 78% 87% 16% 66% 64% 68% 13% 93% 59% 58% 74%
Performance 25% 81% 93% 15% 23% 84% 89% 35% 98% 100% 55% 82%
Target 86% 98% 97% 67% 100% 97% 96% 98% 100% 98% 100% 96%

Figure 20. Proportion of Children aged 24 - 59 months de-wormed, 2012 EFY

Other major nutrition achievements and activities

Major activities
In addition to implementation and achievements on the above nutrition interventions, the following
major activities have been performed in 2013 EFY:
 Costed ten-year National Food and Nutrition Strategy (2021-2030) is developed, endorsed by the
National Nutrition Coordination Body (NNCB)
 A comprehensive and integrated nutrition service package and its implementation guideline is
developed, approved and disseminated for pastoralist and agro-pastoralist areas
 A proclamation on the establishment of food and nutrition council and agency was finalized and
submitted to the office of the prime minister for approval
 Food and Nutrition resource mapping was conducted, report compiled and utilized for the food
and nutrition strategy
 Emergency nutrition preparedness, response and rehabilitation support provided to IDP sites,
areas with manmade and natural disasters
 Operational guideline on infant and young child feeding in Emergencies (IYCF-E) was developed
and familiarized to regions and other stakeholders through a consultative workshop. A joint
statement was signed and launched with the presence of all implementing parties (MoH, NDRMC,
UNICEF, WHP,WHO)
 A family-MUAC approach kick off was conducted in Somali region, a national guideline was
prepared and translated into six local languages
 Different capacity building nutrition related trainings were provided. More than 90 media and
public relation professionals were trained on Global and National nutrition situation, and on
basics of food and nutrition policy landscapes. More than 30 regional nutrition coordinators were
provided with training of trainers’ course on developmental nutrition/Maternal, Infant and Young
Child  Nutrition  (MIYCN) training. In addition, nutrition leadership training for 30 national and
regional nutritional leaders and training on the revised acute malnutrition guideline was provided
to regional and national nutrition experts and coordinators

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 World breast feeding week was celebrated at national and regional level through panel discussions,
message dissemination via TV/Radio spots, preparing and printing banners, brochures, stickers,
masks, media packages, media trainings etc
 14 health facilities were recognized for successfully implementing Baby Friendly Hospital/Health
Facility Initiative (BFHI)
 As part of an awareness creation activity, TV and radio spot nutrition messages were prepared in
three languages and broadcasted in four regional television and radio stations for three months
 Supportive supervision, bi-annual review meeting, technical and financial support was provided
to nutrition program implementing health institutions

Challenges
 Weak multi-sectoral food and Nutrition coordination and linkages, accountability, and ownership
among FNS implementing sectors at all levels
 Delayed endorsement of the proclamation for Food and Nutrition council and Agency establishment
 Inadequate lower-level structure and human resource for food and Nutrition
 Inadequate budget for food and Nutrition from government treasury
 Poor coordination and utilization of budget from partners, low donor attention for developmental
nutrition interventions, more focus to emergency nutrition
 Occurrence of frequent emergency situations due to insecurity and instability in different parts of
the country
 The COVID-9 pandemic affect provision of different nutrition services

Way forward
 Strengthen the provision of GMP, vitamin A supplementation, deworming and other existing
nutrition interventions
 Improve adolescent, maternal and child nutrition through 1000 days plus nutrition service delivery
 Ensure the operationalization of food and nutrition strategy (FNS) at all levels
 Ensure the availability of food and Nutrition supplies and commodities at health facilities
 Build the capacity of program managers, leaders, HWs, HEWS and others though various capacity
building trainings
 Advocate the endorsement of a proclamation for the establishment of Food and Nutrition council
and Agency
 Advocate for the establishment of Nutrition directorate at MOH, establishment of appropriate
structure at national and among regional levels across sectors and levels
 work to improve the Monitoring and evaluation platform for FNS implementation
 Update National Guidelines, training manuals, job aids, using the FNS
 Improve partnership and resource mobilization for FNS implementation
 Continue advocacy, social mobilization, and interpersonal communication through various media
outlets

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3.7. Seqota Declaration implementation

Seqota declaration (SD) is government of Ethiopia’s high-level commitment to end stunting in children less
than two years by 2030. Seqota Declaration builds on and accelerates the implementation of the food and
nutrition strategy. It has a 15-year roadmap which is divided into three phases, each spanning a period of five
years.

- The innovation phase (2016-2020) focuses on the implementation of priority nutrition-specific and
nutrition-sensitive and infrastructure intervention packages. It is implemented in 40 woredas, involving
nine sectors/ministries.

- The expansion phase (2021-2025) builds on learnings from the innovation phase. Launching of the
expansion phase was conducted for additional 200 woredas and the eexisting 40 woredas, making the
total SD Woredas to 240. At the end of this phase, the plan ios to increase the number of SD implementing
Woredas to 700.

- National scale-up phase (2026-2030) The National scale up involves full-blown implementation of
evidence-based, innovative and socially-sensitive multi-sectoral interventions. It will include previously
unreached Woredas

Seqota Declaration is expected to be achieved through coordinated multi-sectoral and multi-stakeholder

efforts made in areas of food security, maternal and child health care, improving access to health services,
creation of a healthy environment, and addressing the root causes of under nutrition. In this regard, the
government is strongly committed to making investments to end stunting by focusing on pro-poor and
service-focused sectors. The multi-sectoral investment plan also provides a framework for government and
development partners to allocate resources to ensure nutrition security in the country where Stunting is a
marker and maker of development. The Seqota Declaration Program Delivery Unit (PDU) in collaboration with
the federal and regional sectors and implementing partners have developed a multi-sectoral costed woreda
investment plan for the innovation and expansion phase of Seqota Declaration.

Financing the expansion and scale up phases: source of financing is believed to be government (federal and
Regional), Development partners, private sector and the community. The total Investment for the period of
Expansion phase is estimated to be 84,752,112,929 Birr and 59,669,262,671 Birr for scale up phase.

Major activities and achievements in 2013 fiscal year

- The expansion phase of SD was approved by a high-level meeting and regions were communicated to
make themselves ready for the implementation of the expansion phase. Accordingly, expansion phase
for 240 Woredas was launched at the beginning of the 2014 EFY in the presence of H.E president Sahle-
Work Zewde, Regional presidents, Regional bureau heads and other stakeholders. Besides, the 10 years’
expansion and scale-up phases’ investment plan is currently on preparation

- Review meetings with regions and stakeholders were organized and conducted in 2013 EFY. Accordingly,
two federal level multi-sectoral review meetings, two multi-sectoral technical and partner review meetings,
four quarterly SD program delivery-unit review meetings and two learning visits to SD woredas in Amhara
region were conducted

- Processed the approval of the African Development Bank Financed Project called Multi-Sectoral Approach
for Stunting Reduction Project (MASREP), a 48 million $ project. The project was approved in April 2013
EFY. The project is already launched and project staffs have been recruited

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Figure 21. Multi-sectoral approach for stunting reduction project (MASREP) approval ceremony in April 2013 EFY

- Implementation status of the Seqota declaration Innovations

1. Community Lab:

In 2013 EFY, community lab was implemented in 24 Seqota declaration Woredas. This innovation
identified a number of local solutions to improve diet diversity. Based on this, 1093 pregnant and
lactating women are using Key Hole gardening technologies in Debark Woreda and the adjacent 18
kebeles by growing different vegetables and feed their under-two children. Similarly, communities in
Ebinat woreda started feeding their children a goat milk. In addition, Nader Adet woreda communities
started to eat pumpkin, a foodstuff that was used only to feed animals in the past years.

2. Data innovation

Unified nutrition Information System in Ethiopia (UNISE) guidelines including indicator definitions,
operational guideline were developed printed and distributed in two regions.

Computers were distributed for eight UNISE implementing Woredas and training were given for
Sector nutrition focal persons at all levels. A continuous onsite technical support and orientation
was provided for the Woredas. Currently, UNISE is implemented in 6 sectors per Woreda. The sectors
include Health, Agriculture, Women, youth and children, Social and Labor Affairs, Water Irrigation and
Energy and Education sector. Based on this, sectors were enabled in multi-sectoral data capturing,
data entry, analysis, visualization and utilization for evidenced based decision-making.

3. The 1000 days plus public movement

In the fiscal year, Seqota declaration Food and Nutrition Documentation portal is established
(http://food-nutrition.moh.gov.et/). Multi-sectoral SBCC mainstreaming guideline was prepared
and distributed for Seqota Declaration implementing regional sectors. Radio spots were produced
to promote face and hand washing practice of the community. Documentary that aims to show
community testimony on changes made by Seqota Declaration investment was prepared and shared
for stakeholders.

- Coordinating Implementation of Super school of five (SSo5): This program was implemented with
the leadership of Ministry of Education (MoE) in 287 primary schools in Amhara and Tigray, through which
106,790 students were reached. The program has improved hygiene and sanitation practices (hand and
face cleanliness improved, eye infections reduced, scabies cases reduced) and resulted in a huge increase
in access to water and hand and face washing stations (In Tigray region, from 0% to 72%; In Amhara
region from 40% to 60%). A model/guideline was developed for the adaptation of the program in the
curriculum and for its national scale up by the MoE.

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- Impact study on the Seqota Declaration Innovation Phase was conducted jointly with Johns Hopkins
University with financial support from Big Win using Lives Saved Tools (LiST) methodology. The result
of the impact study showed that the Innovation Phase interventions prevented almost 1,031 children
deaths and averted over 109,831 stunting cases of under 5 years old children in both regions where SD was
implemented (Amhara and Tigray).

Table 9. Number of stunting cases averted (0-59 months) during the innovation phase of Seqota Declaration

Region Category Age group 2018 2019 2020 2021

0-23m - 10,047 11,467 12,196
# of stunting cases avert- 24-59m - 342 6,771 14,934
Tigray
ed (0-59 m)
Sub-total - 10,389 18,238 27,130
0-23 m - 10,219 11,457 11,977
# of stunting cases avert- 24-59m - 280 6,270 13,871
Amhara
ed (0-59 m)
Sub-total - 10,499 17,727 25,848
Total 0 - 23-m - 20,266 22,924 24,173
Innovation Phase - Stunting cases Averted (0-59 m)
- 622 13,041 28,805
Total 24-59 m
- 20,888 35,965 52,978
Total/year
Innovation Phase (2018 - 2021) 109,831

Table 10. Number of lives saved during the innovation phase of Seqota Declaration, by year

  2018 2019 2020 2021 2022 2023

Tigray
0–5m 0 40 45 54 55 56
6 - 23 m 0 83 100 106 109 109
24-59m 0 17 33 40 47 49
Total (0-59 months) 0 140 178 200 211 214
Amhara
0–5m 0 46 44 57 56 56
6-23 m 0 82 97 102 102 101
24-59m 0 16 32 37 43 44
Total (0-59 months) 0 144 173 196 201 201
Total, both regions (0-59 months) 0 284 351 396 412 415
Total lives saved during the innovation 1,031
Phase (Amhara and Tigray) (During innovation phase-2018-2021)

Major challenges

 The security situation in Northern part of Ethiopia delayed the implementation of the planned
activities in Seqota Declaration Woredas in 2013 EFY

 The INSA customs clearance process delayed the installation of the second round imported Yazmi
technology

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Way forward 

 Implement SD expansion phase in 240 Woredas, and provide technical and financial support for its
implementation

 Recruit additional manpower that supports the expansion phase and mobilize resources to initiate
Seqota Declaration program in Sidama regional state

 Formulate and expand innovation phase best practices and complete unfinished SD innovations

 Implement the first year MULTI-SECTORAL APPROACH FOR STUNTING REDUCTION PROJECT
(MASREP), the new project that is supported by African Development Bank

3.8. Prevention and Control of Communicable Diseases

In this section, the major activities and achievements on the prevention and control of major communicable
diseases are discussed. It includes HIV prevention and control program, Tuberculosis and leprosy prevention
and control program and Malaria prevention and control programs.

3.8.1. HIV Prevention and Control Program

HIV infection is one of the global public health challenges causing high morbidity and mortality. It is also one
of the public health concerns of Ethiopia. In Ethiopia, since its first detection in 1984, HIV/AIDS has claimed the
lives of many and has left hundreds of thousands as orphans. The government of Ethiopia took several steps
in preventing further disease spread, and in increasing accessibility to HIV care, treatment and support for
persons living with HIV. According to the National HIV Related Estimates and Projections (2020), the national
adult (15- 49) HIV prevalence is 0.96 %. It also shows that the HIV prevalence varies from region to region
ranging from less than 0.15% in Somali to 4% in Gambella.

HIV prevention and control is one of the priority health programs identified by the second Health sector
Transformation Program (HSTP-II). HIV/AIDS national strategic plan for the years 2021-2025 is developed with
the goals of attaining HIV epidemic control and reducing new HIV infections and mortality due to AIDS. The
strategic plan targets to achieve the three 95-95-95 targets of HIV. It specifically targeted to achieve 95% of
all people living with HIV to know their HIV status, 95% of all people with diagnosed HIV infection to receive
sustained antiretroviral therapy and 95% of all people receiving antiretroviral therapy to have sustained viral
suppression by the end of the HSTP-II period. In order to achieve the HIV/AIDS related targets, various HIV/AIDS
response interventions have been implemented in 2013 EFY, the first year of the HSTP-II period. The major
HIV prevention and control interventions include pre-exposure prophylaxis of HIV (PrEP), Voluntary medical
male circumcision (VMMC) service in Gambella region, HIV testing and counselling service, STI prevention
and treatment, HIV care and treatment, TB/HIV coinfection management, multi-sectoral HIV/AIDS response
interventions and others. In this section, the key HIV prevention and control program activities, achievements
and challenges in 2103 EFY are discussed.

Note: Since there were no reports from Tigray region for more than 9 months in the fiscal year, the
national performance report does not include Tigray region. Plan versus target is discussed
without Tigray region. Tigray’s 1st quarter performance is dealt separately. A separate section is
available for all the major responses in Tigray region.

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HIV Testing and Counselling Service (HTS)

HIV testing and counselling service has been provided to identify HIV new positives, which is key in achieving
the first 95 target. Testing and counselling services have been provided through Voluntary Counselling and
Testing (VCT), Provider initiated testing and counselling (PITC) and index case testing (ICT) service modalities.

In 2013 fiscal year, the plan was to test 7,386,629 individuals (excluding Tigray region) but the annual
performance shows that 7,237, 175 individuals (98% of the plan) were provided with HIV counselling and
testing service. Regarding the number of new HIV positives identified, the 2013 EFY plan was to identify 75,228
new positives (in all regions except Tigray). The annual performance shows that 33,988 new individual were
identified, which is 45% of the target. The national HIV positivity yield is 0.47%. The highest positivity yield is
in Gambella region, with a positivity of 4.76%. The lowest positivity yield is in Sidama region, with a positivity
yield of 0.20%. The testing performance is performed as per the plan but identification of new positives is less
than 50% of the target for the fiscal year. This indicates that the program should strengthen targeted testing
modalities to identify more number of HIV positives in the next fiscal year. Regarding testing performance,
four regions (Oromia, Sidama, Harari and Addis Ababa) have tested more than their target for the fiscal year.
Even if Gambella region has the lowest proportion of people tested compared to its target for the fiscal
year, the highest positivity yield was observed in Gambella region, with 4.76% of yield, which indicates that
targeted testing is properly implementing in the region. However, the lowest positivity yield was observed in
Sidama region, with a positivity yield of 0.20%. In terms of identifying new positives, Afar and SNNP regions
performed better (81% and 60% of the target respectively), while the lowest achievement is in Dire Dawa city
administration (identified 17% of the planned new positives).

Table 11. Number of people tested for HIV and number of new positives identified (2013 EFY Plan versus achievement), by
region

No. of people tested for HIV Number of new HIV positive Identified
Region 2013 EFY Achievement 2013 EFY Achievement
Yield
Target Number Percent Target Number Percent
Afar 129,123 105,770 82% 1,343 509 38% 0.48%
Amhara 1,770,384 1,482,108 84% 22,661 9,006 40% 0.61%
Oromia 2,716,040 3,502,897 129% 17,654 9,848 56% 0.28%
Somali 315,617 118,834 38% 505 289 57% 0.24%
B/Gumuz 120,615 78,202 65% 1,037 226 22% 0.29%
SNNP 1,302,411 996,818 77% 5,860 3,522 60% 0.35%
Sidama 304,420 354,455 116% 2,265 694 31% 0.20%
Gambella 150,051 34,504 23% 6,677 1,642 25% 4.76%
Harari 23,785 38,911 164% 707 316 45% 0.81%
Dire Dawa 65,168 45,794 70% 2,033 344 17% 0.75%
Addis Ababa 396,569 467,931 118% 13,562 7,466 55% 1.60%
OGAs 92,446 10,951 12% 924 126 14% 1.15%
National 7,386,629 7,237,175 98% 75,228 33,988 45% 0.47%

Tigray Region: In the first quarter of 2013 EFY, 102,232 individuals were tested for HIV in Tigray. Among the
tested, 476 (0.47%) were tested positive for HIV. Except for the first quarter report, there is no report about
the performance of the region.

As the HTS is a targeted approach focusing on Key and Priority populations, the highest yield is observed on
partners of PLHIV, FSWs and children of PLHIV followed by Long distance drivers.

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HIV positivity among key and priority population groups

4.5%
3.9%
4.0%
3.5%
3.0% 2.6%
2.5% 2.3%

2.0%
1.5%
1.5% 1.3%

1.0% 0.8% 0.7% 0.7%

0.4%
0.5%
0.0%
Partners of FSWs Children of Long Daily OVCs Prisoners Other KPPs General
PLHIV PLHIVs distance labourers Population
drivers

Figure 22. HIV positivity among key and priority population groups, 2013 EFY

In order to improve HIV case identification and link the identified positives to HIV care and treatment services,
Ministry of Health has started an initiative called Replicate Operation Triple A (RoTA) initiative in second quarter
of 2013 EFY. All regions except Tigray have developed a RoTA action plan and started working on the RoTA
initiative. Accordingly, there was an improvement on case identification or yield (increased from 0.5% to 1.4%)
when compared with the same period of 2012EFY. According to 2013 EFY first six months report (before RoTA)
there were only 12,703 new positives identified (0.5% yield) while the national case finding performance and
yield was increased to 21,869 in the second six months or after RoTA was implemented. This is an increment of
new positives identification by 9,166 in the second 6 months. RoTA has improved data use and performance
review practice. Strong leadership commitment at different levels contribute to the success of RoTA initiative.

In addition, HIV self-test service was also provided in 2013 EFY. In the fiscal year, 26,259 self-test kits were
distributed for HIV self-test service (using both directly assisted and unassisted HIV self-test modalities). In order
to expand HIV self-testing service in the next fiscal year, 500,000 self-test kits were procured and distributed to
regions.

HIV care and treatment services

The 2020 HIV related estimates and projections for Ethiopia shows that the estimated number of people living
with HIV is 622,326 (among which 238,546 (38%) are male and 383,780 (62%) are females). Among the total
estimates of PLHIV, 578,188 (92.9%) are adults and 44,138 (7.1%) are children under 15 years of age.

At the end of 2013 EFY, a total of 441,464 PLHIVs were receiving Antiretroviral Therapy (ART). Before October
2013 EFY, more than 43,000 PLHIVs in Tigray region were receiving ART, but no report was received from Tigray
region since then. Consecutively, the number of PLHIVs currently on ART at the end of the 2013 EFY includes
PLHIVs from all regions but not from Tigray region. Therefore, the estimated versus performance on ART is
done excluding data from Tigray region.

The estimated number of PLHIVs in 2020 is therefore 573,273 (The estimated in Tigray (49,053) is subtracted
from the national (622,326).

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From the estimated 573,273 PLHIVs, 441,464 were receiving ART at the end of 2013 EFY, which shows that 77%
of the estimated PLHIVs were currently on ART. Among the total PLHIVs currently on ART in 2013 EFY, 426,967
were adults and 14,497 were children under 15 years of age.

Table 12. Number and percentage of PLHIV currently on ART disaggregated by age, 2013 EFY

No TIGRAY Estimated PLHIV in 2013 EFY Currently on ART in 2013 EFY (Perfor- ART coverage (From total
Data (Disaggregated by Age) mance, disaggregated by age) estimated PLHIV)
Children Adults Children Adults Children Adults
Region Total Total Total
(<15) (>=15) (<15) (>=15) (<15) (>=15)
Tigray                
Afar 1,372 10,618 11,990 82 4308 4,390 6% 41% 37%
Amhara 13,031 179,613 192,644 4468 141168 145,636 34% 79% 76%
Oromia 13,703 138,588 152,291 5194 111620 116,814 38% 81% 77%
Somali 766 4,896 5,662 78 1874 1,952 10% 38% 34%
B/Gumuz 352 5,723 6,075 156 3936 4,092 44% 69% 67%
SNNPR 3,890 43,483 47,373 1489 31557 33,046 38% 73% 70%
Sidama 1,921 18,344 20,265 469 9664 10,133 24% 53% 50%
Gambela 1,215 12,290 13,505 276 5707 5,983 23% 46% 44%
Harari 224 4,987 5,211 87 4137 4,224 39% 83% 81%
Dire Dawa 485 10,635 11,120 137 6618 6,755 28% 62% 61%
Addis
3,392 103,634 107,026 1823 98891 100,714 54% 95% 94%
Ababa
OGFs     0  238  7,487 -
National 40,351 532,811 573,162 14,497 426,967 441,464 36% 80% 77%

NOTE: In Tigray region, 43,208 PLHIVs (41875 and 1482 children under 15) were receiving ART at
the end of Meskerem 2013 EFY. There is no report about these PLHIVs since then due to insecurity
problem in the region
Disaggregated by age, from the total estimated adult PLHIVs, 80% of the estimated adult PLHIVs were receiving
ART while only 36% of estimated children under 15 years of age were receiving ART. This shows that the
proportion of children who are receiving ART from the total child PLHIVs is low. There is an inequity in ART
service provision among adults and children. This requires intensifying case identification, care and treatment
interventions to increase the proportion of children receiving ART and close the age equity gap.

Viral load testing service

In the fiscal year, 358,109 PLHIVs on ART were tested for viral load. This shows that 81% of PLHIVs were tested
for viral load in the fiscal year. From the total PLHIVs tested for viral load, 340,379 (95%) of them had suppressed
viral load (<1000 copies/ml). High viral load suppression is not only good for the health of the individual PLHIV
but also for the health of the others in the community. High viral load reduction is also an indication that
there is high retention and adherence to ART treatment. The proportion of PLHIVs with viral load suppression
has improved over the years, increasing from 89% in 2011 EFY to 91.4% in 2012 EFY and 95% in 2013 EFY. In
addition, improvement is also observed in terms of increasing the viral load testing coverage through various
demand creation efforts.

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The 95-95-95 HIV/AIDS performance

First 95 performance

The first 95 HIV target states that 95% of all people living with HIV will know their HIV status (95% diagnosed).
The status of the first 95 can best be determined through community-based survey. In Ethiopia, the latest
community based survey on knowing HIV status was done in the 2016 Ethiopian Demographic and Health
Survey (EDHS). The 2016 EDHS report showed that among people who are living with HIV, 78.7% of them have
ever been tested for HIV and know their positive status. Since this is a bit old data and there is no other survey
that was conducted in recent years, the first 95 performance can be estimated from the routine HMIS data. The
number of people who know their status can be computed by summing the following data elements from the
routine HMIS report.

- Number of people who were receiving ART at the end of 2013 EFY (Rx_CURR)
- Number of PLHIV who are documented as lost/lost to follow up in 2013 EFY (LTFU), since these people
know their status
- Number of new HIV positives identified in the last month of 2013 EFY (New positives in Sene 2013)

Accordingly, the numerator for the first 95 target will be the sum of treatment current (441,463) + number who
were lost to follow up in 2013 EFY (17,383) + new positives in Sene 2013 (3,414). This sum up to 462,261, which
is the number of people who know their status. This means that 462,261 people (81%) from the estimated
573,162 PLHIVs (not including Tigray) know their status. Therefore, the first 95 target is estimated to be 81%.

To increase the number of people who know their HIV status and achieve the first 95% target, different
initiatives has been implemented in the fiscal year. Some of the initiatives and major activities that have been
implemented in 2013 EFY include:

 The HIV testing strategy focused on targeted groups who are at risk of HIV infection. The national
testing strategy focused on key and priority populations for targeted HIV testing, including female sex
workers (FSWs) and their sexual networks, children of PLHIV, OVC, long distance truck drivers, mobile/
daily laborer and other MARPs. In 2013 EFY,mMore than 7.2 million individuals were tested for HIV,
among which 33,988 new positives were identified.
 HIV testing algorithm, which is “Three-Test Algorithm”, was implemented in the fiscal year in order to
minimize false negative HIV result (by enhancing the positive predictive value of the test)
 Innovative HIV testing services (HTS) approaches were introduced to increase HIV test uptake and
testing efficiency/yield. The innovative approaches include optimization of provider-initiated testing
and counseling (PITC) by utilizing risk screening for high-risk groups or individuals, providing HIV
recency testing services, introducing HIV self-testing (HIVST) service, and implementation of index
testing and/or partner notification services.
 A minimum standard guideline for index testing was prepared and implemented in order to optimize
the quality of the service
 By taking lessons from Addis Ababa’s accelerated plan called Triple A for improved HIV case
identification, MOH has started implementing replication of the triple A approach to other regions of
Ethiopia. The initiative is called Replicate Triple A approach (RoTA).
 Streamlined and integrated HIV rapid test kits (RTKs) with the existing national logistics system
considering the peculiarities of the product

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Second 95 Performance

The second 95 HIV target aims that 95% of all people with diagnosed HIV infection will receive sustained
antiretroviral therapy (95% PLHIVs who know their status will be on HIV treatment). To compute the second 95
target, the numerator is the number of the PLHIVs who are currently receiving ART. The denominator for the
second 95 target can be computed using two scenarios: 1) considering the target for the first 95, which is 95%
of the estimated PLHIVs; 2) considering the mere 95-95-95 cascade from the first 95 achievement, i.e, 81% of
the estimated PLHIVs (as estimated from the HMIS data)

Using the denominator from the first 95 target (i.e, 95% of the estimated PLHIVs know their HIV status), the
performance of the second 95 target is 81%.However, since we estimated the first 95 performance as 81%
(as described above), the performance of the second 95 is 95% (adults 99% and Children 44%). Addis Ababa,
Harari and Oromia regions have achieved the second 95 target, and Amhara region is at 93%, which is close to
the target. The second 95 performance in the other regions is low, with the lowest achievement in Somali and
Afar regions (43% and 45% respectively).

Table 13. 2nd 95 using 81% (first 95 result) of PLHIVs as denominator, 2013 EFY

Estimated PLHIV in 2012 Numerator: No. of PLHIVs Denominator - Calculated 2nd 95 performance
EFY (Disaggregated by currently on ART in 2013 81% of the total PLHIVs using 1st 95 result as
Age) EFY [i.e. the 1st 95 result] denominator
Region
Chil- Chil- Chil- Chil-
Adults Adults Adults Adults
dren Total dren Total dren Total dren Total
(>=15) (>=15) (>=15) (>=15)
(<15) (<15) (<15) (<15)
Tigray                      
Afar 1,372 10,618 11,990 82 4308 4,390 1,111 8601 9,712 7% 50% 45%
Amhara 13,031 179,613 192,644 4468 141168 145,636 10,555 145487 156,042 42% 97% 93%
Oromia 13,703 138,588 152,291 5194 111620 116,814 11,099 112256 123,356 47% 99% 95%
Somali 766 4,896 5,662 78 1874 1,952 620 3966 4,586 13% 47% 43%
B/Gumuz 352 5,723 6,075 156 3936 4,092 285 4636 4,921 55% 85% 83%
SNNPR 3,890 43,483 47,373 1489 31557 33,046 3,151 35221 38,372 47% 90% 86%
Sidama 1,921 18,344 20,265 469 9664 10,133 1,556 14859 16,415 30% 65% 62%
Gambela 1,215 12,290 13,505 276 5707 5,983 984 9955 10,939 28% 57% 55%
Harari 224 4,987 5,211 87 4137 4,224 181 4039 4,221 48% 102% 100%
Dire Dawa 485 10,635 11,120 137 6618 6,755 393 8614 9,007 35% 77% 75%
Addis
3,392 103,634 107,026 1823 98891 100,714 2,748 83944 86,691 66% 118% 116%
Ababa
OGAs 238 7,487 7,725 - -
National 40,351 532,811 573,162 14,497 426,967 441,464 32,684 431577 464,261 44% 99% 95%

To improve the performance of the second 95 target, the following major initiative/activities were performed
in 2013 EFY.

 Strengthened the provision of care and support services, including ART service at all hospitals and
majority of health centers and private health facilities
 Implemented health facility and community-based differentiated models of HIV care (appointment
spacing, Fast Track ART refill and multi-month drug prescribing). Community base service delivery
options for HIV treatment, such as health care worker managed community DSD model, and peer
lead community-based models were implemented to ensure continuity of care, especially during the
COVID_19 pandemic

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 Implemented new optimized ART regimens: As a continued effort to improve quality of HIV care and
treatment, new ART medicines were introduced. Dolutegravir (DTG) and LPV/r drugs were introduced
as part of the ART medicines following the inclusion of the medicines in the 2018 edition of the national
comprehensive HIV prevention, care and treatment guideline.
 Provision of second line ART drugs were initiated at selected high load health centers.
 Site expansion of third line ART providing centers was done in the fiscal year. The number of sites
providing third line treatment was increased from 35 to 50 sites based on the second line client load
and geographical accessibility

Third 95 Performance

The third 95 target aims that 95% of all people receiving antiretroviral therapy to have a viral suppression.
In 2013 EFY, from the total 441,464 PLHIVs who were receiving ART, viral load test was performed to 358,109
PLHIVs, among which 340,379 (95%) of them were virally suppressed (<1000/ml). This shows that 81% of PLHIVs
on ART were tested for viral load and 95% of them had viral suppression. UNAIDS recommends to estimate the
numerator for the third 90 based on the routine viral load test report when the proportion of PLHIVs who are
currently on ART and tested for viral load is between 50% and 90%. Accordingly, the numerator for the third 95
target will be estimated as (Viral load-suppression rate from routine test)*(PLHIVs who are currently on ART),
which is 95%*426,967 = 419,607. This means that estimated number of PLHIVs who have suppressed viral load
is 419,607. Therefore, the numerator for the third 95 is 419,607 and the denominator is the number of people
who are currently on ART (441.464). This gives the performance of the third target to be 95%.

To increase viral load testing coverage and improve the performance of the third 95 target, 20 laboratories were
providing viral load testing service throughout the country. As part of viral load testing scale up program; an
agreement was made with the laboratory companies (Abbot and Roche) on equipment placement (as part of
reagent cost) and upgraded to automated extraction. Moreover, strengthened counselling service to PLHIVs on
ART has contributed to better achievement in viral suppression.

Other Major activities and achievement in 2013 EFY

In addition to the above mentioned major HIV prevention and control program activities and achievements,
the following major initiatives/activities were performed in 2013 EFY

 Sexually Transmitted Infections (STIs): In 2013 EFY, 262, 400 diagnosed STI cases were diagnosed and
treated. From the total 262,400 STI cases, 223470 (85%) were tested for HIV. HIV positivity rate among STI
cases was 2.6%. There were around 5,690 new HIV cases identified from STI cases, which accounts for 17%
of the total new HIV positives.

 Pre-Exposure Prophylaxis of HIV (PrEP): Provision of Pre-Exposure Prophylaxis (PrEP) to population

groups with substantial HIV risk is one of the biomedical HIV prevention methods that can have a significant
impact to further decrease the transmission of HIV. In 2013 EFY, PrEP service has been provided in all ART
providing health facilities. In the fiscal year, PrEP service was provided to 12,719 individuals (10,781 female
sex workers and 1,938 sero-discordant couples).

 Voluntary Medical Male Circumcision (VMMC): VMMC is one of the public health prevention interventions
to reduce the incidence of HIV in places where HIV incidence is high with low male circumcision. In this
regard, VMMC service was provided in Gambellla region in collaboration with different stakeholders. In
2013 EFY, 35,920 individuals received VMMC service. Among those who were provided with VMMC service,
29,962 of them were tested for HIV and 21 were tested positive for HIV and linked to treatment.

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 HIV Case Based Surveillance (CBS): In the fiscal year, CBS strengthening activities were performed
including, CBS implementing site expansion, laboratory quality improvement and strengthened case
based data visualization and use for decision-making purposes. A guideline that focuses on response
to newly identified HIV positive cases was developed in 2013 EFY. It is an extension of the national CBS
guideline and developed to guide the required individual and cluster response using CBS and recency data.
The manual is intended for use by health care providers, program managers, and relevant stakeholders at
multiple levels

 Implementation of DSD models for PLHVs taking ART service: At the end of 2013 EFY, 232,214 PLHIVs
were on Appointment Spacing DSD model. In addition, UHEP-Managed CAG and Fast track ART Refill
(FTAR) DSD Models were implemented in the fiscal year. To start implementation of Advanced HIV Disease
(AHD) DSD model, a proposal is developed and approved. Training materials for AHD model is under
preparation. Regarding community DSD Models (i.e. HEP CAG and PCAD) 1,436 groups were formed with
members of 7,992(2%). 3,554 (1%) PLHIVs were enrolled to Fast track ART Refill (FTAR).

 TB preventive therapy: Pilot testing short course TB preventive therapy was conducted in four regions
and preparations underway to expand to additional two regions

 Hepatitis prevention and control activities

o Awareness creation on hepatitis was done, hepatitis day was celebrated for the 7th time in Ethiopia
during which different messages were conveyed through media
o The national strategic plan and hepatitis guideline was revised in the fiscal year
o Training of trainers (TOT) was provided on hepatitis prevention and control were provided to
health workers

HIV/AIDS multi-sectoral response program implementation

As a multi-sectoral response to HIV prevention and control program, the following multi-sectoral response
activities, especially for key and priority population groups were performed in the fiscal year.

Care and support to Orphan and Vulnerable Children (OVC)

Orphan and Vulnerable Children (OVCs) and their caretakers were supported with food, education, training
and start-up capital support. In the fiscal year, IGA training was provided to 46,464 OVCs and/or their caregivers
and 51,993 received a start-up capital or material for IGA. With regard to food and education support, 282,277
OVCs were provided with food support and 354,074 OVCs were provided with education support.

Care and support to PLHIVs

Provision of care and support to People living with HIV (PLHIVs) was one of the major multi-sectoral HIV/AIDS
responses in the fiscal year. In 2013 EFY, 31, 085 PLHIVs were provided with training on income generating
activity (IGAs). A start-up capital support was provided to 34, 927 PLHIVs and 120,142 PLHIVs were provided
with food support.

Services to school youth

In the fiscal year, 4,919,688 students were reached with behavioral change communication (BCC), through peer
education and/or life skill education

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Support to vulnerable women

Support was also provided to vulnerable women including commercial sex workers, out of school youth
women who are at high risk to HIV and other vulnerable women. In the fiscal year, 88,076 vulnerable women
were provided with a start-up capital for income generating activity (IGA) and 66,160 received a training on
IGAs.

Condom Distribution

In 2013 EFY, 91,384,361 condoms were distributed (about 47.49 million condoms were distributed to key and
priority population groups and about 43.90 million condoms were distributed to the general population).

Challenges and way forward on HIV/AIDS prevention and control program

Challenges
 Occurrence of insecurities and presence of high number of internally displaced people (IDPs) in many
places affected provision different HIV prevention, care and treatment services
 Supply interruption
 Lack of a robust mechanism to identify repeat HIV testers
 Limited availability of HIV viral load testing service; long turnaround time (TAT) of viral load test results
delivery
 Effect of COVID-19 on program implementation: Due to COVID-19, regular mentorship was not provid-
ed to health facilities regularly. It also caused interruption of routine viral load test sample collection,
transportation and referral services
 Delay in procurement of HIV/AIDS commodities due to problems in the global logistics management
system caused by the global pandemic
 Shortage of budget
 Lack of ownership of multi-sectoral HIV/AIDS responses in some sectors
 Shortage of condoms for distribution
 Low attention for viral Hepatitis and STI program at all levels of the health system

Way forward for next year

 Strengthen implementation of fast track combination HIV prevention activities
 Strengthen targeted HIV interventions and enhance HIV testing in key and priority populations by ex-
panding the recently launched RoTA case finding strategy
 Scale up HIV self-testing (HIVST) service, especially the unassisted HIVST, to all regions of Ethiopia
 Strengthen early infant diagnosis and pediatric HIV care and treatment service.
 Enhance uninterupted routine Viral Loas testing service and improve testing coverage
 Capacity building of health care providers and program managers at all levels
 Scale up of diversified DSDM includihg Fast track pharmacy refill and Adolescent ART age group
 Ensure and follow the scale up of PrEP service for HIV negative high risk female sex workers (FSWs) and
HIV negative partners of serodiscordant couples in all regions
 Strengthen implementation of ART regimen optimization and expand third line ART treatment sites
 Ensure uninterrupted supply of HIV commodities
 Strengthen viral hepatitis prevention, care and treatment
 Revitalize and strengthen multi-sectoral HIV/AIDS committees at all levels
 Conduct assessment of the effect of COVID-19 on PLHIVs and orphans and design interventions based
on the assessment
 Integrate electronic-multisectoral response information system (e-MRIS) with DHIS2 platform

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3.8.2 Tuberculosis and Leprosy Prevention and Control Program

Tuberculosis (TB) is a major global public health problem. About a quarter of the world’s population is infected
with Mycobacterium tuberculosis and thus at risk of developing TB disease. TB is among the top 10 causes of
death globally. According to 2020 WHO Global TB Report, an estimated 10.0 million people fell ill with TB, 1.2
million TB deaths among HIV-negative people and an additional 208,000 deaths among PLHIV in 2019. It is
the leading cause of death from a single infectious agent globally. Drug-resistant TB continues to be a global
public health threat with 3.4% of new TB cases and 18% of previously treated cases having multidrug resistant
TB or rifampicin-resistant TB (MDR/RR-TB). The epidemiologic distribution of TB shows that almost 90% of
those who fall sick with TB each year are found in 30 high TB burden countries.

Ethiopia is one of the 30 high TB burden countries with an annual estimated incidence of 140 cases per 100,000
population (WHO Global TB Report 2020). Ethiopia has recognized TB as a major public health problem nearly
six decades ago. Cognizant of the burden of TB in Ethiopia, the Ministry of Health has given priority to the
prevention and control of TB and implementing high-impact interventions in line with global strategies. As a
result of our past investments and successful implementation of the strategies, substantial gains were made
in reducing the disease burden. The TB incidence has declined dramatically and TB mortality rate has also
declined substantially to reach 19 per 100,000 populations in 2019. This year, Ethiopia has been removed from
the MDR-TB high burden countries’ list. Ethiopia has expressed commitments to end TB epidemic by 2035 by
endorsing the END TB strategy and new global targets set in the political declaration at the first UN high-level
meeting on TB, in September 2018. Ethiopia has also adopted the global strategy to eliminate leprosy by 2030.
The country has revised its National TBL Strategic Plan in line with the global targets. The National End TB
strategy aims to end the TB epidemic by reducing TB related deaths by 95% and incident TB cases by 90%
between 2015 and 2035; and to ensure that no family is burdened with catastrophic expenses due to TB. The
strategy calls for use of robust TB case finding strategies and use of rapid diagnostic technologies to address
the gaps in treatment coverage for both Drug Susceptible TB and RR/MDR-TB. The National TBL Control
program is committed to improve access to equitable TBL services to all vulnerable population groups where
TBL burden concentrates. The program also recognizes the need for intensified research and innovations to
sharply bend the TB epidemic curve to meet the ambitious targets for 2035.

In this section, the performance of key tuberculosis and leprosy indicators, major national and sub-national
level activities performed and challenges are discussed.

TB incidence rate

The annual incidence of TB in Ethiopia has decreased over time. The incidence has decreased from 192 cases
per 100,000 population in 2015 to 140 in 2019 (World TB report, 2020).

192
177
-7.8%
164
151
-7.3%
-7.9%
140
-7.3%

2015 2016 2017 2018 2019

Figure 23. Trend of TB incidence in Ethiopia, 2015 to 2019

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Tuberculosis case notification

Tuberculosis case notification rate is one of the key indicators to monitor the performance of TB prevention
and control programs. TB notification is the number of all forms of TB cases notified per 100,000 population
(including new bacteriologically confirmed, new clinically diagnosed pulmonary and extra pulmonary TB
cases and all relapse cases) from the total estimated number of incident TB cases in the area during a given
time period. In 2013 EFY, 104,450 all forms of TB cases were notified (1,574 of them were in Tigray region
during the first quarter of 2013 EFY). This shows that TB notification rate was 106 per 100,000 population (Since
Tigary region did not report for three quarters, it is not included in the national notification rate calculation).
Compared to the current estimated incident TB cases (140 cases/100,000) the current notification performance
(106/100,000) is low.

Tuberculosis treatment Coverage

The national TB treatment coverage (which indicates the number of all forms of TB (new and relapse TB
cases) that were notified and treated, divided by the estimated number of incident TB cases in the same year,
expressed as a percentage) stands at 76% in 2013 EFY. In 2013 EFY, 104,450 all forms of TB cases were detected
and treated based on the national tuberculosis treatment protocol. This shows that TB treatment coverage in
2013 EFY was 76%, which is higher than the 2012 EFY performance (treatment coverage in 2012 EFY was 71%
in 2012 EFY).

Though the performance of TB treatment coverage was higher than the performance of the previous fiscal
year, it is lower than the target set for 2013 EFY. The target in 2013 EFY was 85% but the performance is 76%.
TB treatment coverage in five regions (Sidama, Gambella, Harari, Diredawa and Addis Ababa) was 100% of
the expected incident cases while the lowest TB treatment coverage was documented in Benishangul Gumuz
region (37%). This shows that there is a huge regional discrepancy between different geographic regions in
detecting and treating tuberculosis cases.

TB treatment Coverage, all forms of TB (New and Relapse) by region, 2013 EFY
120%
100% 100% 100% 100% 100%
100%
79%
79% 76%
80%
67%
61% 62%
Percent

60%
37%
40%

20%

0%
Ben.Gum Dire Addis
Tigray Afar Amhara Oromiya Somali SNNP Sidama Gambella Harari National
uz Dawa Ababa
Baseline 88% 58% 72% 62% 46% 68% 74% 100% 100% 100% 100% 71%
Performance (2013 EFY) 79% 61% 79% 62% 37% 67% 100% 100% 100% 100% 100% 76%
Target (2013 EFY) 90% 91% 85% 62% 87% 87% 93% 100% 100% 100% 100% 85%

Figure 24. TB treatment coverage (all forms of TB) by region, 2013 EFY

Tigray Region: In the first quarter of 2013 EFY, 1,574 all forms of TB cases were detected and treated (Treatment
coverage of 20%). Except for the first quarter report, there is no report about the performance of the region.
As a result, Tigray’s performance is not included in the national performance.

Some of the major effective strategies for reducing the transmission of TB are engaging the community in TB
case detection, PPM, TB among key and priority population groups and childhood TB detection activities. The
community in the context of community TB care refers to trained community volunteers, Health Development

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Agents, health extension workers or, community members supporting patients (treatment supporter). In 2013
EFY, from the total all forms of TB cases detected in the fiscal year, 19% of them were contributed through
community TB contribution. Community contribution to TB case detection in 2013 EFY is increased compared
to the previous year (which was 15.4%). Regarding private contribution to TB case detection, 17% of all TB cases
were notified in public health facilities with initial referral by Public Private Mix (PPM) sites for TB diagnosis or
for initiation of TB treatment.

Tuberculosis Treatment Outcomes

Tuberculosis Treatment Cure Rate

TB treatment cure rate is one of the key indicators to monitor the effectiveness of TB treatment program.
It measures the program’s capacity to retain patients through a complete course of chemotherapy with a
favorable clinical result. In 2013 EFY, cure rate for bacteriologically confirmed new pulmonary TB cases is 82%,
which is lower than the baseline (84%) and the target for 2013 (92%). TB cure rate is the lowest in Somali and
Gambella regions, with a cure rate of 51% and 61% respectively. Harari, Amhara, Oromia and Addis Ababa
performed better with a cure rate of 98%, 88% and 87% respectively.

TB Cure rate among bacteriologically confirmed pulmonary TB cases, 2013 EFY

120%

98%
100%
87% 87% 88%
80% 82%
78%
80% 75%
72%
64% 61%
60%
51%

40%

20%

0%
Ben.Gum Dire Addis
Tigray Afar Amhara Oromia Somali SNNPR Sidama Gambela Harreri National
uz Dawa Ababa
Baseline 68% 87% 86% 35% 84% 84% 78% 75% 86% 89% 88% 84%
Performance 64% 87% 87% 51% 72% 78% 75% 61% 98% 80% 88% 82%
Target 100% 97% 93% 75% 99% 98% 96% 80% 100% 70% 90% 92%

Figure 25. TB Cure rate among bacteriologically confirmed pulmonary TB cases, 2013 EFY

Tigray Region: A performance report for Tigray region is available for the first quarter of 2013 EFY only (Hamle
2012-Meskerem 2013). In the first quarter, TB treatment cure rate among bacteriologically confirmed pulmo-
nary TB cases in Tigray region was 70%.

Tuberculosis Treatment Success Rate (TSR)

In 2013 EFY, treatment success rate (TSR) among bacteriologically confirmed new PTB cases was 95%. This is a
performance, which is similar to the previous year but lower by 2% from the fiscal year’s target. All regions have
a treatment success rate more than 90%, except Gambella region (TSR, 78%). The result shows that among
bacteriologically PTB cases, 95% of them successfully completed treatment indicating the program’s capacity
to retain patients through a complete course of chemotherapy with a favorable clinical result.

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TB treatment success rate among bacteriologically confirmed pulmonary TB

cases, 2013 EFY
120%

96% 97% 96% 99%

100% 92% 93% 93% 95%
92% 91%
87%
78%
80%
Percent

60%

40%

20%

0%
Ben.Gu Dire Addis
Tigray Afar Amhara Oromia Somali SNNPR Sidama Gambela Harreri National
muz Dawa Ababa
Baseline 87% 95% 96% 95% 91% 95% 91% 89% 99% 89% 91% 95%
Performance 87% 96% 97% 92% 92% 93% 96% 78% 99% 91% 93% 95%
Target 100% 97% 99% 96% 99% 98% 97% 90% 100% 95% 96% 97%

Figure 26. Tuberculosis treatment success rate among bacteriologically confirmed new PTB cases, 2013 EFY

Tigray Region: A performance report for Tigray region is available for the first quarter of 2013 EFY only
(Hamle 2012-Meskerem 2013). In the first quarter, TB treatment cure rate among bacteriologically confirmed
pulmonary TB cases in Tigray region was 96%.

Unsuccessful TB treatment outcome

Unsuccessful TB treatment outcome is the percentage of cohort of all forms of TB (new and relapse) of TB
cases (Bacteriologically confirmed, clinically diagnosed) registered in a specified period that failed, died or
lost to follow up during treatment. Unsuccessful treatment outcome is high among clinically diagnosed PTB
cases, with 4.8% of cohort of clinically diagnosed PTB cases having unsuccessful treatment outcome. 3.6% of
bacteriologically confirmed PTB cases and 3.7% of extra pulmonary TB cases have had unsuccessful treatment
outcomes. The percentage of each group who were died, lost to follow up and failed treatment are displayed
in the figures below.

Unsuccessful treatment outcome among PPOS, PNEG and EPTB cases

6.0%
4.8%
5.0%
3.6% 3.7%
4.0%
3.0%
2.0%
1.0%
0.0%
Bacteriologically confirmed Clinically diagnosed PTB EPTB
PTB

Unfavourable Rx outcome

Figure 27. Proportion of all forms of TB cases with unsuccessful treatment outcome, 2013 EFY

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Unsuccessful treatment outcome among PPOS, PNEG and EPTB

cases, by type of outcome
4.0%
2.9%
3.0%
2.2%
1.6% 1.6% 1.8%
2.0% 1.4%
1.0% 0.4%
0.1% 0.1%
0.0%
Bacteriologically confirmed Clinically diagnosed PTB EPTB
PTB

Lost to follow up Died Failed

Figure 28. Proportion of all forms of TB cases with unsuccessful treatment outcome, by type of outcome, 2013 EFY

TB Contact tracing and screening

Contact tracing and screening is one of the key components of TB prevention, especially in children. It is one of
the major initiative in the national TB prevention and control program. In 2013 EFY, a total of 189,740 contacts
with index of TB cases were traced/identified, among which 169,330 (89%) were screened for tuberculosis.
Regarding contact tracing and screening of children under 15 years old, 36,741 children that had contacts
with index of drug susceptible pulmonary TB cases were traced/identified. From the total identified contacts,
35,992 were screened for tuberculosis and among which 33,281 (92%) were screened negative for tuberculosis.
In the fiscal year, 21,345 children <15 year contacts who were screened negative for tuberculosis were put on
TB preventive Therapy or TPT regimens (3HP, 3RH and 6H).

Drug Resistance Tuberculosis (DR TB)

Drug resistant TB continues to pose a major threat in the national response to TB in Ethiopia. The magnitude
and extent of drug resistance in TB is being monitored in Ethiopia through periodic drug resistance surveys
(DRS). The third national DRS was completed in 2019. The prevalence of RR-TB is 1.1% among new and 7.5%
among previously treated TB cases, respectively according to the preliminary report of the 2019 national TB
Drug Resistance Surveys (DRS). MDR prevalence was 1.03% among new and 6.52% among previously treated
TB patients.

To identify DR TB cases, notified TB cases eligible for drug susceptibility testing were provided with drug
sensitivity test according to the national policy. In the fiscal year, 23,839 notified TB cases were eligible for drug
susceptibility testing, among which 14,657 (61%) were tested for drug susceptibility for at least rifampicin.

In 2013 EFY, 634 drug resistant TB (DR TB) cases were detected. This is only 57% of the estimated 1,118 DR TB
cases in Ethiopia. Regarding DR TB treatment in 2013 EFY, 549 DR TB cases were put on second line treatment.
DR TB treatment initiation has been provided in 64 treatment-initiating centers (TICs) and treatment follow up
was provided in treatment follow up centers (TFCs).

Regarding treatment outcome among DR TB cases, from the total number of cohort DR-TB cases that started
short-term second-line anti-TB treatment regimen 24 months earlier, 82% have successfully completed
treatment. Among cohort of DR-TB cases that started long-term second-line anti-TB treatment regimen 36
months earlier, 65% have successfully completed treatment.

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Leprosy Prevention and Control Program

Leprosy Case Detection Rate

In 2013 EFY, 2535 leprosy cases were detected and started treatment (703 were pauci-bacilliary (PB) and 1855
were multi-bacillary leprosy cases). This shows that the incidence of leprosy cases is 0.25 cases per 10,000
population. Leprosy case detection is high in Gambella (0.66 per 10,000) followed by Harari (0.41 per 10,000).
In Somali region, no new case of leprosy was reported in the fiscal year (See table below).

Table 14. Number of Leprosy cases detected, 2013 EFY

Number of cases per 10,000

Region No. of new cases detected
population
Tigray - -
Afar 22 0.11
Amhara 745 0.33
Oromia 1451 0.37
Somali 0 0.00
Ben.Gumuz 44 0.38
SNNPR 106 0.06
Sidama 49 0.11
Gambela 33 0.66
Harari 11 0.41
Dire Dawa 13 0.25
Addis Ababa 61 0.16
National 2535 0.25

Tigray Region: A performance report for Tigray region is available for the first quarter of 2013 EFY only (Hamle
2012-Meskerem 2013). In the first quarter, 23 new cases of leprosy were reported from Tigray region.

Grade II disability rate among new cases of leprosy

In 2013 EFY, grade II disability rate among new cases of leprosy is 12%. This is lower than the previous year
(it was 15% in 2012 EFY) but disability rate is still higher than the expected (should be <10%). The highest
disability rate is reported in Addis Ababa, SNNP and Sidama regions with a grade II disability rate of 31%, 25%
and 22% respectively. The lowest disability rate is reported in Harari and Dire Dawa regions.

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Table 15. Grade II disability rate among new cases of leprosy by region, 2013 EFY

Region No. of new cases No. with grade II disability Grade II disability rate
Tigray
Afar 22 6 27%
Amhara 745 85 11%
Oromia 1451 136 9%
Somali 0 0 NA
Ben.Gumuz 44 5 11%
SNNPR 106 27 25%
Sidama 49 11 22%
Gambela 33 3 9%
Harari 11 0 0%
Dire Dawa 13 1 8%
Addis Ababa 61 19 31%
National Level 2535 293 12%

Leprosy treatment Outcome

Leprosy treatment-completion rate for Pauci-Bacillary (PB) leprosy cases was 87% and for multi bacillary
(MB) leprosy cases was 88%.

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Tuberculosis and Leprosy prevention and control program: Other major activities and achievements,
challenges and way forward

Other major activities and achievements in 2013 EFY

 Updates on national guidelines: The national guidelines on clinical and programmatic manage-
ment of TB, TB/HIV, DR-TB and Leprosy in Ethiopia has been revised to reflect the latest global recom-
mendations and policies. The national training materials were also updated accordingly
 Capacity building: Training of trainers (TOT) and basic trainings have been provided to health man-
agers and health workers on various TB and Leprosy prevention and control program and patient man-
agement topics. The training areas include: comprehensive TBL; TB and HIV collaborative activities,
Drug resistance tuberculosis, TB preventive therapy (TPT), community TB and leprosy
 Advocacy and Awareness creation activities: To raise the awareness of the community on TB pre-
vention and control, various awareness creation messages were transmitted through different media
of communications. Some of these include; A 3 months TV and radio spot program on tuberculosis,
260 radio spots were transmitted on leprosy prevention, different booklets leaflets and pamphlets were
printed and distributed, , celebrated different World TB day, World leprosy day
 Mobile TB/HIV Clinics Service initiation in pastoralist areas: To strengthen community TB de-
tection and services, vehicles that provide mobile TB and HIV clinic services were distributed to three
regions to support TB service delivery at pastoralist communities
 TB Preventive Therapy with new TPT regimens rollout: 3HP service is started in 150 health centers
in Addis Ababa, Oromia, SNNP and Sidama Zones
 TB screening service at congregated areas: TB screening was done for 78,870 people in selected 20
urban slums in Addis Ababa, Dire Dawa and Harari regions. Among the total screened individuals, 3,406
individuals were screened positive for TB. From the 3,406-screened positives, 89 were diagnosed with
tuberculosis and linked to treatment. In addition, TB screening was done in selected areas in Oromia
and Amhara regions, among which two individuals were diagnosed with tuberculosis and linked to
treatment. TB screening was also conducted for 3,692 mineworkers in Oromia, among which 16 were
diagnosed with TB. Screening was also done for 3735 people at religious bathing places, from which
three TB cases were identified and linked to treatment.
 National Launching and Rollout of an all-oral Bedaquiline based RR/MDR-TB Regimens: Na-
tional launching and complete rollout of an all-oral Bedaquiline containing shorter RR/MDR-TB reg-
imen was conducted in accordance with the latest WHO recommendation on DR-TB treatment. The
injectable containing regimen was completely rolled out during the 2013 EFY. The required medicines
for the rollout of an oral-shorter MDR-TB treatment were procured and distributed to 64 treatment-ini-
tiating centers. In addition, the implementation manual was revised and health workers were trained
 More than 800 patients on DR-TB treatment follow up have been provided with nutritional support
 Monitoring and Evaluation: TB and leprosy program specific supportive supervision was conducted,
the national TB and leprosy program review was done and data analysis and review conducted every
quarter. Moreover, special program performance review was conducted on prison TB, TB preventive
therapy (TPT) and childhood TB

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Challenges
 Weak TB sample transport mechanism and lack of strong laboratory networking system
 Low coverage of universal drug sensitivity testing (DST) Coverage
 Suboptimal community engagement and contribution in case notification
 Low DR-TB Case detection
 High attrition and turnover of trained man-power
 COVID-19 pandemic affecting case finding and treatment activities
 Conflicts and high number of internally displaced people (IDPs)
 Weak domestic resource mobilization for tuberculosis and leprosy prevention and control program
implementation
 Poor supply request and logistics management system for TB drugs (especially SLDs)
 Reporting and requisition problems by HFs although sufficient supply especially SLDs

Way forward
 Improve TB laboratory networking and sample transportation
 Expand DST in order to ensure that all bacteriologically confirmed PTB cases will get DST for at
least rifampicin
 Focus on strengthened community TB interventions and activities by increasing the involvement
of leadership at all levels of the health system
 Engage more Public-private mix (PPM) sites and strengthen the existing PPM sites for improved TB
prevention and treatment services
 Enhance monitoring and evaluation of TB and leprosy program
 Map Woredas with a low or decreasing TBL case notification during the COVID-19 pandemic and
conduct catchup campaigns
 Prepare evidence based advocacy and budget request to increase budget for TB program

3.8.3. Malaria Prevention and Elimination Program

In Ethiopia, malaria remains to be one of the major public health and socioeconomic problems despite its
dramatic reduction in the last two decades. Apart from illness and deaths, it causes persistent socio-economic
impacts particularly to more than eighty per cent of the country’s rural communities. A survey in 2018 showed
that malaria accounts for loss of 30% of the overall disability adjusted life years (DALYs) as well as imposing
a high economic cost. Accordingly, malaria stands to be one of the top priority programs in the national
health and overall socioeconomic development agenda. Malaria prevention, control and elimination have
been given due attention by the government and its partners. Moreover in 2010 EFY, the country launched a
malaria elimination program, which in turn demonstrated the government’s commitment in the fight against
the disease. The major activities, achievements and challenges in EFY 2013 are described as follows.

Malaria Cases and Deaths

The number of malaria cases diagnosed over years has been decreasing until 2011 EFY but it has increased
in 2012 EFY and then declined in 2013 EFY compared to EFY 2012. In 2013 EFY, 1,220,027 total malaria
cases (clinical and laboratory confirmed) were diagnosed, among which 1,135,338 (93.1%) were laboratory
confirmed malaria cases, 201,111 (16.5%) cases were under five children, 19,140 (1.6%) were admission cases

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and 976,801 (80.1%) were plasmodium falciparum malaria. The number of total malaria cases in EFY 2013
shows a decrease by 289,155 cases (19% reductions) from the 2012 EFY, this might not show the full picture as
Tigray region’s data is not included in the 2013 EFY data analysis.

2000000 1747251
1509182
1500000 1220027
1580777 1206891
993999 1398750
1000000
1065850 1135338
904495
500000

0
2009 2010 2011 2012 2013*

Total Case (Confirmed + Clinical) Confirmed

Figure 29. Trend in number of malaria cases, 2009 EFY to 2013 EFY

*Note: Tigray data not included in 2013 EFY analysis since there was no report from the region

Malaria incidence rate per 1,000 population at risk has been decreasing consistently until 2011 EFY but in 2012
EFY it increased. In 2013 EFY it showed a slight decrement, this might not show the full picture as Tigray region
is not included from 2013 data analysis. The malaria incidence rate in 2013 EFY was 23 per 1000 population
which is less by five cases per 1000 population than the 2012 EFY figure.

Regarding regional distribution, malaria incidence rate per 1000 population at risk was the highest in
Benishangul Gumuz region (86.4 cases per 1000 population at risk) and the lowest in Dire Dawa (1.9 malaria
cases per 1000 population at risk).

Regarding malaria deaths, there were 132 deaths due to malaria, which were 0.25 malaria deaths per 100,000
populations at risk and 36 (27.3% of malaria death) malaria deaths were among under-five years’ children. A
malaria death per 100,000 populations was lowest in Oromia (0.1) and highest in Benishangul Gumuz region
(2.4). The death rate is lower than the previous preceding years’ reports and decrease by 36% from the 2012
EFY data.

Nationally, in 2013 EFY around 53.7% of the total population (approximately 57 million people) is at risk of
malaria. The proportion of population who are at risk of malaria differs among regions, where more than 95%
of the population in Afar, Somali, Benishangul Gumuz, Gambella, and Dire Dawa are at risk of malaria. In Harari,
86.9% of the population is at risk of malaria.

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Table 16. Malaria Incidence rate per 1,000 populations at risk and Malaria Deaths per 100,000 populations at risk, 2013 EFY

Malaria case Malaria death

Region Total case Incidence per >5 Malaria
<5 year Total
<5 year case > 5 years case (clinical & 1000 popula- years death per
death death
confirmed) tion at risk death 100,000
Afar 22747 79,921 102,668 52.5 0 0 0 -
Amhara 53807 422,238 476,045 56.6 1 15 16 0.19
Oromia 24656 121,932 146,588 7.1 7 14 21 0.1
Somali 14310 55,780 70,090 11 8 10 18 0.28
B. Gumuz 20100 77,027 97,127 86.4 2 25 27 2.4
SNNP 49554 209,117 258,671 26 11 20 31 0.31
Sidama 4569 19,780 24,349 9.1 5 6 11 0.41
Gambella 10939 29,075 40,014 80.9 2 2 4 0.81
Harari 167 1,284 1,451 6.2 0 1 1 0.43
Dire-Dawa 64 920 984 1.9 0 1 1 0.19
AA 198 1,842 2,040 - 0 2 2 -
National 201,111 1,018,916 1,220,027 23.4 36 96 132 0.25

Long-lasting Insecticidal Nets (LLINs) Distribution

Distribution and utilization of LLINs at household level is one of the primary malaria control interventions
in the country. In 2013 EFY, LLIN procurement and distribution were performed to households at risk of
malaria. Based on the 2013 EFY revised national malaria risk stratification, there was a plan to procure and
distribute 10.6 million LLINs. Of these 7.8 million (74% of the plan) was procured and 5.3 million (68%) LLINs
were distributed to Dire-Dawa, Harar, Somali, Amhara and Oromia regions. From the 2012 EFY procured LLINs
111,969 were distributed to the displaced people due to flooding and conflicts.

Indoor Residual Spraying (IRS) of Unit Structures

Indoor residual spraying (IRS) of unit structures is one of the vector control interventions that have been
conducted in targeted risk areas. In 2013 EFY, there was a plan to spray 2.8 million unit structures, 2,090,640
(73% of the plan) of the unit structures spayed with the distributed 683 tons of chemicals for regions.

Table 17. Indoor residual spraying coverage and the type of chemical used, 2013 EFY

Planned number of No. of unit struc- Type and amount of chemical

Coverage used
Region unit structures to be tures sprayed with
(%) Propoxure 50% Actellic 300Cs
sprayed with IRS IRS
WP in Kg in Bottle
Tigray 331,618 106,870 32 42,748 -
Afar 67,062 73,579 110 7,870 -
Amhara 660,523 443,421 67 200,583 -
Oromia 635,686 703,221 111 221,960 57,120
Somali 100,000 100,210 80 20,042 -
Benishangul Gumuz 256,603 276,405 108 - 54,197
SNNP 463,908 222,182 48 110,568 -
Sidama 81,873 55,485 68 25,977 -
Gambella 113,820 109,267 96 - 21,425
Total 2,861,091 2,090,640 73 629,748 132,742

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Malaria Elimination Activities

The goal of the malaria elimination program is to eliminate local transmission of malaria nationally by 2030.
A workshop was conducted to strengthen the case investigation and response activities in pre-identified 239
elimination woredas and at the end of the workshop, respective regions have developed accelerated plan to
strengthen the malaria elimination activities.

In the fiscal year, supporting the case and foci investigation and response activities includes: provide feedback
in the malaria elimination woredas, standard operating procedures (SoPs) were developed and training of
trainers (ToT) as well as cascade training was organized. Using case and foci investigation and responses
protocol and the S0Ps, cases investigation and response has been done for 13,409 (80%) from the plan 16,867
malaria cases and feedback shared with targeted regions.

Other activities performed on malaria prevention and control

- Five years malaria strategic plan (2021 – 2025) developed

- 439 microscopes were distributed for public health facilities in malaria elimination woredas
- 423 health care providers and 90 laboratory professionals trained on malaria case investigations and
management
- 14.56 Millions Rapid Test Kits (RDTs) and malaria treatment medicine (Coartem) distributed in all regions
for the treatment of 3.3 million malaria patients.

Major achievements

- Malaria Epidemiology: Mortality and morbidity attributed to malaria declined significantly from 2008
EFY – 2011 EFY, though morbidity has increased in 2012 EFY. Death due to malaria has declined by 65%
from 0 .71/100,000 population to 0.25/100,000 population at risk between 2009 and 2013 EFY. Similarly, the
annual incidence rate has declined by 34% from 35/1000 population at risk to 23/1000 population at risk
between 2009 and 2013 EFY.

- Entomology: Monitoring of insecticides susceptibility, survey on geographical distribution of An.

stephensi and other entomological works have been carried in collaboration with partners.

- Vector Control: Various activities have been performed to control malaria vectors such as distribution of
LLINs and IRS spraying.

- Malaria case management: National malaria diagnosis and treatment guidelines, which align with the
WHO guidelines is being used throughout the country. Malaria RDTs and drug availability has increased
over the years. Integration of malaria EQA with the TB EQA achieved to ensure quality of microscopic
examination, which will kick-off in EFY 2014. Refresher training on case management was held to health
workers drawn from various health facilities.

- SBCC: Different SBCC activities have been implemented in the fiscal year including broadcasting varies
message in television and radio programs using national as well as regional media platforms to reach the
community. In selected 246 malarias woreda campaign was organized with the slogan “Zero malaria starts
with me” involving relevant stockholders.

- Surveillance and epidemic preparedness and response: Since 2003, there has not been a major
malaria epidemic except a few local malaria outbreak reports in some parts of the country. Malaria
surveillance and response system improved through monitoring a weekly malaria data and providing a
timely feedback as well as issuing an alert letter in case of unusual natural or man-made events, which
could facilitate a surge of the disease.

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Challenges

- Protracted internal conflicts and massive IDPs

- Resistance of the local vectors to the commonly used insecticides and lack of adequate as well as affordable
insecticides to implement an insecticide resistance management (IRM) plan
- Getting adequate budget to cover all the targeted unit structure with IRS
- Timely replacement and maintenance of IRS equipment based on the agreement
- Sub-optimal use of interventions, like LLINs by at risk communities
- The detection of HRP2/3 deletion in parasite population that may scape diagnosis by RDT
- The detection of new vector An. stephensi in urban and rural settings with potential to transmit malaria
parasites
- Lack of malaria drugs consumption data and discrepancy between DHIS2 malaria morbidity data and
commodities issue data

Way forward

- Improving preparedness through procuring and prepositioning of anti-malaria commodities to hard-to-

reach areas or IDP centers before the peak transmission season,
- Implement IRM to delay or reverse insecticide resistance,
- Identify the possible source of budget and timely initiate the purchase process to cover the target unit
structures with IRS,
- The management should follow up IRS equipment replacement implementation status of per the
agreement,
- Design and implement effective and targeted SBCC activities to improve utilization of anti-malaria
interventions at household level.
- Currently, conducting research on prevalence of HRP2/3 deletion at EPHI and AHRI to inform switching of
diagnostic kit and where to implement the rollout
- Drafted An. stephensi surveillance strategy and NMEP will plan and follow up with pilot implementation

3.9. Prevention and control of Non-Communicable Diseases and

Injuries
According to the 2019 global burden of disease (GBD) report estimate, the number of all deaths in Ethiopia
annually is 559,997. Of these 39% were attributable to non-communicable diseases (NCD) and 8% due to
injuries. Most of death from NCD are due to cardiovascular diseases (30%), cancer (15%), digestive diseases
(13.5%) and diabetes and kidney disease (8.7%). More than half (51%) of the NCDI mortality occurs before age
40, and 63% occurs before age 50 years. Additionally, NCDIs were found to contribute 42% to total DALYs lost in
Ethiopia. Over 60% of DALYs lost due to NCDIs in Ethiopia occurred before age 40 showing a very high burden
in the productive age group. The major NCD prevention and control achievements in 2013 EFY are described
below.

Policy, strategies and proclamations related to NCD and risk factors interventions

 The second major NCDs prevention and control strategic plan (2020-2025) was launched and
disseminated

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 The draft proclamation on the regulation of unhealthy diet was further enriched and made ready for
public debate before its endorsement by parliament
 Cervical cancer guideline was revised and launched
 Cervical cancer training manual and mentoring guideline are finalized
 Management protocols of the major NCDs (Diabetes Miletus (DM), Hypertension, rheumatic health
disease (RHD) and chronic Respiratory disease (CRD) were finalized and ready for printing

Awareness Creation on NCDs and their risk factors

In 2013 EFY, a series of awareness creation activities such as panel discussions, printing of brochures, posters,
job-aids and message dissemination was accomplished. SMS messaging through Ethio-telecom and radio
spot messages were aired through national and regional mass media channels. Additional accomplished
awareness creation activities are:

 Provided budget support in a childhood cancer awareness creation video dissemination

 Cervical cancer awareness campaign was conducted through Walta TV and Ethiopian Radio for
1 month. Furthermore 1500 cervical cancer counseling cue card and brochures were printed and
distributed
 Awareness raising messages developed and transmitted (through press release, panel discussions,
radio spot message and social mobilization events like screening for NCD and physical exercise)
during commemoration of World NCD days such as hypertension day, diabetes day, kidney day,
world breast cancer awareness month, tobacco day, sight day and world glaucoma awareness day.
 Salt reduction messages developed in five local languages (Amharic, Oromiffa, Somaligna, Tigrigna
and Sidamigna).

Integration of Major NCD Services (Hypertension, RHD, DM and CRD) to Primary Health Care

To further strengthen integration of major NCDs into the existing health delivery system, a number of activities
were accomplished in 2013 EFY. NCD guidelines and other patient support tools were distributed to 291 health
facilities and a TOT was provided to 60 health care providers from all regions major NCDs (Hypertension,
RHD, DM and CRD). NCD and Eye Health modules, which are part of integrated refresher training (IRT) for
level IV health extension workers, was prepared. A total of 479 Health extension workers from Amhara (122),
Oromia (212), Somali (53) and Dire Dawa (92) Regions were trained on hypertension screening, prevention
and management. In addition, a total of 157 Health care providers from primary hospitals, health centers and
regional health bureaus were trained on integrated management of major NCDs.

NCD screening, diagnosis, management and follow up care training is one component of the Ethiopian Primary
Health Care Guideline initiatives, which is currently implemented in more than 2086 health centers. Currently
291 hospitals are delivering integrated management of major NCDs from all regions. In EFY 2013, additional
110 primary hospitals have initiated integrated management of major NCDs and will service as training and
referral sites for the health centers in their catchment.

To address supplies related shortcoming, medications for the treatment of major NCDs worth 885,000 USD
was procured and distributed to 289 health facilities through EPSA. The health facilities are expected to retain
the money and revolve the fund for procurement of medicines for major NCDs. Medicines donated by World
Health Organization like insulin and other essential medicines were distributed to the health facilities.

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Hypertension prevention and control

In EFY 2013, a total of 5,532,744 (more than twice of last year performance) individuals were screened for
hypertension out of which 48% were male and 52% were female. From the total screened, 468,536 (8%) had
raised blood pressure (8.9% of the screened male and 8.2% of screened females). Out of those with raised
blood pressure, 196,083 (42%) were enrolled to care. Regarding treatment outcome, the plan was to monitor
status of cohorts at six month however; the existing data do not support this analysis for this fiscal year which
is expected to be improved in the subsequent year.

5,532,744

2,509,921

311,591 468,536
132,777 196,083

Screened Raised BP level Enroled to care

2012 2013

Figure 30. Number of individuals screened for hypertension and enrollment to care performance, 2012 and 2013 EFY

Diabetes Mellitus Prevention and Control

In EFY 2013, a total of 1,195,051(81% increase from last year performance) individuals were screened for
diabetes out of which 51% were male and 49% were female. From the total screened, 148, 007 (12%) had raised
blood sugar level (12.8% of the screened male and 11.9% of screened females). Out of those with raised blood
sugar, 65,754 (44%) were enrolled o care. Regarding treatment outcome, the plan was to monitor status of
cohorts at six month however the existing data do not support this analysis similar with that of hypertension.
To improve data quality of both hypertension and diabetes, their indicators definition was included in the
MoH HMIS reference guide and the data source and reporting format was revised in such a way to address the
existing data quality.

1,195,051

660,388

115,582 148,007
54,456 65,754

Screened Raised BP level Enroled to care

2012 2013

Figure 31. Number of individuals screened for diabetes and enrollment to care, 2012 and 2013 EFY

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Cancer Control Program

According to 2019 GBD report, in Ethiopia cancer accounted for about 10% of total annual death while the
Addis Ababa cancer registry study reported that about two-thirds of reported annual cancer deaths occur
among women. Breast and cervical cancer among women and colon and prostate cancer among men are the
leading cancer type in the country.

Increasing cancer screening and treatment service was the major cancer control initiatives in 2013 EFY. During
the fiscal year, 441 additional health facilities started providing cervical cancer screening and treatment
services. Currently, 1041 health facilities are providing cervical cancer screening and treatment service.
Similarly, four out of the 5 planned hospitals for new breast cancer service had started providing full provision
of services increasing the total number of hospitals currently providing breast cancer treatment service to 16.
To increase cancer radiotherapy service sites out of planned expansion to 3 more cancer treatment site, 1 at
Tikur Anbessa Hospital has started full service and another at Jimma Hospital has done all preparatory work
and will soon start full service provision in the first quarter of 2014. The total number of hospitals providing
childhood cancer in the country has reached five with the two new additions at St. Paul and Gondar Hospitals.

To increase the service uptake, the Combat Cervical Cancer (3C) Initiatives led by the Minister and State
Minister of Health was launched in EFY2013. A weekly performance monitoring and twice monthly webinar was
conducted as part of the 3C campaign. In this fiscal year a total of 160,290 women aged 30-49 were screened
for cervical cancer which is about 28% of a plan i.e. 578,778 and only 1.2% of illegible women. Despite almost
tripling 2012 performance of 59,241, the 2013 performance is not proportional with the 1041 service providing
facilities. From the total screened, 148,441 (92.6%) had a normal cervix, while the remaining 7.4% has either
precancerous lesion 9,222(5.8%) or cancerous lesion 2,627(1.6%) %). About 67% of women with pre-cancerous
lesions were treated with either Cryotherapy or LEEP.

Regarding human resource for cancer care, training program for cancer radiation-treatment technologists
was started in collaboration with Addis Ababa University and Kotebe Metropolitan University. In-service
capacity-building training was given for 55 zonal cervical cancer focal person on program management and
basic cervical cancer training for 688 health workers. A number of another training: on a protein based cervical
cancer-screening test, HPV DNA testing, LEEP, Cryo and LEEP machine maintenance and thermal ablation
were provided for health facilities staff.

Cancer chemotherapy subsidy drugs were purchased at a cost of 2.5 million USD and were distributed to
the 16 cancer chemotherapy centers. Additionally, cervical cancer supplies like Acetic Acid (10,000 liters) and
Cryotherapy machine maintenance tools were distributed.

Eye Health

In Ethiopian cataract, trachoma, refractive error and glaucoma are the leading causes of blindness. Five
tertiary and 47 secondary public eye care units are serving the highly in need of people with eye problems in
the country.

The development of second eye health strategy aligning with HSTP II was initiated considering lessons learnt
from 2016-2020 eye health strategic plan implementation. To strengthen standardization of eye health service
delivery cataract surgical guideline was prepared, printed and distributed to health facilities and glaucoma
toolkit was developed and launched. To equip the eye care units, 53 eye operation microscopes were procured
and distributed for hospitals; glaucoma diagnosis and treatment equipment and supplies were given to Debre
Tabor and Felege Hiwot Hospitals; Optical workshop instruments were supplied to Maichew Hospital in Tigray
Region.

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The national eye-health service assessment was done at 35 secondary and tertiary eye care centers selected
from all regions. The objective of assessment was to assess the performance of the sites, identify major
challenges and generate evidence on eye health service. The report, which was submitted to MoH senior
management, indicate major successes, performance gap and challenges. The major identified challenges
were shortage of human resource, shortage of equipment, equipment maintenance problems and supply
interruptions of consumables for cataract surgery and other eye health services.

From the cataract backlog, a total of 33,882 (about 14% increase from 29,632 performance of 2012) cataract
surgeries were provided, which is 17.5% against 194,144 annual target. Additionally, 92,194 (60% are male
while female account 40%) patients were treated for glaucoma and a total of 70,003(56% are male while female
account 44%) were treated for refractive and ocular muscle related disorder.

NCD prevention and control of Non-Communicable Disease

Challenges
 Absence of strong NCD coordination unit at RHB and woreda structures
 Shortage of budget for implementation of NCD program at RHB, Zonal and Woreda level
 Low awareness of the policy makers, HCWs and the community on NCDs and risk factors still re-
main a challenge
 Poor service uptake, which is not proportional to service expansion
 Poor equipment maintenance and calibration system
 Poor recording and under-reporting of data and weak performance monitoring and evaluation of
NCD activities
 Gaps in referral and linkages to NCD/chronic follow up clinic

Way forward
 Advocate for revision of NCD structure at RHB and woreda levels and allocation of adequate fund
 Use EPHCG implementation as an opportunity to strengthen integration of NCD service delivery in
primary health care
 Conduct awareness creation campaigns on NCDs and Risk factors at all levels targeting the public,
HCWs and political leaders
 Develop a multisectoral strategic action plan on NCDs and Risk factor;
 Finalize the unhealthy diet proclamation on salt, sugar, saturated fats and trans fatty acids
 Improve documentation, recording and reporting of NCD data
 Strengthen NCD commodities forecasting and procurement
 Conduct the national NCD STEPS Survey
 Expand secondary eye care centers to emerging regions

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3.10. Mental Health

Mental health promotion, prevention, and management of common mental health problems such as
depression, bipolar disorder, and schizophrenia are among the top priorities in HSTP-II. To address the mental
health problems, the national mental health strategy (2020-2025) preparation was finalized and launched in
July 2021. About 1,000-printed copy of the document was distributed to key stakeholders.

Low public awareness on mental health has been affecting service seeking behavior. Hence, mental health
and neurologic disorder awareness creation to the public was conducted using different methods such as
developing spot message and airing for about two months by ETV. Additionally, a high-level advocacy and
media briefing during the world mental health day commemoration was done under the theme of “Move for
mental health, increased investment in mental health”and world epilepsy day commemoration event. On top
of this, facility level health-education material on mental health was developed to enhance provision of health
education on mental health topics.

School or university based health club can play great role in increasing awareness creation to peers and
minimizing substance use and drug addiction. Cognizant of this in 2013 MoH has worked with Ministry of
Science and Higher Education (MOSHE) and Food and Drug Administration Authority (FDA) to establish anti-
drug club in 10 Ethiopian Public Universities. So far anti-drug club term of reference was drafted and shared
to stakeholders for its enrichment. Khat addiction prevention and control directive was also prepared in this
fiscal year.

Capacity building raining on mhGAP was given for federal prisoner health workers and five regions (SNNP,
Sidama, Gambella, BG and Afar). Similarly, in-service training on Epilepsy was given for a total of 140 health
workers. Currently about 35% of hospital and 10% of health centers are proving mental health service. Mental
health topics were included in the HIV program in-service training materials to strengthen mental health service
integration with HIV care and treatment. In this reporting period, 248,080 and 278,799 patients have received
treatment for mental health disorder and neurological illness respectively. Schizophrenia account for more
than half (53%) reported mental disorder while almost all-individual treatment for epilepsy i.e 272, 999 (98%)
were diagnosed to have epilepsy and recurrent seizure. Additionally 444 (46% male and 54% female) patient
have received psychotherapy, which indicate that currently mental health intervention is primary focused on
medication only.

Table 18. Nationally reported mental and neurological illness by sex during 2013 EFY

Reported mental & neurological

Sr. # Male Female Total
illness
1 Psychosis 100,344(58.4%) 71,617(41.6%) 171,961
2 Depression 22,256(47.7%) 24,367(52.3%) 46,623
3 Bi-polar disorder 14996(50.8%) 14500(49.2%) 29,496
4 Epilepsy 158,892(57%) 119,907(43%) 278,799
Total 526,879

Challenges

 Absence of well-established structure for mental health program at regional and sub-regional level
 Shortage of budget for mental health program at all level
 Lake of motivation among stakeholders in the process of integrating mental health with
communicable and none communicable disease program
 Limitation on using routinely reported data for mental health program, monitoring

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The way forward

 Continue advocacy, social mobilization and behavioral change interventions to create public
awareness on mental health and mental illnesses
 Advocate toward improving budget and resource allocation for mental health program and service
delivery
 Advocate for the establishment of well-defined and functioning mental health structure at region and
sub-regional level
 Work toward further integration of mental health service in the primary health care service delivery
 Improve routine monitoring of mental health and mental health research

3.11. Prevention and control of Neglected Tropical Diseases

Prevention and Control of Neglected Tropical Diseases (NTDs)

HSTP II identified schistosomiasis, soil-transmitted helminthiasis, onchocerciasis, podoconiasis, lymphatic

filariasis, leishmaniasis, trachoma, scabies, and snakebite envenoming for control and elimination. In
addition, dracunculiasis (Guinea worm disease) is targeted for eradication during the HSTIP II period. Priority
interventions, which are under implementation for NTD prevention and control are preventive chemotherapy,
transmission control, innovative and intensified case management, transmission containment, prevention of
zoonotic diseases, vector ecology management, social and behavioral change communication and WASH.
Moreover, service integration, multi-sectoral approaches and large-scale treatment campaigns or mass drug
administration were under implementation. The major key achievements in the first year of HSTP II period are
described below.

Preventive chemotherapy of neglected tropical diseases (PC-NTDs)

Trachoma

As part of the SAFE (Surgery, Antibiotics, Facial cleanliness and Environmental improvement) strategy, close to
20 million people get Zithromax treatment in 363 endemic districts in 2013 EFY.

In addition, surgery was done for 34,077 (45%) people with Trachomatous Trichiasis (TT), while facial cleanness
was integrated with the WASH and TT surgery interventions. According to 2020/21 trachoma impact survey
(TIS), 256 Woredas stopped MDA by achieving the WHO TF elimination threshold of below 5%. To accelerate TT
surgery, 183 health workers were trained and deployed as integrated eye care workers for woredas with high
TT backlog.

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Figure 32. Trachomatous Trichiasis screening and Surgery at community level, Photo, 2013 EFY

Onchocerciasis and Lymphatic filariasis

In 2013 EFY, over 17.7 million people treated with Ivermectin drug for the prevention of onchocerciasis in 217
woredas and 6 refugee camps. In addition, 3,284,519 people in 37 Woredas were treated for lymphatic filariasis,
which is close to 50% of the target. In addition, over 1,015 individuals received hydrocele surgery and 15,780
received Lymph edema management. In 2020/21 according to the Impact survey, 31 Woredas stopped MDA by
meeting the threshold.

Schistosomiasis (SCH) and Soil transmitted helminthiasis (STH)

In 2013 EFY, a total of 6,977,208 (84%) people treated for soil transmitted helminths in 348 (99%) districts. In
addition, School age children in 22 woredas of “Gashyero” Project in Wolayita Zone in SNNP region treated for
STH and SCH with therapeutic coverage of 93% and 91.5% respectively.

Leishmaniasis

In 2013 EFY, a total of 1,178 visceral and 1,389 Cutaneous leishmaniasis patients received treatment with cure
rate of 84.5% and fatality rate of 2.8%. Also, then the same year, the total number of treatment centers has also
increased from 28 to 29 for visceral leishmaniasis and capacity building provided for 275 health workers on
case management, data recording and reporting procedure.

Other NTD related activities

 Epidemiological survey is undergoing in 134 and data collection completed in 120 Onchocerciases
endemic woredas
 The launching of the Trachoma advisory group and first meeting was conducted
 NTD-WASH integrated to all interventions and best experience was documented and shared with regions
 The 3rd edition of the national NTD master plan was finalized inline with the HSTP II
 Different SOPs were developed for COVID-19 mitigation in NTD interventions

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Challenges

 MDA and Survey interrupted due to COVID-19 pandemic and security challenges
 Inadequate coordination and co-implementation of WASH and NTD interventions impeding efficient use
of limited resources ultimately slowing progress towards set goals and targets
 Limited resource for morbidity management and disability management
 Scarcity of resources for effective vector control measures
 Inadequate surveillance system for effective monitoring of progress
 Weak supply chain management system(reverse logistic ) at all level
 Poor data recording, entry, reporting and use at all level

Way forward

 Finalize the 3rd edition of the national NTD Master plan

 Strengthen coordination and co-implementation of WASH-NTD interventions at all levels
 Strengthen multi-sectoral coordination and promote community engagement
 Strengthen domestic resource mobilization and partnership
 Strengthen integrated mass drug administration for PC- NTDs

3.12. Clinical Services

Hospital Leadership, Management and Governance

The major interventions planned to strengthen the leadership, management and governance of hospitals were
to enhance the capacity of hospital senior management team and strengthen hospitals board functionality.
To this aspect, capacity building trainings were provided for selected 24 hospital senior management
team members (and total of 426 executives) on different hospital improvement programs and initiatives.
Contextualized quality improvement plans were developed based on the identified gaps. In addition, Hospital
Governing Board Implementation Manual was prepared and introduced to hospitals, a follow-up assessment
had been conducted, and finding were discussed with regional health bureau representatives.

Clinical Leadership

National clinical leadership baseline assessment was conducted in the reporting year and based on the
assessment findings; Clinical Leadership Improvement Program (CLIP) implementation manual and training
Guidelines have been developed. Currently, a pilot implementation is started in selected 12 hospitals.

Access to Specialty and sub-specialty Service

A first in its kind, ten years National Specialty and Sub-specialty Service Road Map is prepared and launched in
the fiscal year. The aim of this document is to improve access and ensure the quality of specialty/subspecialty
services at all levels of the health care system; considering the economic, social and epidemiological realities.
Moreover, Basic Dermatological Care and basic ophthalmologic care training manuals and pocket clinical
guidelines have been prepared through extensive engagement of senior specialists. In collaboration with
regional health bureaus, dermatological care need assessment was done and financial support has been
provided to fill existing resource gap. As part of the implementation process, basic dermatological (for 22
hospitals) and ophthalmological (20 hospitals) trainings were provided for General Practitioners and outpatient
basic dermatology and ophthalmology services have been started on these hospitals. Compounding and
diagnostic training on dermatological care was also provided to pharmacy and lab professionals. On the
other hand, forensic psychiatry service has been initiated in four hospitals and two additional hospitals have
finalized the preparatory phase to start the service.

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Access to Rehabilitation Services

In 2013 EFY, a five year Rehabilitation Service Strategic Plan is developed. The main objective of this strategic is
to ensure that person with disabilities and injuries have access to comprehensive quality rehabilitation services.
In addition, the National Assistive Technology and Medical Rehabilitation Service Management guideline has
also been developed. Accordingly, training was provided for regional rehabilitation center leaders. Along with
the guideline, assistive technology specification list is developed for rehabilitation services such as mobility,
vision, hearing and communication and cognitive services. Furthermore, organizational structure, legislative
document and infrastructure renovation plan has been developed for the establishment of the National
Medical Rehabilitation Center. Besides the documents, infrastructure expansion and renovation of the center
is being carried out.

Diagnostic Service Improvement Initiative

As part of diagnostic service improvement initiative, the National Radiology and Pathology Services
Management Guideline was developed with the engagement of senior experts and professional associations.

Hospital Service Improvement initiatives

The major initiatives planned for hospital service improvement includes finalizing the EHAQ 3rd cycle program,
I-CARE and IPC. The national EHAQ validation was done on 44 hospitals and all recognized based on their
validation score. In addition, best experiences were identified, documented and shared with regional health
bureaus, hospitals and stakeholders based on the third cycle focus area.

I-CARE Program implementation comprehensive training was given for 24 selected hospitals on how to
conduct I-CARE lab sessions. Twenty-two hospitals have completed the sessions and conducted an open day
program. In addition, the National I-CARE Program Management Guideline has been developed. Furthermore,
the national IPC policy, strategy and roadmap were also prepared and launched.

Tele-Health Service

The other key achievement in the reporting year is regarding the tele health services. The National Tele Health,
Tele Radiology, Tele Pathology and Tele Dermatology technical and clinical guidelines were developed and
training was given for seven teaching hospitals. As part of the pilot implementation, tablets were distributed
to these hospitals.

Challenges

These key achievements in the year were gained passing through both internal and external challenges.
Federal and University hospitals governance structure, shortage of budget to improve access and quality of
specialty and sub-specialty service, limited access to health technology infrastructure, shortage of skilled work
force in rehabilitation service, poor coordination and efficiency in improving diagnostic service were the key
amongst all the challenges faced. Therefore, overcoming these challenges through an innovative approaches
and well-designed improvement plans will remain to be the next priority.

OPD Attendance per Capita

OPD attendance per capita is one of the key health-service quality indicator, which is used to measure
frequency of visit to the health facilities per person per year. It also indicates the availability and accessibility of
health services. A low OPD attendance per capita is usually attributed to barriers such as physical accessibility,
increased user fee and behavioral factors. Whereas a lower OPD attendance per capita implies poor service
quality due to so many reasons such as lack of hospital beds, lack of proficient staff, unavailability of services,
medical equipment and supplies.

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In 2013 fiscal year, nationally, about 105, 662, 828 individuals have visited health facilities making the OPD
attendance per capita 1.09. This is a relatively higher record when compared to the previous years, 0.9 in
2011EFY and 1.02 in 2012 EFY. A significant regional variation was seen in 2013EFY. The highest OPD attendance
per capita was recorded from Addis Ababa (1.79), Amhara (1.49) and Harari (1.42). On the other hand, the
lowest OPD attendance per capita was seen in Somali (0.25), Afar (0.35) and Gambella (0.40).

ANNUAL OPD ATTENDNCE PER CAPITA, 2013EFY

2013EFY Target OPD Attendnce Per Capita

2.25
2.15
1.93

1.87

1.87

1.79
1.49

1.42
1.41

1.41
1.25

1.22
1.17

1.15
1.10

1.09
0.95

0.94
0.93

0.75
0.55

0.40
0.35

0.25

AL
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Figure 33. Annual OPD attendance per capita, 2013EFY

Average Length of Stay (ALOS)

The Average Length of Stay is an indicator, which is often used to measure efficiency in health service provision.
It is the average number of days patients spend in the health facilities.

In the 2013EFY, the national annual average length of stay (4.63) has shown a slight increment as compared to
the previous year (4.57). A higher ALOS is reported from Addis Ababa (5.80) and Amhara (5.02) and the lowest
ALOS was recorded from Somali (2.82) and Benshangul Gumuz (3.24).

ANNUAL AVERAGE LENGTH OF STAY BY REGION, 2013EFY

Baseline 2012EFY Average length of stay
5.80
5.39
5.02
4.76

4.69

4.63
4.57
4.54

4.47
4.31
4.27

4.27
4.26

4.25

4.19
4.02

3.77

3.71
3.56

3.24

3.23
3.19
2.82
2.68

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Figure 34. Annual average length of stay by region, 2013EFY

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Bed Occupancy Rate (BOR)

Bed occupancy rate is an indicator used to measure inpatient-service efficiency. The international standard
set for the hospitals BOR is 80 – 90%. A lower BOR of this range is considered to be least efficient and a higher
BOR that the upper range is regarded to have poor inpatient care management and overstated length of stay.

Though the annual hospitals BOR could not make it to the optimal range, it has shown a fair level of increment
when compared to the previous years. In this reporting fiscal year, the annual hospitals BOR is found to be
55.0% with the highest being recorded in Harari (66.9%) and the lowest in Afar (28.6%).

HOSPITALS BOR % BY REGION, 2013EFY

66.9%
66.2%

61.9%

55.0%
54.4%

52.9%
47.1%

32.9%

33.0%
31.6%
30.9%
28.6%

AL
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IA

A
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AT
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Figure 35. Hospital Bed Occupancy Rate (BOR) by region, 2013EFY

2.13. Emergency and Critical care services

Emergency care system is an essential part of universal health coverage. It is the first point of contact to the
health system for many. A well-organized emergency and critical care service is a key mechanism to reduce
preventable deaths and disabilities. Recognizing this fact, the ministry of health has designed various initiatives,
which aims to improve the country’s emergency and critical care services. Major activities performed in the
2013 EFY are presented in this section.

Flagship initiatives on emergency and critical care service

In 2013 EFY, the ministry of health has designed and implemented two flagship initiatives namely the Addis
Ababa pre-facility ambulance service improvement project and the Major Cities Emergency and Critical Care
Improvement Program (MECIP).

1. The Addis Ababa pre-facility ambulance service-improvement project

This project was initially designed in response to the high COVID 19 case burden in Addis Ababa. The project
was designed to facilitate easy access to the ambulance service for the acutely ill. With this aim, different
activities have been conducted under this project and results were achieved.

 A project implementation document and various training manuals were developed

 A study has been conducted in Addis Ababa on the utilization of ambulance service by the community

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 A workflow process has been developed to integrate the Addis Ababa pre-hospital project with the
COVID 19 homebased isolation care (HBIC)
 Capacity building training has been given to 153 health professionals working on basic ambulances,
40 professionals working on advanced ambulances and 16 call handlers
 Ambulance stations are under construction at nine sub-cities in Addis Ababa
 Analog system has been employed to initiate the call center service until the bidding and procurement
process for a modern call center technology. The emergency number “633” has been designated for
this service and calls made through other emergency numbers, 8335 and 6406, are being directed to
ambulance dispatchers located at the sub cities
 23 ambulances with basic emergency equipment have been assigned for this service by Addis Ababa
City Administration Health Bureau and 63 professionals are hired
 Service performance indicators were developed, and regular reports are being gathered. Moreover,
performance review workshops were organized engaging all relevant stakeholders
 The bidding process has been initiated for the branding of ambulance service and initial document
has been developed
 All relevant stakeholders were engaged as part of creating a sustainable structure for the pre-hospital
emergency services in the city

2. The Major Cities Emergency and Critical Care Improvement Program (MECIP)

The major cities emergency and critical care program is the other major initiative undertaken by the ministry of
health to improve the emergency and critical care service. After its official launch, this program has continued
its second year of implementation in the five pilot cities: Jimma, Bahirdar, Mekelle, Hawassa and Harar.
The MEICIP program has created a unique platform for communication and collaboration among relevant
stakeholders for emergency and critical care service improvement. It has also created an opportunity for the
universities in these cities to take the lead on the national program, which greatly benefits the host community.

This program was successful enough in creating a sense of ownership among various stakeholders and was
insightful that emergency care goes beyond the facility-based emergency services.

The major activities and achievements of the MECIP program are presented below:

 City based steering committee and communication and collaboration forums have been established
in all cities
 Benchmarking and experience sharing visits to emergency and critical care services in Addis Ababa
have been arranged for city representatives
 Functional ambulance call and dispatch centers have been established in all cities with a four digit
emergency number
 Five basic and five advanced ambulances have been distributed to these cities
 The web-based referral system has been piloted in these cities and 30 liaison officers in Bahirdar and
50 from Hawassa have received capacity development training
 Continuous program performance monitoring has been conducted through regular supportive
supervisions, virtual national steering team meetings and program review meetings
 Various capacity-building trainings have been given under the MEICIP program in these cities.

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Major achievements of MECIP

- Ambulances were allotted for this specific program and professionals were trained
- A significant improvement was realized on ambulance response time
- Community awareness-creation campaigns have been conducted using all types of media including
local radio and TV programs, Billboards, T-shirt, face masks etc.
- Renovations on the emergency service units including installation of mechanical ventilators (Jimma)
- Quality improvement projects were designed and implemented
- City wide disaster response drill has been performed and a disaster store is established (Harar)
- A stand-alone emergency and critical care service center (Harme emergency center, Harar) has been
established with 156 rooms, 97 beds, 2 advanced ambulances, 2 operation theaters, X-ray, ultrasound
and an advanced laboratory service.
- Referral service audit has been conducted and city-wide service directory has been developed
(Bahirdar)
- Central oxygen delivery system has been established (Hawassa and Adare hospitals)

To scale up such an endeavor, additional eight cities were selected based on set of criteria. Baseline assessment,
action plan development and program costing have been conducted in these cities. Program implementation
of these sites has been officially launched after an agreement was signed between the ministry and the
implementing stakeholders (city mayors, regional health bureau heads, university presidents and hospital
administration).

Community ownership and participation on emergency and critical care services

“First aid day” and “Road traffic accident victims’ day” were celebrated to enhance community awareness and
ownership on emergency and critical care services. Health education messages on injury prevention, burn
care and ambulance utilization were broadcasted through various media. A documentary video on MEICIP has
also been developed and shared on public media.

Pre-facility emergency services

In the 2013 EFY ambulance service was given to 917,833 clients and ambulance response has been given to
95.2% of the calls received this year.

Nationally there are a total of 4,011 ambulances under governmental and non-governmental organizations.
Among these, 83% are fully functional. Ten advanced ambulances have been procured by the ministry of health
and distributed to Addis Ababa and the five MEICIP cities. Two advanced ambulances are assigned under the
ministry of health for national emergency response.

Basic ambulance equipment has been distributed (for 400 ambulances) to all regions and city administrations
and additional equipment for 700 ambulances is under procurement process. Activities are underway for the
renovation of the internal structure of basic ambulances for better functionality.

Facility based emergency service

WHO Basic Emergency Care (BEC) tool kit implementation has been initiated on 10 primary hospitals. From
these hospitals, 195 health care workers have received basic emergency care training. This training was also
given to 347 healthcare workers from 99 health centers selected from areas with high incidence of road traffic
accident. In the implementation, use of WHO checklist has been initiated, triage and resuscitation services
reorganized; and support was given to avail emergency drugs and equipment at these sites.

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In this fiscal year, facility-based emergency service was given to 3,725,090 clients. The annual national
emergency mortality rate is 0.45%. Exceptionally high emergency mortality was observed from Somali (3.08%)
region and the lowest was recorded in Benshangul Gumuz with 0.16%. The second and third highest emergency
mortality were recorded from Afar (1%) and Harari (0.82%).

Annual Emergency Mortality Rate by Region,

2013EFY
National 0.45%
Addis Ababa 0.63%
Dire Dawa 0.28%
Harari 0.82%
Gambella 0.38%
Sidama 0.50%
SNNP 0.28%
Ben.Gumuz 0.16%
Somali 3.08%
Oromia 0.50%
Amhara 0.31%
Afar 1.00%

Figure 36. Annual emergency mortality rate by region, 2013EFY

Surge capacity development

To improve the preparedness and response of health facilities to mass causality incidents, capacity
development training has been given to health care workers from Addis Ababa and the five MEICIP cities. A
citywide preparedness and response plan have been developed in these cities and drills have been conducted
to test the practicality of the developed plan. Mass-casualty management training has been further cascaded
to 15 regional hospitals with high occurrence of mass casualty incidents. Supportive supervision and tabletop
drills have been conducted at these hospitals to improve their preparedness and response.

Critical care

Service assessment and leveling of Intensive Care Units (ICUs) has been conducted at 51 health facilities. Out
of these, only one hospital has a level one ICU, 11 hospitals have level two ICUs and 39 hospitals have level
three ICUs. Financial support was provided to three hospitals to improve the level of their ICUs. In the 2013
fiscal year, 12 hospitals have newly introduced ICU service. Capacity development training has been given to
1,479 professionals from all regions and city administrations.

Onsite mentorship and coaching was conducted to 42 hospitals with high ICU mortality rate. As a result, ICU
renovations have been initiated at certain sites, ICU service quality-improvement projects have been designed,
separate COVID-19 ICUs have been established and resource sharing among hospitals has been facilitated.

Regarding the COVID-19 pandemic response, COVID-19 ICU training of trainers was given to 25 health care
workers and the basic training was given to 204 professionals. Two hundred fifty (250) mechanical ventilators
have been distributed to regions. In addition, service assessment was conducted at 64 COVID-19 treatment
centers and based on the finding technical support was given to 15 centers.

The national annual ICU mortality rate for the 2013EFY was 25.5%. Afar and Gambella have recorded the
highest ICU mortality rate with 52.6% and 50% respectively. On the other hand, the lowest ICU death were
recorded from Harari (15.5%) and Oromia (18.7%). Of the total ICU deaths documented in the reporting period,

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47.6% of them were on mechanical ventilator support. In Somali region, three-fourth (76.1%) of the ICU deaths
were on mechanical ventilator support. These findings suggest that addition efforts and interventions may be
required to increase the service quality of ICU and mechanical ventilator utilization.

Annual ICU Mortality Rate, 2013EFY

52.6% 50.0%

36.8%
29.9% 30.4% 29.6%
26.6% 26.8% 25.5%
18.7% 21.4%
15.5%

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Figure 37. Annual Intensive care unit (ICU) mortality rate by region, 2013 EFY

Road Traffic Injury

Among the total road traffic injury cases in the fiscal year, one-fourth (27.0%) of the injuries were due to
motorcycle accident. On the other hand, 44,699 (17%) of the injury cases were attributed to vehicle accidents.
Accidents on pedestrian also contributed 11% of injury cases in the year. Among the regions, Oromia (37.1%)
has the highest percent share among the regions with 100,608 road-traffic injury cases. The second highest
share is from SNNP (29.5%) with 80,092 total road-traffic injury cases. Sidama and Amhara also take the third-
and fourth-percent share with 13.1% and 10.3% respectively. The fewest road-traffic injury cases were reported
from Gambella with 416 (0.16%) cases.

Proportion of road-traffic injury cases by type, 2013EFY

17%

Vehicle occupant
45% Motor cyclist
Pedestrian
27%
Others

11%

Figure 38. Proportion of road-traffic injury cases by type, 2013EFY

Third party insurance

In 2013 EFY, 136 health facilities have started to use the third-party insurance scheme. From these facilities,
15,990 clients have received the service with the cost of 14,584,852.00 Birr. In order to strengthen this service
with reliable use of data, registries and recording and reporting formats are being developed. Moreover,

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assessment has been conducted with stakeholders to raise the third party insurance coverage from 2000.00
Birr to 8000.00 Birr per person.

Referral service

National service directory application software has been developed for the public, which can work seamlessly
with other software developed by MOH and are accessible on smart phones and desktop computers.
Furthermore, a web-based referral system has been developed and piloted in MEICIP cities. A referral directory
and patient transfer protocol have been developed for COVID-19 treatment centers in seven regions. In 2013
EFY, there were 928,922 referrala, among which 30% of them were emergency referrals.

Challenges (Emergency and Critical care services)

The shortage and lengthy procurement process of emergency and critical care equipment and drugs,
inappropriate utilization of ambulances and the current conflict in the northern part of the country were the
pertinent ones among the challenges faced in the year.

Way forward

The ministry of health has launched a five-year strategy for emergency and critical care services. In the coming
year, this strategy will go into implementation to strengthen and expand the pre-hospital system and to improve
facility-based services with special emphasis on the community ownership and engagement. Focus will also
be given to strengthen coordination and collaboration among several stakeholders for emergency and critical
care. There are also various activities planned to strengthen the surge capacity and disaster management with
the aim of building a resilient health system.

3.14. Blood Services

In 2013 EFY, blood service in Ethiopia has registered remarkable results despite the COVID 19 pandemic and
security issues in our country. The service has successfully mitigated the risks and has managed to ensure
sustainable accessibility of safe and adequate blood and blood products to recipients. Various blood and blood
related services were implemented in the fiscal year. The major services include:- blood donation, collection
and counselling service; blood component production, distribution and testing; promotion of appropriate
clinical use of blood, improving the quality and safety of blood and blood products, expanding blood bank
service in different parts of Ethiopia and other related activities. The major activities and achievements in 2013
EFY are described below.

1. Governance and National Coordination of blood transfusion service

The blood bank transformation plan II development was finalized, and its implementation was started in 2013
EFY. In order to improve evidence-based decision making in blood services, a new blood bank reporting and
monitoring tool called “electronic Vein to Vein Reporting Tool (eVVRT)” was developed and launched in the
fiscal year. Implementation of eVVRT has improved the availability of quality data to monitor, evaluate and
enhance the performance of blood services.

The 8th and 9th Blood Bank Service Annual Review Meetings were conducted in Gondar town (Tikimt 2013 EFY)
and Arbaminch town (Sene 2013 EFY) respectively. The performance of the service and next planned activities
were reviewed during the meetings and recognitions given to best performing blood banks and collection
sites. The 2021 World Blood Donor Day was also commemorated in conjunction with the ARM in Arbaminch
town.

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Blood Safety Information System (BSIS) was scaled up and implemented in Adama and Dessie blood Banks
as an initial phase to expand the system to all blood banks across the country. This will greatly improve the
service and reinforce the coordination and data sharing between sites to sustain effective and efficient use of
blood.

Figure 39. World Blood Donor Day Commemoration event at Arbaminch Town; June 14, 2021

2. Blood Donation and Counseling Service

In 2013 EFY, 281,760 units of blood was collected, of which 99.8% was collected from voluntary non-remunerated
blood donors. From the total blood donated, 171,874 (61%) were male donors and 109,886 (39%) were female
donors. The majority (85%) of the collected blood was collected through mobile blood collection and the
rest was at blood banks and collection centers. Regarding the types of blood donors, there is a significant
improvement in increasing the number of blood donors from replacement to voluntary donors. Ten years back,
only 10% of the total units of blood collected was from voluntary blood donors and 90% was from replacement
donors. The proportion of voluntary blood donors has increased from 18.8% in 2004 EFY to 99.8% in 2013EFY.

Every blood donation from blood donors is screened for transfusion transmissible infections as per the WHO
recommendations. In line with this, the number of blood banks providing post donation counseling services
to notify blood donors of their health status after blood donation has increased from 16 to 26 in the fiscal year.
In 2013 EFY, the total number of donors who have received this service was 21,132 (7.5% of total donation).

3. Blood Component Production, distribution and Testing

One of the main objectives of blood bank transformation plan is increasing component production and
improving its availability to health facilities and recipients. Component production includes converting whole
blood to its components such as concentrate red cell, platelet concentrate and fresh frozen plasma and
cryoprecipitate. In 2013 EFY, from the total blood donated, 45,293 units (16%) was converted to its components.
The number of blood banks that perform component production has reached 17. Eighty five percent of the
demand for component blood from health facilities was satisfied in the fiscal year.

All the blood donations were tested for the four transfusion-transmissible infections (TTIs) Markers. From the
total teste donations, 12,108 donors (4.3%) were tested positive for TTIs. Among those who were tested positive
for TTIs, the majority (56%) were tested positive for hepatitis B, followed by syphilis (27%). The Ethiopian blood
bank will strengthen the pre-donation education and counseling services to increase donors’ awareness and
further reduce blood wastage. In 2013 EFY, the total blood discard rate from the total collection due to different
reason was 9.7 %.

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Prevalence of Blood Transfusion Transmissible Infections (TTIs)

among Blood Donors tested positive for TTIs, 2013 EFY

870; 1271;
7% 10%

HIV 1 and 2
Syphilis
3220; 27%
Hepatitis B
6747; 56% Hepatitis C

Figure 40. Prevalence of Blood Transfusion Transmissible Infections (TTIs) among Blood Donors tested positive for TTIs, 2013
EFY

4. Promotion of appropriate clinical use of Blood

In order to promote appropriate clinical use of blood, technical support was provided for 80 health facilities
to establish functional Hospital transfusion committees. In the fiscal year, 65 adverse events related to blood
transfusion has been reported from health facilities. Detailed analysis and investigation have been conducted
for each reported adverse event and feedback was given to the reporting health facilities. Mentorship and
supportive supervision was provided to 74 health facilities (50 in Addis Ababa). Training was provided to 100
health professionals on appropriate clinical use of blood.

5. Blood quality assurance and safety

The national blood bank service has provided support to regional blood banks to implement internal quality
control testing. In 2013 EFY, 20 blood banks have started performing internal quality control.

National quality-assurance scheme samples were sent to 27 regional blood banks to assess and strengthen
the quality of laboratory testing across sites. Preventive maintenance and installation service was provided
to regional blood banks. A training on quality management system was provided to 38 regional blood bank
quality control experts. In addition, quality accreditation preparation assessment and mentorship visits were
conducted at 3 regional banks.

6. Expansion of Blood Bank service

- The number of blood banks that collect blood from voluntary blood donors has reached 43 (figure
below)

- The number of blood banks that perform component production has increased from 10 in 2011 EFY
to 17 in 2013 EFY

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Table 19. List of blood banks in Ethiopia, 2013 EFY

Way forward/ major focus areas for next year

- Improve communication and incentive mechanism for blood donors

- Improve leadership and governance system
- Expand blood safety information system (BSIS) at regional blood banks
- Improve and expand electronic vein-to-vein reporting tool (EVVRT)
- Improve the availability of logistics
- Initiate blood cost recovery system

3.15. Laboratory Services

During HSTP II period, the health sector will continue to improve access to quality laboratory service through
laboratory capacity building, quality assurance programs, infrastructure development and maintenance and
expansion of basic and advanced lab services at health facilities. Moreover, a laboratory quality-management
system, a step-wise accreditation process, preventive and curative equipment maintenance, and a laboratory
information system will be implemented. .

The Ethiopian Public Health Institute is implementing a national laboratory quality-improvement program,
through an internal and external quality assurance and accreditation programs. In 2013 EFY, 90 laboratories
were planned to score 1-5 star level for SLIPTA; however below half, 44(48%) of them were able to achieve the
minimum score level (9 Star-1; 20 got star-2; and 15 got star-3 levels). On the other hand out of planned 360
laboratories for external quality assurance (EQA), only 160(44%) of them scored minimum standards. In this
reporting period, 17 (51%) out of planned 33 laboratory were certified for ISO 15189.

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40
35
35
30
30
25
20
20 Plan
15 15
15 Performance
9 10
10
5
0
0
Star-1 Star-2 Star-3 Star-4-5

Figure 41. Performance of medical laboratories for SLIPTA in Ethiopia 2013 EFY

Strengthening laboratory information system (LIS) for 10 laboratory was planned while actually implemented
in 8 (80%) and follow up support was provided by EPHI for six of hospitals which have already functional LIS.

Laboratory equipment management is one of the key areas for laboratory quality-improvement programs.
EPHI has been performing tremendous activities on equipment management systems such as technical
assistance provision in preventive and curative maintenance, calibration of a biosafety Cabinet (BSC) and
negative pressure; and calibration of ancillary laboratory equipment.

Preventive maintenance was given for 216 (86.4%) laboratory machine out of 250 request; calibration of
biosafety was done for 163 (73%) out of planned 230; annual calibration was done for a total of 50 laboratory;
and preventive maintenance was done for 6 laboratory that have negative pressure system

Laboratory-equipment maintenance center with equipped personnel and required toolkit play an instrumental
role in ensuring the laboratory service continuity. From EPHI supportive supervision finding trained bio
medical engineers are available at regional level where as laboratory equipment maintenance center was not
established in the majority of regions except at Addis Ababa (AA), SNNP, Harari, DireDawa and Afar. It took
one to two weeks to get maintenance upon the request from laboratory department in AA while there is no
system to timely track and fix non-functional medical equipment in other region especially in health facilities in
Amhara and Afar where equipment’s are not maintained for years. Skills and capacity gaps were also reported
for new generation and sophisticated machines. Test menu was prepared and posted in the majority of visited
health facilities (except health facilities in Afar and Sidama), but it lacks regular updating and information
sharing system for interrupted tests and services.

The commonly reported non-functional laboratory equipment are chemistry machine, BSC, A25 bio system
chemistry, Centrifuge, Microscope, Complete Blood Count (CBC) machine, Gen Xpert, SYSMEX, Hematology
machine and Fax count. Recurrent service interruption was reported almost in all visited health facilities either
due to lack of required reagents/kit or non-functional lab machine.

3.16. Health Service Quality and Safety

Quality and equity of health care continued to be the transformation agenda of the health sector in the HSTP
II to build a high performing health system, which continually improves health outcomes and the public trust
on the system. The implementation of the health care quality and safety agenda in the year 2013 EFY was
guided by HSTP II priorities, the National Quality Strategy I review findings including the continuation of some
uncompleted agenda of the first National Quality Strategy (NQS I) and saving lives through safe surgery (SaLTs).
Accordingly, five major initiatives were prioritized and implemented in the 2013 EFY period.

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Institutionalizing quality culture within the health care system

Though Institutionalization of quality culture in the health care system is a long journey to realize in settings like
ours, different efforts have been conducted in the past periods, which spans from implementing improvement
initiative to creating a structure that leads and coordinate the quality-of-care activities at all levels. As part
of continuing the efforts in creating a culture in the health care system, the following major initiatives and
activities have been implemented during the 2013 EFY;

 Development and launching of the National Health care quality and safety strategy II (2021-2025):
National Health care quality and safety strategy was developed to continually improve health outcomes
and confidence in the system through the realization of the following five Objectives:

1) Improve evidence-based essential health care provision

2) Improve people-centered Care
3) Reduce harm arising from the care delivery
4) Improve efficiency in the health care delivery
5) Create a quality culture through continuous learning and improvement

 National quality coaching guide have been developed and introduced with the aim of enhancing quality
coaching skills and components at different level of the health system

 Health facility accreditation-roadmap has been drafted with the determination of putting an illustrative
futuristic pathway for health facility-accreditation system in the country

 To enhance quality culture at health facility level, technical support has been provided to conduct
regular clinical audit, dashboard utilization, and onsite QI coaching and QI training

 The hospital clinical audit tool has been revised and clinical audit tool has been developed for health
centers

 The 6th National Annual Healthcare Quality Summit was held since its establishment in 2007EC. It is
one of the platforms where facilities and organizations share their experiences on quality and safety and
continuous learning for a better outcome

Improving health care safety

The second national quality and patient safety strategy (NQPS) II defined patient safety as the absence of
preventable harm from healthcare; and reduction of risk of unnecessary harm to an acceptable minimum
(Adapted from WHO). With the aim of strengthening Healthcare safety practices in health facilities, the following
major activities have been implemented during the 2013 EFY period,

• The second World Patient Safety day was celebrated on September 07, 2020 with the theme of:
“Health Worker Safety: A Priority for Patient Safety” and the slogan of “Safe health workers, Safe
patients”.

• Patient safety training material is developed for use by healthcare professionals

Establishing national health care quality hubs

The ultimate goal of the initiative is to create a center of excellence for health care quality and safety that are
geographically accessible for the rest of health facilities and serve as a center for continuous learning and
demonstration on quality and safety improvements. Accordingly, seven teaching hospitals (Tikur Anbessa,

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Hawassa, Jimma, Ayder, Tibebe Ghion, St.Paul, and Hiwot Fana Hospitals) have been selected and continuous
technical and financial support have been provided to build the capacity to become learning hubs in the
country. Draft learning hubs initiative guidance document have been developed. Financial support was
provided to six learning hubs for conducting quality improvement training, learning collaborative sessions,
and QI project implementation. A total 6,000,000 ETB (1,000,000 for each Hospital) has been provided during
the fiscal year. Basic QI training was given for 332 health professionals from these 6 learning hubs. In addition,
on-site coaching and mentoring were also conducted to these learning hubs to design and implement QI
projects and conducting learning collaborative sessions.

Saving Lives through Safe Surgery (SaLTs) initiative

The SaLTS strategic plan focuses on availing a package of essential and emergency surgical and anesthesia
care at all levels of the Ethiopian health care delivery system. This initiative places special emphasis on
improving service access through strengthening primary health care facilities to provide essential surgical care.
Based on this, the following major activities have been executed in the year. Primary health care facilities were
technically supported to initiate surgical services. Along with the Daycare Surgery guide, technical support
was also given for selected health facilities to introduce day care surgical services. Rigorous supervision and
mentorship have been given to RHBs and health facilities to improve surgical efficiency and effectiveness and
to enable facilities to design and implement surgical QI projects. The outcome of the first SaLTs (2016-2020)
strategy has been evaluated in terms of expanding access to safe, efficient and equitable surgical care. The
second National Surgical Care Strategic Plan Saving Lives through Safe Surgery II (SaLTS II) 2021–2025 has
been developed with the goal of reducing surgical related morbidity and mortality. This strategy also has 5
strategic objectives namely: Improve equitable access to safe surgical and anesthesia care, improve efficiency
of surgical systems, improve effectiveness of surgical system, improve people-centered surgical care, and
reduce harm arise from surgical care provision. Besides these, peri-operative mortality review guide has been
developed to standardize and institutionalize peri-operative mortality audit and streamline the reporting
mechanisms. Standard operating procedure (SOP) has been developed for surgical procedures. This SOP aims
to achieve efficiency, quality output, and uniformity of performance while reducing miscommunication and
failure to comply with health service standards and clinical Quality. Currently, many health facilities are trying
to provide quality surgical services, but the services are far from being provided in a standardized and uniform
manner. Therefore, to bridge this gap this standard operating procedure (SOP) manual has been developed
to standardize and formalize the provision of Quality surgical services in health service delivery. In addition,
PACU training manual has been developed to equip health professionals on up-to-date knowledge and skills
to ensure the safety of patients at early stage of post-anesthesia recovery.

Maternal and Newborn Quality of Care (MNH QoC) initiative

The maternal and newborn quality of care (MNH QoC) learning network initiative was launched in early 2017
to operationalize the National Quality Strategy I agenda of improving Quality of Care for Mothers, Newborns,
and Children following the launch of the National MNH quality of care Roadmap.

The goal of the Quality, Equity and Dignity for Maternal and Newborn Health initiative is to halve institutional
maternal and newborn deaths in health facilities in selected learning districts and improve the experience of
care over the strategic years.

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The initiatives is implemented in selected 14 districts representing the agrarian, pastoralist, and urban setups
in the country (3 - 5 learning health facilities per district with a total of 48 learning health facilities consisting
of 8 referral & general hospitals, 12 primary hospitals, and 28 health centers). The WHO MNH QoC monitoring
and evaluation framework was also adopted and implemented to track the implementation of the program
and results that include fifteen common core indicators measuring provision of care, the experience of care
and WaSH.

Since the launch of this initiative, establishment of TWG, development of MNH QoC standards and audit tool,
development of national QI coaching guide, training, organizing semi-annual learning collaborative sessions
and regular site level monitoring and coaching were conducted. The MNH QoC network implementation have
shown promising results when the pre and post implementation performance is compared in the reporting
health facilities.

o Pre-discharge maternal mortality ratio (MMR) per 100,000 live births declined by 17% (from 163 to 135
per 100,000 live births)
o Pre-discharge neonatal mortality rate (NMR) per 1000 livebirths decline by 5.4%, from 24.0 to 22.7 per
1000 live births
o Fresh stillbirth per 1000 births declined by 18%, from 19.7 to 16.1 per 1000 births

Major Achievements

Delay for elective surgical admission (in days) has reduced from 52.0 days in the 2012 EFY Period to 32.7 days in
the 2013 EFY Period indicating a 37% reduction. Rate of surgical checklist utilization has increased from 80.7%
in 2010 EFY to 90.3% in 2013 EFY.

DELAY FOR ELECTIVE SURGICAL ADMISSION (IN DAYS)

Ham 2011 to Sen 2012 Ham 2012 to Sen 2013

212.2
84.7

52.0
43.8

32.7
32.3

11.5
9.0
7.9

7.7
7.3
5.1

3.3
2.8

3.0
2.3

2.5

2.2
0.8
1.3
0.4

0.5

0.5
0.1
Z

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A
RA

RI
A
P

A
LI

BA
R

A
U

N
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A

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M

O
A
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A

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A

TI
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.G

A
M

M
SI

A
O

E
A

IS
N

IR

N
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D
D

D
A

Figure 42. Delay for elective surgical admission (in days) by region

Major Challenges

 Lack of uniformity in quality structure at sub-national and health facility levels

 The emergence of the COVID-19 pandemic compromised the quality of care audit practice in the
health care system.
 Inadequate Human resources for quality structure at all level

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 CHAPTER

LEADERSHIP AND GOVERNANCE

ANNUAL PERFORMANCE REPORT

CHAPTER 4: LEADERSHIP AND GOVERNANCE

4.1. Regulatory System

4.1.1. Food, drug and medicine regulatory functions

T
he Ethiopian Food and Drug Authority (EFDA) through its five year (2013-2017E.C) Health Regulatory
Sector Transformation Plan (HRSTP-II) works towards the realization of protecting the public from unsafe
food, safeguarding the public from falsified, substandard and ineffective health products, protecting
the public from tobacco and alcohol related health risks and attaining public confidence on food and health
product regulation.

The major activities conducted during 2013 EFY plan period are presented as follows.

Quality and safety regulation of food

In the fiscal year, the regulatory functions focused on improving the registration and licensing of organizations
that produce and import food items. Thus, in 2013 EFY, 79 child foods (infant formula, follow up formula and
supplementary foods) and 900 different types of food were registered. Altogether, 979-market authorization
and 1,900 pre-import notifications were issued. Moreover, 109 producers and 984 importers and distributors
were issued license.

In addition, post-licensing inspections were carried out in 1,617 food facilities (568 food manufacturers and
1,049 importers and distributors). As per the plan, internal quality assurance system was conducted in 166 food
factories as well as 355 food exporters, importers and distributors. Findings showed that 67.1 % of the assessed
companies have established an internal quality assurance system. Low performance was registered because
of the low interest of owners that may call for discussion with their associations.

Regarding the inspection and control of food market centers and retailer’s, product based surveillance and
inspection on oil, salt, honey, peanut butter, Moringa, Vinegar, Vimto at retail outlets was undertaken to ban
illegal trade/trading. This was implemented in 14 rounds at a total of 49 towns and necessary administration
measures were taken on 86 illegal and substandard defective products. Meanwhile, information about these
defective products was disseminated to the public to prevent the public from using them and to the relevant
stakeholders for administrative measures.

In addition, 17 illegal trade operators (nine food distributers, four un-iodized salt distributers, two flour
factories, one illegal food importer and one retail outlet) involved in unethical trade practices in four different
towns were caught red-handed and the necessary administrative measures were taken, in collaboration with
the local customs offices and notification was given to the public through mass media.

During the plan period, consignment test was conducted for 36 food items (94.7 % of the plan). Besides, post-
marketing test was undertaken for 417 samples edible salt, for 198 samples edible oil and for 32 samples of
pasteurized milk, cheese, and yogurt. In addition, about 6.8 million tons of imported infant formulary and
follow-up formulas, supplementary foods, raw foods items for processing, other imported foods such as salt
were issued permits of entrance after passing the necessary quality control and safety certification.

Regulation of health products

In order to ensure provision of quality and safety of drug and medical equipment, registration and licensing of
these products is essential. During the 2013 fiscal year, the Authority had planned to issue market authorization
for 1,080 pharmaceuticals and 4,900 medical equipment, and out of which 779 (72%) pharmaceuticals and

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2,891 (59%) medical equipment licenses were issued respectively. Moreover, as per the special pre-entrance
registration request from government bodies, the Authority provided a certificate of registration for 487
medicines.

The other main activities of the regulation is to provide certificates of competency (CoC) to newly established
health and health related services. Accordingly, one large and 69 small-scale pharmaceutical manufacturing,
376 medicines exporters, importers and distributors, and 87 medical devices importers and distributors
fulfilled the necessary requirements, given CoC and issued new licenses. In addition, a new license was issued
to 9 cosmetics manufacturers, 115 cosmetics importer and distributer.

To ensure provision and use of quality pharmaceutical and medical equipment, post- license auditing inspections
were also conducted domestically and for foreign providers. As a result 10 medicines manufacturers, 886
medicines import, wholesalers and distributers, 91 small scale medicine items manufactures, and 121 medical
devices import, wholesalers and distributers, 51 cosmetics producers, 186 cosmetics import, wholesalers and
distributers were inspected. Fifty-eight foreign pharmaceutical manufacturers were also inspected.

To ensure the proper and rational drug uses and to take timely measures to avoid defective and substandard
products, the Authority conducted an inspection and regulation of distribution, prescribing, dispensing
and proper uses of drugs in 1,242 health institutions. In the fiscal year, the Authority undertaken supportive
inspection at different health related institutions. For instance, support was provide to domestic pharmaceutical
manufacturers nearby to enable them produce quality products for the foreign market. This will, in the long
run, contribute to increasing foreign currency and to overcome foreign currency shortages of the nation.

During the plan period, consignment test of pharmaceuticals to ensure quality and safety was done for a total
of 2,475 medicines samples (1,227 at head office and 1,248 in branch office). Out of the total tested, 2,457 (99%)
complied the standard. Microbiological test was also done for 63 samples of medicines, and quality test for
42 sensitizers were made and all of the products met the standard. In addition, 167 (99%) out of 169 sample
medical devices tested, 209 (95%) out of 219 sample condoms tested and 49 (56%) out of 87 sample gloves
tested complied the standard. Similarly 11 medical devices for physico-chemical lab test from 98 different
types of pharmaceuticals, 105 samples of nine types of medicines and 219 types of medical devices were
tested for microbiological parameters from 228 different types of pharmaceuticals.

With regard to post market surveillance (PMS) tests, 267 (87%) out of 307 medicine samples tested for physico-
chemical met the standard. Furthermore, microbiological test on 45 medicines samples and quality test on
146 samples of sanitizer products were conducted and all of them have met the standard. On the other hand,
out of 116 condom samples tested, 111 (96%) complied with the standard.

In the fiscal year, 29.2 billion ETB worth of medicine, 9.3 billion ETB worth of medical device and 770.1 million
ETB worth of medicine raw materials were given import permits after checking their quality and safety. In
addition, entrance permits has given to 2.5 million ETB worth of cosmetics products and 2.5 million ETB worth
of raw materials for cosmetics products.

In the reporting period, in collaboration with customs offices, regional health regulatory offices and law
enforcement bodies, several rounds of illegal medicine circulation survey were conducted in the 10 regions and
two cities administrations. These operations resulted in capturing 18 illegal operators (nine illegal medicines
distributers, four illegal cosmetics vendors, two Chinese mask products distributors, one another illegal masks
distributor, a hand sanitizer producer and a distributer). Therefore, in accordance to the regulation necessary
administrative and legal measures was taken.

With regard to clinical trial (CT) regulation, there were 17 CT’s authorizations made for the following: Pregart,
DOTS, 2 AVAREEF, 3 TM for COVID-19, FLAME, LAMPREG –AHRI-malaria, anti-malaria/TES trial, EFFORT, ALIVE,

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traditional medicine (at Debre Birhan University), optimizing place of treatment and antibiotic regimens.
Two Fred Hollows anticov, mechanical ventilator, copcov New CT protocols were evaluated and have given
required responses.

As part of health products safety regulation necessary inputs were provided and a center for

Pharmaco-vigilance was established in Haromaya University Hospital.

About 6,870 adverse drug reaction reports were collected from different parts of the country, analyzed, and
submitted to WHO database. This number is big because the Authority provided good follow-up on the
COVID 19 pandemic vaccination activities. Moreover, a COVID 19 pandemic vaccination safety monitoring was
conducted through the necessary follow-up and support to all regions, and inspection of pharmaco-vigilance
has been done rigorously.

As part of strengthening the inspection of narcotic and psychotropic substance, a countrywide performance
report on demand and supply information was submitted nine times to International Narcotics Control Board
(INCB). In addition anti-drug clubs were established and supported at 10 universities.

Control of tobacco and tobacco products

In the fiscal year, 202 million ETB worth of cigarettes have been imported from abroad. These cigarettes have
notification that describes the hazards that smoking cigarettes has on health. On the other hand, 119 million
ETB worth of cigarettes that did not fulfill the standard for importing were rejected at port of entry and have
been returned back to their country of origin.

In order to control smoking at public places, a total of 15,538 sites were inspected (6,166 more when compared
with last year 2012 EFY). Moreover, smoking-free public places were promoted through different Medias and
public mobilization activities. To prevent and control illegally imported cigarettes, one round of surveillance
and operation was undertaken in five major towns and the necessary actions was taken for illegal operators.

Legal framework preparation and its enforcement

In line with its plan to revise 24 directives this year, EFDA drafted, revised and developed eight directives. These
documents were also shared with key stakeholders and their comments are being incorporated. Similarly,
three model directives (for health products, for food products and for traditional medicines practitioners) were
developed and shared for regional regulatory units for them to customize in their own context.

Improve public ownership

Creating community awareness on health regulation and empowering them to protect their own health from
unsafe food and health products has been given a priority this year. Accordingly, educational information about
preventive measures of the regulation results were transmitted to the public 626 times through electronic
media and printed materials. As a result, it is estimated that 49.5 million people accessed this information.
Moreover, 10,772 people have shared their opinions and feedback to EFDA’s free-toll – 8482.

COVID-19 related prevention activities

To enhance public awareness about the challenging aspect of COVID-19 pandemic, its vaccination and clinical
trial on its traditional medicines, messages in the form of experts interviews were transmitted through different
electronics media, free toll of 8482, and through demand-based in person consultations upon demand.
Posters on improved and best food safety practices, and COVID -19 masks sewing instruction were developed
and disseminated to the public. In the fiscal year, a serious adverse drug reaction investigation and Causality

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Assessment was conducted on about 13 cases of COVID-19 vaccination. Moreover, reports on vaccination
safety and adverse events were collected from different parts of the country and submitted to WHO’s database.

A supportive supervision visit was provided to all regions that received training on adverse event following
immunization (AEFI) which has enabled to strengthen the Pharmaco-vigilance inspections across all regions.
Discussions on the COVID vaccination safety was held with health practitioners at health facilities. Training to
the trainers (TOT) on PCV10 to PCV13 switch vaccine campaign for AEFI was also given to the EPI coordinators.

EFDA has revised the previous directive for CoC to producers of masks, and for market-authorization (MA) of
the products to ensure the quality, safety and performance of the products needed to prevent the spread of
COVID-19 virus.

Other Achievements in the fiscal year

 In response to the health service’s urgent need of health products, EFDA played its role to ensure
availability of drugs, devices and other health products in the market, on time and with the required
quality and safety standards by following a new and efficient registration and quality assurance
strategies and systems.
 Improved efficiency of the registration system and timeliness of permit of entrance for imported food
items particularly for baby and child foods
 EFDA also worked to improve the food quality control laboratory that has now grown its capacity to
handle the food related quality testing activities.
 An extensive training and awareness creation program on regulatory processes and legislation was
provided to all regulatory bodies, mainly regional regulatory bodies to help them understand &
proactively play their role and standardize regulatory functions.
 Though rampant in some regions, illegal products movement and trade, seems to be limited due to
close intelligence led surveillance and operation and the law enforcement measures taken based on
scientific analysis and operation and in collaboration with multiple stakeholders.

Challenges encountered during regulation

 Low capacity of regional health regulatory bodies, especially gaps in human resource availability and
skill, scarcity in budget availability, to align with & collaboratively implement common regulatory
activities.
 Scarcity and/or unavailability of laboratory reagents from local market
 High threat of food adulteration, illegal food & sub-standard medicines in the market, irrational
medicines uses by the public and consumption of alcoholic and tobacco at restricted public places
 Unrestricted acts of the social media on promoting of alcohol and tobacco uses
 Low public awareness and engagement
 Low collaboration mechanism with different stakeholders on regulation activities
 Gap of knowledge and limitations in capacity to utilize high technology
 Interruption of power especially for laboratories functions/activities
 Threats of COVID-19 pandemic and peace and instability issues in some places

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Way forward

 Promote awareness and mobilize the general public, especially the youth, to tackle hazardous food,
illegal food trade, food adulteration, sub-standard and illicit health related products, improper uses of
medicines, tobacco use on restricted public places etc.
 Improve collaborative efforts with all key stakeholders, incorporate regulation strategies in all public
policies and sectors and also alignment of regulation strategies with the HEP
 Strengthen capacity of regional health regulatory bodies with skilled manpower & mix, sufficient
budget, necessary logistical services and structural & organizational rearrangements to make the
regulation standardized and be a nationwide concern
 Monitoring and banning of alcohol and tobacco advertisement and promotion on social & electronic
medias
 Undertake extensive awareness program & training on regulatory standards, policies and systems to
all Professionals & other related bodies of regulation.
 Working to assure desirable political commitment to support the regulation’s efforts
 Promoting and motivating self-regulation, immediate reporting on defects of food & drug safety issues
by volunteers operating in the field

4.1.2. Health and health related institution regulatory functions

In this section the regulation of health institutions, hygiene and environmental health of health-related
institutions, development and ensuring the implementation of standards, capacity building activities and
support, and public awareness are discussed.

Development and revision of standards

In 2013 EFY, 45 health institution standards have been revised and 24 of them were endorsed by Standard
Council. Moreover, 21 hygiene and environmental health standards of health related institutions have been
developed and 10 of them were endorsed by Standard Council. In this year, 4 new health institution standards
(Medical Plaza, Medical Office Practice, Women Health Clinic, and Implementation Scheme) were developed.
These standards are not yet endorsed by the Standard Council yet.

Health and health related institutions Regulation

In 2013 EFY, a total of 33 health institutions and 45 Health related institutions were inspected at the federal
level. The findings suggested that most of the health institutions have gaps in implementation of national
standards. Feedback was given for each health institution based on their specific inspection findings. In
addition, the inspection findings of health facilities were presented to the health institutions in the presence of
key stakeholders and higher officials of the Ministry.

COVID-19 response

Regional and city administration health regulatory bodies were supported financially and technically for the
implementation of COVID-19 Directive 30/2013. A close follow up and support was provided to regions and city
administrations on the implementation of the directive. In general, more than 30,000 health related institutions
were regulated.

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Challenges

 Shortage of manpower
 Difficulty of conducting inspection operations due to security concerns
 Less willingness of government health institutions to take certificate of competency
 Budget limitation to strengthen COVID-19 NPI activities
 Lack of coordination with law enforcement bodies to enforce COVID-19 NPI on health related
institutions

Way forward

 Strengthen relationships, collaboration and partnership with stakeholders

 Design ways to improve the licensing of government health facilities
 Strengthen National COVID-19 NPI regulation on health related institutions
 Enforce endorsed health and health related standards
 Strengthen development and revision of health and health related institutions standards
 Finalize MFR signature domain and initiate and finalize the entry of service domain
 Strengthen coordination with regions and provide technical support to regions
 Request and follow to meet the required manpower
 Initiate / strengthen health and health related institutions self-regulation
 Increase coverage of health and health related institutions inspection

4.1.3. Health Professionals’ Competency Assessment and Licensure

During the reporting period, task analysis for Medical Radiology Technology, Dental Medicine, Nursing and
Pharmacy cadres were developed/revised. In addition, blueprint for Medical Radiology Technology and Dental
Medicine cadres was developed. In the fiscal year, the other accomplished activity was the development of
question items for Medicine, Nursing, Health Officer, Anesthesia, Midwifery, Medical Laboratory Technology,
Pharmacy, Medical Radiology Technology and Dental Medicine,

In this reporting period, a new directive is developed for Health Professional’s registration & Licensing.
Licensing/Re-licensing health professionals coming from abroad, issuing letter of good standing and providing
document authentication service has been provided. Moreover, Licensure exam was administered in 3 rounds
for 31,294 candidates out of which only 12,363 (40%) passed the exam. Feedback on exam result /with domain
analysis/ was disseminated for all stakeholders (HEI’s, MoSHE, HERQA, Professional Associations). In line with
this, remediation guideline was developed to make higher education institutions provide knowledge/skill gap
trainings for exam failing candidates.

In addition to the above achievements, integrated human resource information system (iHRIS) software
development is being conducted so as to implement e-licensing at federal level and across all regions. Studies
have also been conducted to assess licensing practice at regions & exam development/administration process
in higher education institutions.

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Challenges

 Exam schedule inconveniences due to covid-19 pandemic

 Lack of readiness for the exam among HEI’s & candidates
 Inconsistent licensing practices among regions

Way Forward

 Implementing computer based examination

 Implementing e-licensing using HRIS
 Making preparations to start Objective Structured Clinical Examination/OSCE/
 Working with stakeholders to improve the quality of diploma level competency assessment /CoC/
 Working with stakeholders (MoSHE, HERQA & HEI’s) to introduce remediation in higher education
institutions for exam failing candidates

4.2. Health Infrastructure

Under health infrastructure development, the health sector is increasing access and quality of health services
through the rehabilitation of existing health facilities and construction of new facilities. The main tasks of
health infrastructure program includes providing adequately equipped, staffed and governed health facilities,
customer friendly and standard health facility layout, sustainable facility and equipment maintenance and IT
supported health system. The main accomplishment under health infrastructure program in the fiscal years
includes; construction, maintenance, renovation and rehabilitation of Health Facilities

Construction of Health Posts

In the fiscal year, the cumulative number of functional health post in the country was 17,699 and additional
391 health posts are under-construction. The majority of health post 232 (53.3%) under construction are from
SNNPR region. The detail of health post distribution by region is displayed in the table below:

Table 20. Number of functional and under construction Health Posts by Region, EFY 2013

Regions Functional Under construction Total

Tigray 743 0 743
Afar 343 3 346
Amhara 3565 32 3597
Oromia 7099 27 7126
Somali 1327 86 1413
B/Gumz 424 2 426
SNNPR 3437 232 3669
SIDAMA 550 2 552
Gambella 147 6 153
Harari 28 1 29
Dire Dewa 36 0 36
Addis Ababa 0 0 0
Total 17,699 391 18,090

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Construction of Health Centers

The number of functional health center at the end of the year was 3,777. In addition to the functional health
centers, 113 new health centers are currently under construction from nine regions and two city administrations.

Table 21. Number of functional and under construction Health Centers by Region, EFY 2013

Regions Functional Under construction Total

Tigray 226 3 229
Afar 97 11 108
Amhara 872 13 885
Oromia 1,411 5 1416
Somali 215 30 245
B/Gumz 60 7 67
SNNPR 608 23 631
SIDAMA 135 8 143
Gambella 28 4 32
Harari 8 1 9
Dire Dewa 15 0 15
Addis Ababa 102 8 110
Total 3,777 113 3,890

Construction of Hospitals

At the end of 2013 EFY, the total number of functional hospitals (specialized, general and primary hospitals)
across the country was 367; In addition to the functional hospitals, 67 new hospitals are under construction.
The distribution of public hospitals in each region is shown in the table below.

Table 22. Number of functional and under construction Hospitals by Region, 2013 EFY

Regions Functional Under construction Total

Tigray 41 4 45
Afar 7 0 7
Amhara 88 20 108
Oromia 109 15 124
Somali 13 3 16
B/Gumz 6 1 7
SNNPR 62 17 79
SIDAMA 19 3 22
Gambella 5 0 5
Harari 2 0 2
Dire Dewa 2 1 3
Addis Ababa 13 3 16
National 367 67 434

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Federal Infrastructure Projects

• Bidding advertised to recruit a consultant to renovate and construct four health facilities: Alert Dermatology
and plastic surgery, Amanuel Emeregncy hospital, St Peter diagnostic, and Amanuel staffs dormitory and
agreement was signed for the three facilities constructions and the detail design was prepared.
• International bidding advertised for the construction of Amanuel staffs dormitory and preparation finalized
to advertise the construction of dermatology and plastic surgery
• The problem encountered with the land ownership to construct Amanuel Emergency hospital was resolved
and detail design for the hospital is being prepared. Similarly, St Peter diagnostic design was finalized

Laboratory Infrastructure Projects

• Preparations for the construction of 15 laboratory facilities in eight regions was finalized; the preparations
work includes availing land, detail design preparation, detail work specifications, and bidding documents.
The construction of these laboratory infrastructures is with the support from the World Bank and received
no objections from Word Bank on the design but later the bank requested to prepare foundation design
for all laboratory facilities and this make a bit delayed in the process.

Regional Infrastructure Projects

• Supported four project with an estimation cost of 35 Million birr to Amhara region (Boru-Meda Dental clinic
center and Alem-Ketema Enat Hospital), Somali region (Gode Maternity and delivery center), and SNNPR
(Butejera Emergency medical center)
• Awareness creation workshop given for the regional health bureau and stakeholders on HSTP-II and 2013
health infrastructure strategic directions
• Focal persons were assigned and providing technical support for all regional health bureaus and city
admirations
• To fill the gaps with engineers for Sidama and Harare health Bureau, engineering staffs were assigned
temporarily from MOH
• Quarterly supportive supervision conducted in Somali, Afar, Gambela Benishangul Gumuz regions

4.3. Gender, Youth and People with Disability Mainstreaming

Ministry of health has been implementing different initiatives on women, children, youth and people with
different ability to ensure equitable access to health services, increase their participation and to address their
rights and benefits. Some of the major activities performed in the fiscal year include:

 Analysis made on women participation on leadership and decision making role and used for planning
purpose,
 Women forum was established to enable female workers gets support from each other
 A study was conducted on work environment convenience for female workers and the findings are
being used to improve the gaps,
 Harassment survey on work place was conducted and based on the finding
 Training manual and guideline developed, training given for female directorates to improve their
leadership and decision making roll.

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To address information needs for people with different abilities (disability), health and health related
information is being disseminated with sign language, 900 copies of braille printed and distributed to regions
on different topics including cervical cancer, MDR TB and sexual assaults. To ensure equitable access for
persons with different abilities (disability) training manual was prepared and basic training on sign language
was provided for health care workers. A study audit was conducted on institutions convenience for people with
disability, feedback was provided on the study conducted on COVID-19 response access for disabled people.

In order to keep children safe and healthier, childcare centers have important role and in the fiscal year
awareness and advocacy was done on the establishment of childcare centers, material support and training
provided for nurses and caretakers, guideline developed and orientation provided for federal offices on the
opening of childcare centers. Furthermore, in collaboration with Lideta sub city, Ministry of Health is supporting
20 vulnerable children permanently.

Challenges

 Lack of clear structure in the regions to deal gender, youth and people with disability, shortage of
budget, lack of expertise, gaps in the professional capacity,

Way forward

 Create clear structures in the regions and institutions, independent budget and qualified professionals
has to be assigned.

4.4. Policies and Strategies

According to the world health organization (WHO), an explicit health policy can achieve the vision for the future,
it outlines priorities and the expected roles of different groups, and it builds consensus and informs people. In
the fiscal year, some of policy and strategies activities accomplished include:

 Developed and disseminated a ten years health sector strategic plan. In addition, the second Health Sector
Transformation plan (HSTP II), spanning for the period 2021-2025 was developed and disseminated
 Conducted subsequent consultation on the revised draft health policy document and enriched the
document
 Submitted first revised draft health policy document to Ethiopia attorney general director for comment,
and MoH received feedback, revised the document and resubmitted for approval. Ethiopia attorney general
director reviewed and approved the final revised draft health policy and communicated it to Ministry of
health with official letter. Currently, the draft document is already submitted to Council of Ministers and
House of People Representative for ratification
 Implementation of HSTP II has started and also prepared cascaded other programs /FMoH agencies
strategic/ road maps plan in more detail
 Thirty-eight (38) different programs, including FMoH agencies have finalized their five-year strategic plan
or road maps and most programs have already endorsed and some of them are on process to endorse.
 Implementation of the previous health policy was evaluated using performance review of various programs
 Researches on selected major relevant issues have done by Ethiopia public health institutions, AHARI,
Universities and other programs area in collaboration with different partners.

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4.5. Health reform and good governance

Strong health governance at all levels is necessary to ensure that resources devoted to the health sector ensure
adequate access to health care and improved health. When governance is carried out efficiently, effectively,
and equitably, responsive and sustainable health services lead to positive health outcomes.

To improve social accountabilities of the health sector, health facilities are being monitored using community
scored card (CSC) system. In the fiscal year, three national technical working group meeting were held, CSC
training provided for 236 health care workers and management staffs, and CSC implementation was started in
102 new Woredas. At the end of 2013 EFY, CSC implementation has reached to 707 Woredas. Based on the CIC
indicator 69.5% of health center rated as clean and safe, and in 65.2% health centers have basic infrastructure
(electricity, water, rooms etc) services, 65.8% of facilities indicated the availability of medicines, diagnostic
services and medical supplies.

In the fiscal year, good governance plan was developed jointly with RHBs, agencies, federal hospitals and
MOH directorates, and agreed the implementation of the identified gaps by the respective agencies and
directorates. Semiannual and annual performance review meeting was held, 95 good governance issues were
identified from the ministry, agencies, regions and federal hospitals and 54 (57%) issues were resolved and 8
are on the process. Good Governance Index (GGI) assessment was conducted in 27 hospitals and the analysis
was shared with management body. A training on good governance index was given for 30 hospital reform and
good governance directorate director experts.

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CHAPTER 5: HUMAN RESOURCE FOR HEALTH

Human Resource Development and Management

T
he health sector has invested in human resource development and management in parallel to the
intensive expansion of infrastructure for the last two decades that has resulted in improved health
service coverages with better number and distribution of health workforce. Subsequently, HSTP II
was developed and being implemented since a year back to further improve the health workforce
through proper human resource planning, development and management (training, recruitment, deployment,
performance management and motivation) that will result in the presence of motivated, competent,
compassionate and committed health professionals in adequate number and skill mix.

As 2013 EFY is the first year of the second HSTP, several activities that emanated from this health sector strategic
plan have been implemented in 2013 EC to put a foundation for the improvement of the health workforce in
the strategic period. Human Resource development and administration is the key area that has been given
due attention where the efforts of various stakeholders have been pooled, and different strategies have been
developed and implemented to create conducive environment for the upcoming interventions that will result
in improved access to health workforce, health service coverage, equity and quality. The major activities that
have been implemented in this budget year are discussed below based on the following subtitles: Capacity
Building, human resource information system (HRIS), Deployment, motivation and retention, technical
assistance management and Distribution of health workforce.

5.1. Capacity building/Training

MOH has used different strategies and interventions to equip the health sector with adequate and well-trained
health workforce that is equitably distributed, motivated, and enabled to provide quality health service
with passion. Among the interventions are coordinating pre-service and in-service training in collaboration
with key stakeholders which have been implemented through Motivated, Competent and Compassionate
(MCC) workforce and continuous professional development programs. MCC workforce program is among
the priority areas of HSTP II that has been given due attention and has been initiated through implementing
several interventions. The detail description of MCC workforce performances is indicated under the subtitle of
Transformation agendas/priority areas of HSTP II (Chapter 2). Therefore, activities performed in strengthening
CPD are described as follow.

Continuing professional development program (CPD)

At federal level, efforts have been exerted to strengthen the implementation of CPD with selected professionals,
and institutionalize the program through intensive advocacy and resources support to the key implementers.
The following are among the key activities performed in these regards. These are:

 Transferred budget to Regional Health Bureaus and professional associations to strengthen their
internal capacity in CPD and to create awareness among health professionals
 Prepared awareness creation messages and broadcasted through radio, and disseminated via social
Medias
 Conducted advocacy on continuous professional development for Health Professionals and relevant
stakeholders at the Ministry of Health, regional health bureaus and professional associations
 Held consultation forums with Regional Health Bureaus, professional associations, regional regulatory
bodies and CPD centers

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 Recognized 81 continuous professional Development program centers who met the training
requirements for national CPD
 Developed Digital platform (web-based) for training modules, installed and made available on the
Ministry of Health’s CPD Server/database for use
 Facilitated the initiation of the training of thirty trainees in the second round of the Leadership
Incubation Program
 Provided senior leadership skills training to State Ministries, Directors, and agencies
 Handed over a series of professional development activities to regional Health Bureaus and regional
regulatory bodies, and enabled them to link Continuous Professional Development (CPD) with renewal
of professional license in seven professional fields starting from March 2021
 Completed the development of web-based service (digital platform) for CDP and started preparation
to start deployment. The development of iHRIS database for CPD was also completed and ready for
deployment.

To strengthen the capacity of medical and health science practical areas, nine clinical practical areas are
selected (Bishoftu, Dilchora, Shenengibe, Arbaminch, Adare, Debre Markos, Wollo, Minilik and Gondar Health
center) and supported to create suitable environment for medical and health science training. Accordingly,
to strength organizational collaboration, the selected institutions are supported to develop Memorandum
of understanding (MoU), assigned clinical coordinators, and conducted awareness creation activities for the
professionals of those institutions.

A clinical guideline for preceptorship has been developed and Preceptor training was provided to more
than 100 professionals, which has created a huge potential for the institutions. Training materials for clinical
practices were developed and distributed to the selected institutions. Moreover, some Institutions (Dalchora,
Adere, Bishoftu, Debre Markos, Dessie and Menelik) organized reading corners for their students where others
collected books and in process to arrange reading corners.

Finally, with the aforementioned and other efforts, the number of institutions that provide continuous
professional development accreditation has increased from 10 to 32 where the number of institutions that
provide continuous professional development training has increased from 8 to 81.

5.2. Human Resource Management Information system (HRIS)

In order to document and update staff information, data of 1185 MOH staff were documented to HRIS, and
made accessible for use. Concerning the sector wide health workforce, data on 296,156 (98.4% of the planned
figure) are compiled in a way that it shows distribution of the human resources by regions, city administration
and agencies suitable for use disaggregated by education levels, professionals and sex. In addition, a taskforce
has been established to strengthen the implementation of the National Health workforce account (NHWA) and
has started its mission.

Regarding digital system, integrated HRIS is under development by customizing it from an open source eHRIS
system. It handles the functionalities HR ADMIN, HR Development, and the HR Licensure services. The features
that have been selected for first release include the personnel management, leave management, performance
tracking and dashboard feature. On the HRD side, as a part of early release, graduate tracking feature, trainee
registration and course update is being developed. To date, the iHRIS development status reached 58%.

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To enhance the iHRIS development and implementation, electronic materials that include 2194 Desktop and
150 laptop computers and 150 hard disks were purchased and distributed to regions. Besides pre training
awareness creation works was done on iHRIS implementation to the officials of regional health bureaus,
universities and federal agencies, training of trainers and end user training was given to 104 trainers and 1259
professionals respectively.

5.3. Deployment
As most of the hiring process of health cadres was decentralized and managed at RHB level, MOH focused
on interventions that help to improve job opportunities in health through increasing the number of health
workforce of the health sector, and improving employment opportunities for the health professionals outside
the health sector. Accordingly, efforts were made both at federal and regional levels to increase the uptake of
health workforce, For instance, the number of workforce was increased from 73.3% to 75.5% at federal level,
but it is below the target figure (85%) for the year. Though data compilation is not completed, it is expected
that several health workers joined the sector through regions. On the other hand, study was conducted to
determine workload in the health sector and magnitude of available health professionals in the market. The
report will be released soon signifying the findings on workload. Findings from the national health labor-market
study revealed that while there has been significant increase in health workforce density over the last ten years,
there is still a significant need-based shortage of health workforce to deliver essential health service package.

A committee consisting of relevant stakeholders has been established to lead and oversee activities that
contribute to improve employment opportunities for health professionals outside the health sector and
improve access to health workforce. The committee held various consultations and identified options for
job opportunities in the health sector that include group and private (Solo), physician plaza, home based
care and treatment, mobile and tele health therapy. Considering the gathered information, implementation
procedures/steps have been developed and submitted to the Management Council for a decision, to initiate
implementation promptly. Job opportunities like home based care and treatment, mobile and tele health
therapy are ready to initiate the implementation. The heads of the offices have signed a memorandum of
understanding to work with the Job Creation Commission.

In collaboration with the Job Creation Commission, a system has been set up to register unemployed
professionals. Subsequently, 10,265 professionals have been registered in various fields. Of these, 2,796
professionals have completed their registration. Training materials have been developed to train prioritized
professionals that include health officers, midwifery and nurses. Discussion was also undertaken with Ministry
of Foreign Affair considering the common alternatives to widen employment opportunities abroad. Hence, the
Ministry of Foreign Affairs is working to establish relations with embassies and consulates in various countries.

During the COVID-19 pandemic, MOH was able to deploy an additional 6,721 health professionals for the
prevention and control of the pandemic. These professionals were deployed through digitized methods of
registration, screening, recruitment, and deployment mechanisms. In order to deploy these COVID-19 front
line workers, a huge resource mobilization was done to effectively motivate and retain them.

In collaboration with the Federal civil service commission and the ministry of finance and regional health
bureaus, the Ministry can permanently employ health professionals that have been deployed in the fight
against the pandemic in contract basis. This has been considered as a great achievement in prevention and
control of the pandemic in one hand and creating enormous job opportunities in the health sector in another
way.

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5.4. Motivation and retention

MOH has been highly engaged in revising the current health professional incentive directive, which has been
in effect since 2005 E.C. Through an extensive consultative process with various relevant stakeholders, an
inclusive, cost efficient and health workforce-incentive directive draft has been prepared and will be sent to the
councils of ministers for possible endorsement. This will have a great impact on creating motivated, competent
and compassionate health workforce and in return creating healthier citizens for a prosperous nation.

As part of the COVID-19 response, MOH has taken major decisions in health workforce motivation and retention
mechanisms. Amongst the major milestones achieved regarding Health workforce motivation and retention,
mechanisms include: Introduction and implementation of the special risk allowance payment guideline for
COVID-19 workers which was endorsed by the prime minister office; Life insurance coverage for health workforce
in case of fatality; National recognition week was celebrated for acknowledgement of all stakeholders involved
in the response against COVID-19. In addition, MOH has permanently employed health professionals that
have been temporarily deployed in the fight against the pandemic. Through the aforementioned motivational
mechanisms, it can possibly retain the health workforce and motivate them to fight the pandemic with all due
responsibility.

5.5. Management of Technical Assistance

In order to strengthen the health system, MOH has been recruiting and deploying various Technical Assistants
(TAs) using financial assistance from development partners in two ways: project based employment and as
seconded staff. To effectively utilize such a technical assistance, a national guidelines for technical assistance
is developed.  Accordingly, a technical assistance coordination unit is established. Since its establishment, the
unit has been organizing the TA data, follow up of TA performance appraisal, contact renewals and hiring new
TAs. There has also been a transition plan to minimize the number of TAs by replacing them with permanent
staff.

5.6. Distribution of Health workforce

5.6.1. Stock of Health workforce
Human Resources data collected at the end of 2013 EC shows that the total health workforce who are
employed in public health facilities is increased from 273,601 in 2012E.C to 325,374 in 2013 EFY. From the total
health workforce, 212,185 (65%) are health professionals and the remained 113,189 (35%) are administrative/
supportive staff.

Regarding the health professional categories, the top three health professionals in public health facilities
are Nurses (69,824), Health Extension workers (42,630) and Midwifery (20,355). There is no updated data on
number of health workforce working in private health facilities for the year 2013E.C, but it is estimated to be
about 71,500 personnel in 2012E.C.

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Number of Health Workforce By Category

120000
Number of Health Workforce

100000

80000

60000

40000

20000

0
Other
Health
Health Health Administrat
GP+ Nurses Midwives Pharmacists Medical Lab Ansthensia Extension Radiology
Officer Professiona ive Staff
Worker
l
Series1 12174 69824 20355 15498 12757 16595 1358 42630 1156 19838 113189

Health Workforce Category

Figure 43. Summary of National Health Workforce in 2013EFY (2020/21)

5.6.2. Distribution of Health workforce by Region

Distribution of health workforce is among the basic factors affecting health service provision (service coverage,
quality and equity). Hence, disparity in staff distribution is used as equity indicator, to measure differences
among regions in staff distribution, and to indicate the gaps to be narrowed.

In 2013E.C, the highest Health workforce to population ratio is observed in Harari and B/Gumuz regional state
followed by Addis Ababa City Administrations and Gambela regional state, where lowest health workforce to
population is seen in Oromia and Somali regional States followed by Amhara regional state from bottom to up.

Table 23. Health Workforce Distribution by Region, 2013 EFY

Gp+ Spe-
Health Officers

Professionals
Other Health
Radiography
Medical Lab

Pharmacist

Supportive
Ansthensia

cialist+
Admin and
Midiwife
Nurses

Sub-spe-

Total
HEW

S.No Regions staff

cialist+
Dental
Surgon
1 Tigray 913 6355 1504 1044 696 966 3074 99 112 736 7597 23664
2 Afar 73 1090 264 241 194 225 752 6 21 339 3975 7262
3 Amhra 2516 12288 5323 3422 2883 3952 8496 294 317 3628 20941 65005
4 Oromia 2535 18900 4700 3338 2876 4059 15918 267 260 4432 28484 86927
5 Somali 671 3268 1839 693 678 790 2197 26 42 1029 3580 14547
6 B/Gumuz 102 1629 580 219 244 406 1028 14 8 48 2731 7277
7 SNNP 1687 11206 3692 3569 2469 2087 7354 209 86 2614 19852 55621
8 Sidama 305 4127 661 909 712 608 1672 30 38 538 5927 15613
9 Gambela 70 1153 59 144 144 41 688 4 3 151 204 2667
10 Harari 77 417 111 55 90 99 134 13 25 129 594 1752
Dire
11 139 462 109 70 80 99 261 19 10 125 696 2093
Dawa
Addis
12 3086 8929 1513 2891 1691 2166 1056 377 234 1059 18608 42946
Ababa

NATIONAL 12174 69824 20355 16595 12757 15498 42630 1358 1156 19838 113189 325374

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5.6.3. Health professionals to population Ratio

According to World Health Organization, the Health professional density level is a key criterion to measure
health sector staffing. It identified as the SDG index threshold” of 4.45 doctors, nurses and midwives per
1000 population as an indicative minimum density representing the need for health workers (Health Workforce
Requirement for UHC & SDG, 2016, WHO), where HSTP II sets target of 2.3 per 1000 population. The health
professional density for Ethiopia is 1.16 doctors, Health Officers, nurses and midwives per 1000 population at
the end of 2013EC, which needs more efforts to attain the HSTP II target.

Regarding health professionals to population ratio, the national physicians to population ratio is 1: 8,448 (which
is 1.18 physicians per 10,000 population). The nurse to population ratio at national level is 1: 1,473 (which is
6.79 nurses per 10,000 population). Health professionals to population ratio varies among the regions where
the ratio of medical doctors (GP+ Specialist) per 10,000 populations is about 8.18 in Harari whereas it is 0.37 in
Afar regional state. This means one medical doctors (GP+ Specialist) is expected to serve 27, 256 population
in Afar Region, where one medical doctor (GP+ Specialist) is expected to serve 1,222 peoples in Addis Ababa.
Similarly, nurse to population ratio per 10,000 populations are high in Addis Ababa, Gambella, Harari, and B/
Gumuz regional states with ratio of 23.7, 23.1, 15.4 and 13.9 respectively, where the lowest Nurse to population
ratio is seen in Oromia (4.8) and Somali (5.1) and Amhara (5.5).

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Nationally, one medical doctor (GP plus specialist), Nurse, Midwife and Health Officer is serving a total of 8448; 1473; 5053 and 6198 population respectively. For
detail, information refer the table below.

Table 24. Selected Health Professionals to Population Ratio by Region, September 2013 EFY

Gp+ Specialist+-
Sub-specialist+ Dental Nurse Midiwife HO Medical Lab Pharmacist
Re- Estimated Surgon
S.No
gions Population
Num. 1GP+:Pop Number 1Nurse:Pop Num. 1Mid:Pop Num. 1HO:Pop Num. 1Med.L:Pop Num. 1Parm:Pop

1 Tigray 5,640,507 913 6,178 6355 888 1504 3,750 1044 5,403 696 8,104 966 5,839
2 Afar 1,989,674 73 27,256 1090 1,825 264 7,537 241 8,256 194 10,256 225 8,843
3 Amhra 22,536,586 2516 8,957 12288 1,834 5323 4,234 3422 6,586 2883 7,817 3952 5,703
4 Oromia 39,074,864 2535 15,414 18900 2,067 4700 8,314 3338 11,706 2876 13,587 4059 9,627
5 Somali 6,354,731 671 9,471 3268 1,945 1839 3,456 693 9,170 678 9,373 790 8,044
B/Gu-
6 1,173,123 102 11,501 1629 720 580 2,023 219 5,357 244 4,808 406 2,889
muz
7 SNNP 16,552,023 1687 9,812 11206 1,477 3692 4,483 3569 4,638 2469 6,704 2087 7,931
8 Sidama 4,469,029 305 14,653 4127 1,083 661 6,761 909 4,916 712 6,277 608 7,350
Gam-
9 498,671 70 7,124 1153 432 59 8,452 144 3,463 144 3,463 41 12,163
bela
10 Harari 270,031 77 3,507 417 648 111 2,433 55 4,910 90 3,000 99 2,728
Dire
11 521,000 139 3,748 462 1,128 109 4,780 70 7,443 80 6,513 99 5,263
Dawa
Addis
12 3,770,554 3086 1,222 8929 422 1513 2,492 2891 1,304 1691 2,230 2166 1,741
Ababa
National 102,850,793 12,174 8,448 69,824 1,473 20,355 5,053 16,595 6,198 12,757 8,062 15,498 6,636

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Other Administrative issues

Several administrative issues were addressed in line with the basics of good governance. Some of the activities
related with these issues are salary of the specialists in training, performance-appraisal completion techniques
and Job Evaluation and Grading (JEG) issues.

Regarding JEG, up on the revision of the previous two years professional career development that was changed
to three years based on new JEG, a guide for health professionals was developed in consultation with regions,
professional associations, agencies, health professionals, and Civil Service. It was approved and in use since
January 1, 2013 EC. On the other hand, there are professions that were previously evaluated and graded but
currently under re-evaluation due to complaints (Nurse, midwifery, Health Informatics, HIT, Health care service
managers, Biomedical (diploma & degree)).

Challenges

• Lengthy purchasing process

• Delay implementation of the new course catalogue by Ministry of Science and Higher Education
• Failure to perform National Specialty Test (examination) and placement on time
• Delay in establishing a team in Tigray and Afar regions to manage CPD
• Delay in submission of health workforce data from regions and other concerned bodies
• Delay in Infrastructure development for digital learning modalities of CPD
• Delay in iHRIS development

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HEALTH INFORMATION
SYSTEM
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CHAPTER 6: HEALTH INFORMATION SYSTEM

6.1. Evidence based decision-making

E
nhancing Informed Decision-Making and Innovation is among HSTP II strategic direction, which
focused on generation of quality evidence, research, and innovations, building a culture of evidence-
based decision-making, and developing and using technology (new and/or improved tools). It also
promotes use of data from routine and non-routine data sources, including new research supported
with appropriate information communication technology (ICT), and using an established HIS governance
framework. This section describes major achievements in 2013 EFY.

Health sector planning

The HSTP II strategic document, which was initiated in 2012 EFY was further refined and translated to Amharic
language and made ready for printing and distribution. Orientation was given to MoH staff during the whole
staff meeting and to stakeholders during 2012 EFY health-sector review meeting. Furthermore, the ministry’s
higher officials have highlighted the major objective of the plan to general public using virtual meeting
platform during which a total of 120 individuals have attended. In line with HSTP II, about 40 sub-strategies
were developed by MoH directorate and agency.

The current HSTP II was developed using the strategic planning and management framework which is
somehow different from the balanced score card approach which the ministry has been using since HSDP IV
period. To align health sector woreda based planning process with the HSTP II framework the existing planning
guide was modified based on the direction given from plan and development commission. Accordingly, the
2013 compressive annual woreda based plan was prepared using both routine and non-routine data source
for establishing the baseline and considering HSTP II target for annual target setting. The revised 2014 planning
process manual was also shared with region and 65 staff from RHBs and Agencies’ plan, monitoring and
evaluation directorate was given orientation on the core plan. A total of 48, 728, 645 ETB was transferred for
regions to support them in preparation of plan.

Ensuring health in all policy is one of the focus area of HSTP II to enhance synergy among different government
sectors. In 2013 EFY, the MoH have reviewed the policy documents of 12 sectors to assess whether health issue
is considered or not. Of the 12 sectors assessed 9 (75%) of them have clearly indicated health either in their
respective policy or strategic plan document.

Improving Data Recording and Availability

Routine health management information system (HMIS) is the main source of data for the health sector. Since the
Ethiopian HMIS was redesigned in 2007/2008 under overarching principles of standardization, simplification,
and integration, it went through two revisions in 2014 and 2017. The revision process is generally expected to
happen every three to five years to align with major programmatic developments, new strategic plans, and
initiatives. In order to respond to the additional monitoring and evaluation (M&E) requirements of HSTP II, .the
existing health HMIS indicators and source documents were reviewed in iterative and participatory approach.
The existing 131 HMIS indicators was increased to 169 and a total of 18 new register and 7 new tally sheet was
introduced making the total number of register and tally sheet 59 and 23 respectively. The remaining revision
process is expected to be finalized by the end of 2014 EFY first quarter.

Recording and reporting quality data on causes of morbidity and mortality is a critical component of the
routine health information system. Observations during regular data analysis and use, supervisions and a rapid
assessment in selected facilities of Addis Ababa showed that the quality of data was found to be unacceptably
poor which call for systematic assessment. NCoD assessment was conducted on 51 HFs and two directorates

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in seven selected regions and two city administrations with a general objective of determining NCoD
implementation status and major gaps to inform NCoD revision process. The major findings of the assessment
were: Nearly 40% of service units of a HF do not use NCoD to prepare the monthly disease report; Availability of
existing NCoD resources such as OPD/IPD registers, tally sheets, NCoD booklets, and access to National Health
Data Dictionary (NHDD) pocket mobile application was inadequate; health workers low competency on using
NCoD; missing diagnosis, erroneous use of parenthesis, redundant list of diagnosis and inconsistent NCoD ID/
code.

Civil registration and vital statistic is among the source of data for health sector. In this reporting fiscal year the
MoH in collaboration with vital events registration agency have conducted national level assessment on vital
events registration and identified major bottlenecks. To address the existing gaps and challenges the five years
strategic plan was developed and community level birth and death notification TOT was given to a tota1 of 121
participants from all region except Tigray and Somali to enhance community level birth and death notification.
In addition, verbal autopsy manual was drafted which will be finalized in the coming 2014 Ethiopian fiscal year.

CHIS implementation

AS part of continued effort to strengthen implementation of agrarian CHIS cascaded training was given to a
total number of xxxx HEWs (92% of available HEWs). At regional level Amhara, SNNP, Oromia, Harari Dire Dawa
and sidama have completed cascaded training while Benishangul have reached 37% training coverage. The
revised format was printed and distributed to 54% of health post with very wide regional variation: Dire Dawa
and Harari (100%), Oromia (95%), Sidama 91 %( only 3 of the format out of 7), Amhara (60%), SNNP (42%) and
Benishangul Gumuz only 9%. Currently the regions are on the printing process to fulfil the remaining CHIS
format using the budget transferred to them by MoH. Out of the total required 39,308 CHIS implementation
manual 2,377 were printed and distributed to region while the remaining 36,932 are on printing process.

A total of 15 towns have been selected for the implementation of urban CHIS and implementation start up
activities were also undertaken during HSTP I period. In 2013 EFY 103,847 community folders were printed
and 95,847 (92.3%) were distributed for all planned town except that of Tigray region for known security
reason. Except Benishangul Gumuz and Gambella region the rest of them have cascaded urban CHIS training
and printed the required format. About 50% of kebeles in 15 urban CHIS implementation town have started
reporting while 40% of them have categorized households based on demographic characteristic, disease
condition and income. Categorization helps urban family health team in providing targeted follow up and
home care support. Furthermore, 904 copy of urban CHIS implementation manual were distributed to region.

Pastoralist CHIS manual was revised and its final version was also translated to local language (Amharic,
Oromiffa, Somali language…). Printing of the revised pastoralist CHIS registers could not be finalized due to
lengthy printing process.

Transforming culture of data use practice

Performance monitoring team (PMT) remains one of the main platform for using data for action at all levels of
the health system. In these forums, the PMTs analyze performance data, detect gaps, identify root causes for
observed gaps, and develop actions to remedy them. To strength MoH level PMT TOR was prepared along with
calendar to further standardize the process.

Periodic feedback on data quality focused on completeness, timeliness, outlier and consistency of HMIS data
was among accomplished activity in 2013 EFY. A total of three rounds of feedback was given to each region
except Tigray. The representative service and disease monthly report completeness at national level was 93%
and 90% respectively while timeliness of the two monthly reports type was 68% and 70% respectively. There
are wide regional variation in both service and disease report completeness and timeliness as depicted in
below figure.

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Service Report Completeness and Timeliness by Region in 2013 EFY

100%
90% 85%
80% 73%
68% 68%
70% 61% 62% 64%
59% 57%
60%
Axis Title

50% 43%
40% 36% 34%
30%
20%
10%
0%
Dire Addis
Afar Amhara Oromiya Somali BG SNNP Sidama Gambella Harari National
Dawa Ababa
Report Completeness 84% 98% 96% 76% 65% 96% 98% 63% 99% 99% 97% 93%
Report Timeliness 61% 62% 68% 64% 36% 59% 73% 34% 85% 57% 43% 68%

Figure 44. Service Reporting completeness and timeliness, 2013 EFY

Disease Report Completeness and Timeliness by Region in 2013 EFY

100% 96%
91% 92%
90%
81%
77%
80%
70%
70% 66% 64% 62%
60% 57%

50% 45%
38%
40%
30%
20%
10%
0%
Dire Addis
Afar Amhara Oromiya Somali BG SNNP Sidama Gambella Harari National
Dawa Ababa
Report Completeness 86% 97% 94% 71% 67% 83% 89% 66% 91% 98% 96% 90%
Report Timeliness 66% 64% 81% 62% 45% 57% 77% 38% 91% 96% 92% 70%

Figure 45. Disease Reporting completeness and timeliness, 2013 EFY

In an effort to increase health managers and policy makers’ demand and use of routinely reported data through
DHIS2, MoH has sustained monthly and quarterly data analytics which was initiated during the 2012 EFY to
monitor progress of KPIs related to maternal and child health, quality of health service, communicable and
non-communicable diseases disaggregated by region. In 2013 First Quarter Data Analytic Report, Six-Month
Data Analytic Report, Nine-Month Data Analytic Report and Five monthly analytic reports for the months of
Tikimt, Tir, Yekatit, Miazia and Ginbot were produced and shared with MoH senior management and all regions.
Integrated data quality data use and DHIS2 training was provided to enhance the capacity of health worker at
all levels on DHIS2 utilization and data analysis for evidence generation from routinely collected data. More
than 70 million ETB was transferred to region to cascade the training.

Integrated supportive supervision (ISS) was conducted with the overall objective of monitoring the program
performance against HSTP II and identify performance gaps and challenges related with skill and supplies to
enable informed decision making. Important parameters of data quality and data use, including indicators for
verification, were included in the HIS section of the ISS checklist.

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The ISS covered all regions except Tigray, 11 zones, 25 woredas, 15 hospitals, 57 health centers, 96 health post,
and 125 households. According to the findings, most of the data use and data quality parameters showed
improvement. To mention some, 61% of the sites use an updated DHIS2 dashboard, 88% of health facilities
(HFs) have functioning PMTs, and 89.5% of the them conduct reporting consistency checks using LQAS.
Regarding the verification factor of recounted to reported values for skilled birth attendant indicator (N=73),
Penta3 (N=169) and TB detection (N=73) indicators, 92%, 78%, and 85% of the facilities, respectively, have a
verification factor between 0.9 - 1.1. The average (national level) verification factor for the three indicators
were 1, 0.96, and 0.97 respectively which indicates that verification factors for those indicators fall within the
acceptable range. The comprehensive ISS report was prepared and major finding was presented for MoH
Senior Management team.

The 22nd annual health sector review meeting was conducted in November 2020 with few people participation
in person considering COVID-19 situation. The events was live streamed which create an opportunity for other
stakeholders to attend the events virtually. During this event the HSTP II and 2013 core plan were presented
and discussed. The information product such as 2013 annual performance report, health and health related
indicators report and special bulletin was also shared with the participants. Additionally a number of program
specific review meeting has been conducted.

IR Model woreda Creation

In this reporting period, MoH has continued working with six universities (Addis Ababa University, Haramaya
University, Hawassa University, Jimma University, Mekelle University, and University of Gondar) in implementing
capacity building and mentorship program (CBMP) in a total of 225 sites (38 WoHOs, 181 HCs, and 36 hospitals)
of 36 woreda on implementation of IR model woreda creation approach. Remarkable progress was achieved in
terms of IR measurement tool parameter from the baseline. The proportion of model, candidate and emerging
sites was 1.4%, 20.7% and 77.9% respectively during baseline assessment on June 2018. The assessment result
of June 2021 shows that 62% of the sites are model and candidate constitute about 36%. A total of 8 woeda
(2 University of Gonder (UoG) supported, 3 Hawasa University (HU) supported and 3 Jimma University (JU)
supported) were reported reaching model status through self-assessment. Upon versification by MoH team
four of them (2 JU supported and 2 HU supported) were verified reaching model status.

Likewise encouraging IR progress was also reported from 8 IR learning woreda and 28 high case load IR
targeted hospital. The proportion of model health facilities in this woreda is increased to 56% from 0% during
baseline and proportion of emerging facilities have decreased to 7% from 59% of baseline. Out of 28 hospitals
the latest IR assessment result was reported from 23 of them which shows that all of them have reached high
level candidate status which can be improved to model status with little efforts. Overall in 2013 MoH have
scaled up IR model woreda creation to a total of 208 woreda in partnership with regional health bureau and
HIS implementing partner.

The RHBs and CBMP implementing University have recommended revision of IR assessment measurement
tool to further standardize it. To this end, the assessment tool for WoHos, Health center and Hospital were
revised using input from field level feedback and made it ready for implementation in 2014 EFY.

HIS governance

HIS governance is considered as a foundation for IR agenda implementation. At national level two HIS steering
committee meeting chaired my MoH higher official was conducted to monitor the overall progress of IR agenda
implementation. The committee gave direction to map partner working on HIS, finalization of different HIS
governance documents and proposed revision of the existing HIS governance framework.

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Accordingly the HIS governance framework was revised and 7 out of 12 region have customized the HIS
framework to their regional context. Regarding governance documents stage of development during the year,
national HIS governance framework and MFR governance protocol are finalized and endorsed. Likewise, the
final draft of 10 years digital health blue print, five year national HIS strategic plan (2020/21-2024/25) and data
access and sharing guideline were developed.

Operational and Basic Researches

CBMP has positively contributed in strengthening relationship between academics and actual implementation
practice. Evidence generation is among the area MoH has been working with CBMP Universities. Currently 12
operational research is been undertake by those University in collaboration with MoH and RHB. All of the 12
implementation researches received IRB approval and eight teams started conducting their research. In four
of the researches, baseline assessment is completed and an implementation strategy was introduced. In six of
the researches, baseline data analysis was completed and the implementation strategy is revised and ready
for implementation.

EPHI and AHRI are mandated with conducting basic and operational research to enhance evidence based
policy and strategy formulation. In 2013 EPHI had published a total of 37 research articles on peer reviewed
journal. A total of 45 study on COVID-19 was initiated out of which four are completed. The finding was used
to enhance evidence informed COVID-19 epidemic control and response measure. A unique clinical trial with
the objective of testing care for critically ill and moderately ill COVID-19 patient has been undertaken by EPHI.

Challenges

• Lengthy HMIS format printing process

• Shortage of budget to implement HIS related initiatives
• Inability to get IR self-assessment result timely
• The health workers attitude toward data capturing and using it before reporting did not reach the
desired level
• Low reporting rate from private health facilities except hospital

Way forward

• Strengthen coordination of the HIS activities of RHBs, CBMP Universities and HIS partners on
monitoring the progress of IR agenda
• Finalize revision process of HMIS indicators, data recording and reporting format as well as NCoD and
ensure their consistent implementation across region
• Finalize and endorse the HIS governance documents such as digitization blue print HIS strategic plan
etc and formally communicate with stakeholders
• Improve HMIS implementation at private health facilities

6.2. Use of Technology and Innovations/Digital health

The Digital Health Ecosystem Blueprint for Ethiopia

Cognizant of the inevitable digital revolution that has already started to happen in many countries over several
fields, the Ethiopian government has set an ambitious agenda of envisioning a “Digital Transformation for
Ethiopia’s Inclusive Prosperity by 2025”. In light of this umbrella initiative and based on global digital innovation
leaders’ assessment that the health sector would be the most likely sector to highly benefit from the digital
revolution, the Ministry of Health (MOH) of Ethiopia decided to proactively embrace digital solutions and services

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to catch up with the booming digital era. One significant measure taken in this regard is the preparation and
endorsement of the Digital Health Ecosystem Blueprint for Ethiopia (DHBp), the principal document – that is
meant to guide all actors in the health sector. The MOH has started to share experiences on this game-changer
decision, the inclusive approaches followed to come up with this massive mother document, “the early bird”
opportunities the health sector has unlocked, and the aspirations of the health sector for the coming decade
regarding digital health.

The EHR Standard Development

For long, the MOH was challenged to govern the demands of multiple vendors’ EMR/EHR systems. The
implementing parties, facilities and stakeholders also didn’t have reference for their EMR/EHR solutions
selection. This for long left MOH and its partners with ineffective EMR solutions that failed to respond to
the dynamic needs of the Ethiopia’s health sector. Cognizant of this, MOH with other key digital health
stakeholders has developed and endorsed a comprehensive national Electronic Health Record system (EHR)
Standards after a series of consultations and workshops. This standard will govern and assist all stakeholders
in selecting, developing/customizing and implementing individual patient health recording (public, private,
other government & non-government health facilities) systems in Ethiopia.

The HIS Maturity Assessment

Driven by the IR Agenda of the HSTP, the MoH is committed to install a strong digital health system at national
and sub-national levels. While a lot has happened over the last few years regarding the implementation of
different initiatives to strengthen HIS in the health system, the level of maturity of those systems has yet to
be measured from different information systems perspectives. Therefore, during the reporting period, MoH
conducted a national HIS Maturity Assessment to bridge the information gap, measuring the overarching HIS
maturity level based on the major domains and subdomains of the system.

This assessment was conducted with strong engagement of relevant stakeholders (MoH directorates, agencies,
universities, and strategic digital health partners) in two phases. First, a current status assessment and goal
setting meeting followed by the write-up of the future state and improvement roadmap setting workshop. The
current 2021 overarching HIS maturity level was measured based on the HIS Stages of Continuous Improvement
(SOCI). The goals and the roadmap for high-impact interventions were set for each subcomponent up to 2024.
In general, the workforce and data quality and use domains scored higher than the other domains, scoring
between 2.99 -3.27 (out of 5) and seem to be on the right track. However, the leadership and governance, ICT
infrastructure, and standards and interoperability scored the lowest, between 2.29 – 2.47 (out of 5), and were
identified as areas that need more concerted investment moving forward.

Ethiopia Digital Health Projects Inventory System

In the reporting period, MoH finalized the development and launching of the Ethiopian Digital Health
Projects Inventory System and its governance and operational documents to guide all stakeholders on the
operationalization of the inventory system. The inventory system will serve as an epicenter to conduct current
digital health landscape analysis, assess what activities have been done thus far and used as a clearing house
for the standards followed in a certain application. The registration and approval criteria are also documented
and communicated to all relevant stakeholders. Training manuals and end-user guides have been prepared
and shared with all relevant stakeholders, and the wider use of and compliance to the system will be ensured
in the years to come. Stakeholders have already started to use the application to register, certify and update
their systems.

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Master Facility registry (MFR) Improvement

This year, the MFR technical working group was revitalized with additional roles in the current reporting period.
This TWG conducted series of meetings to review the implementation status of the master facility registry and
recommend the way forward. MOH has closely worked with strategic partners on MFR project coordination,
implementation, identification of challenges, and documentation and amendment of software requirements
(both functional and nonfunctional). Driven by careful investigation of the existing system (Resource-Map),
MOH has improved the existing MFR by changing its backend in the bid to enhance data exchange and
interoperability with different digital health systems. After successive consultations, the technical team agreed
to follow HAPI FHIR-based implementation as a backend standard to represent health facilities and services,
and IHE-mCSD standards for facility data exchange and interoperability. Accordingly, an improved MFR was
developed, and system bugs were fixed. Currently rigorous user acceptance testing is underway to ensure that
the improved MFR is interoperable with different HIS.

In the reporting year, technical and financial support was provided to regional and city administration health
regulatory bodies to register health facilities on the MFR. Through close monitoring and follow up, so far 95%
of health facilities signature domain has been registered on the system. In addition, in order to address the lack
geospatial information on the MFR database, MOH with its key partners [Ministry of Information Technology,
Geospatial Information Institute & Central Statistical Agency] worked to reconcile facility data from multiple
sources and to create a harmonized single list of health facilities with geospatial data elements. Considering
the large number of health facilities in the country, to make the facility matching exercise manageable, public
facilities were prioritized in the first phase, followed by private and non-government owned ones in the second
phase. Currently, more than 80% of the facility geospatial data has been reconciled. MOH is still working with
the concerned stakeholders to get all geospatial information of the facilities.

Enhancing the Use of the Digital Health Innovation and Learning Center (DHILC)

The MOH has established a national Digital Health Innovation and Learning Center (DHILC) at St. Peter’s
Comprehensive Hospital to create collaborative problem solving, innovation, experimenting, and learning
space for different digital health systems. The Center has dedicated rooms for the digital health innovation,
digital health applications development and testing, capacity building, resource/knowledge management,
and client support (Call Center).

The Center is functioning in partnership with the Hospital and implementing partners to lead the realization
of innovation in data-driven health care by building and implementing interoperable HIS that are owned and
led by the government. It is currently serving as a resource for the MOH, hospital staff, and external partners
and offers accredited, advanced-level training. The DHILC immediately features a software development and
testing environment for different systems (example, eCHIS, iHRIS, EHR) and will serve as a clearinghouse for
any new digital health tools planned to be implemented in the health system. Furthermore, the DHILC is a
space where practitioners can seek and receive technical and professional support to help overcome any
health system implementation challenges. Based on the experiences of other countries, the Center is expected
to solve around 85% of minor health information system related challenges encountered by users.

Documentation of interoperability and messaging standard

The Ethiopian eHealth architecture envisions a holistic and harmonized exchange of data between and
among the participating components and HIS. To realize this feature MoH prepared the Interoperability and
Messaging Standards document in order to stipulate, compare, and adopt the globally known interoperability
and messaging standards to the Ethiopian eHealth context. In this process, a comparison matrix to compare
the use cases with similar global use cases were prepared and necessary messaging and interoperability use
cases were identified. Accordingly, the global Health Information Exchange (HIE) and underlined standards to
support the data exchange and interoperability implementation of the use cases.

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When finalized and endorsed by the MoH, this document will give clear direction on how to take the next step
towards eliciting interoperability and data exchange use cases within globally known and nationally endorsed
frameworks and standards. In addition, it supports in ensuring the implementation of the vision of the DHBp
and achieving the future state in which all different components and applications of the eHA could exchange
data seamlessly and securely.

eCHIS/DHIS2 data exchange pilot testing

The Ethiopian eHealth Architecture (eHA) provides an architectural solution to enable interoperability and data
exchange between point of service applications (e.g. eCHIS) and HMIS (e.g. DHIS2) through an interoperability
layer which is based on OpenHIM. The eCHIS/DHIS2 interoperability solution helps to automate the process of
data exchange between the two systems and make the work of HEWs to be directly and automatically synced.
This capability is expected to enhance the process of data collection and improve accuracy and timeliness of HP
data. To enable data exchange between these systems, the mediator service was developed as a component
of the eHA interoperability layer that utilized capabilities of eHA shared services (i.e. terminology management
service [TMS] and Master Facility Registry [FR]). The mediator used eCHIS’s MNCH module data elements for
the data exchange, as the other modules are not fully matured.

Having achieved a promising eCHIS/DHIS2 data exchange in the testing environment, MOH has identified
piloting sites for the actual data exchange from health facilities. Accordingly, two woredas (Alelitu and
Walmera) from Oromia region and one woreda (Dangla Zuria) from Amhara region were selected for this
purpose. Currently the MoH and partner team are working with the woredas and respective facilities, and have
started the piloting phase. In this process, the HEWs and supervising health centers in the woredas will be
closely monitored for their consistent use of the eCHIS tool for the available modules, and the MOH team
will follow up for an automatic data exchange between eCHIS and DHIS2 systems. The full-fledged eCHIS/
DHIS2 data exchange will be implemented in the production environment based on the lessons and areas of
improvements identified from the pilot test.

The eCHIS Implementation

Different programmatic modules of the eCHIS have been developed. The programmatic modules are
organized in to five releases for easier testing and rollout. The Release-1 of the eCHIS mobile application suite
which consists of the digital family folder, maternal health, family planning and immunizations module is
already developed and implemented in 6,320 agrarian health posts across seven regions (Amhara – 1,172,
Oromia – 2966, SNNP – 1,739, Sidama – 268, Harari 24, Diredawa 21, Tigray – 130). Benshangul Gumuz region
is expected to start the implementation in one woreda soon, with training already provided. To bootstrap the
implementation HEWs have focused on household registration. To that end, more than 2.8 million households
and more than 12 million household members have been registered. Though the implementation was a
success in terms of household profiling, it lacks on usage of actual health service delivery modules.

The Release-2, which comprises of Child health, Nutrition/GMP, has been developed and is currently being pilot
tested in two woredas. The Release-3 which includes TB and Malaria is also developed and being piloted in 10
woredas. The development of the Release-4 consisting of NTD, and Non-communicable Diseases is completed
and pilot testing is planned to start in the second quarter of the EFY. The Logistic Supply and Management
module which assists HEWs in managing essential drugs is planned to be developed and piloted in this EFY.

The customization of eCHIS to pastoralist setting is being completed, with pilot testing planned for the second
quarter. Scaling up of the agrarian edition to more health posts, increasing the usage of the available service
delivery modules, and expansion of eCHIS in pastoralist regions is planned for EFY14.

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DHIS2 Implementation

DHIS2 Academies: DHIS2, apart from its use as a standard HMIS tool across all health facilities and
administration levels in the Ethiopian Health sector, it has also been extended to other domains including
disease tracking and analysis, public health emergency management (PHEM) and COVID-19, KPI tracking,
multisector-based nutrition performance management, and other related initiatives. There have been several
capacity building activities performed at national, regional, and health facilities levels to enable data capturing,
reporting, and analysis using DHIS2. In light of this, MOH conducted two successful DHIS2 academies locally:
DHIS2 Analytics Academy and DHIS2 Design and Customization Academy in this reporting period. These
trainings were designed to have a trained pool of experts who have the necessary skills and expertise to carry
out the needed customization and related tasks in the years to come.

 A successful bilateral agreement (Memorandum of Understanding, MOU) was signed between the
MOH & University of Oslo to jointly work on advanced tasks of DHIS2, research and development,
demand-driven app development and customization support (like DHIS2 Customization, Apps
Development, and Data Use Academies). Joint planning between the two parties has already been
initiated. Currently MOH has prioritized the DHIS2 tasks in light of the current MOH’s HMIS indicator
revision & the envisaged version upgrade of DHIS2 (from the current v2.30 to v2.36, the most stable
recent version).

 Ongoing support to DHIS2 functionality which include increasing the HealthNet/VPN coverage,
connectivity monitoring, fixing issues and recovering offline versions, managing new and retiring
users, handling the dynamic organizational hierarchies (that includes facility creation and upgrades),
troubleshooting, and capacity building has been done. In addition to the HIS and HIT staff, the number
of program staff using the system continued to increase. The MOH team also supported importing
legacy data for the Oromia RHB and migration of 2007–2010EFY eHMIS data to DHIS2 in Amhara.
The DHIS2 TWG was revitalized and started reviewing issues that occur at all levels, identifying and
prioritizing new requirements, keeping track of data quality issues, and other DHIS2 related tasks.

National HealthNet/VPN:

So far, a total of 3,632 health facilities, agencies and administrative institutions are connected to the National
HealthNet VPN through an ADSL Modem, 3G Dongles and Tailored solutions. That means, nearly 78% health
institutions had active HealthNet connectivity of the expected 4,618 which have been given online access to
the national DHIS2 server, making the number of offline public users as low as 986. Moreover, efforts have been
made to connect more than 207 health posts through the Yazmi Satellite System. Further efforts are underway
with Ethio-Telecom to increase the number of connected sites and to enhance the bandwidth for the sites.
MOH also has deployed a standard connectivity monitoring tool to remotely follow up the National HealthNet
connectivity.

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6.3. Basic and Operational Researches

As part of Evidence generation Ethiopian Public Health Institute (EPHI) and Armauer Hansen Research Institute
(AHRI) have been conducted different clinical operational research during the fiscal year.

During 2013 EFY, EPHI generated and disseminated different research findings to support decision-makers, and
different stakeholders to make evidence-based decisions on key priority communicable & non-communicable
diseases, nutrition program evaluations, and the health system issues. About 75 peer reviewed research
published on scientific journals and this shows 29% increment from last year performance. Also, different
technical reports generated and shared to support routine program management, policy, and strategies
developments on nutrition (food fortification, chemical and functional properties, under nutrition reduction,
food based dietary, consumption levels of vegetables and fruits and vegetable oil fortification), Climate change
and air pollution, Biosafety and microbiology and WASH.

In 2013 EFY AHRI has contributed five policy briefs including Anopheles Stephens in Ethiopia findings for action,
Flow cytometry for the diagnosis of acute leukemia in Ethiopia, Look-see Neglected Tropical Diseases: Shout
for Podoconiasis, Detection of the exposure to malaria parasites as a viable means for malaria elimination:
Evidence from serological assay and development of SARS-CoV-2/COVID-19 Antibody Testing (SCAT) Kit. These
policy briefs were prepared from biomedical and clinical research to the Ministry of Health (MOH) aiming to
inform the potential policy implication of pieces of research evidence produced and the policy options with
pragmatic translation strategic approaches into population practice and standard laboratory procedures to
COVID-19 laboratories in Ethiopia.

In the same fiscal year, the institute has published 73 publications in scientific peer reviewed journals and
prepared one research digest which has been distributed. In addition, AHRI has established a center of
excellence in Integrated Knowledge Translation (IKT) in partnership with the Collaboration for Evidence-Based
Healthcare and Public Health (CEBHA+) for training on evidence to policy translation for health systems to
various stakeholders.

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 CHAPTER

PHARMACEUTICALS AND
MEDICAL SUPPLIES
ANNUAL PERFORMANCE REPORT

CHAPTER 7: PHARMACEUTICALS AND

MEDICAL SUPPLIES

In this section, summary of major activities and achievements in pharmaceuticals supply management,
medical equipment management and pharmacy services.

7.1. Pharmaceuticals supply

T
his section summarizes major achievements in the areas of pharmaceuticals supply chain
management. It aims at improving the continuous availability of pharmaceuticals at an affordable
price in a sustainable manner. The Ethiopian Pharmaceuticals and Supply Agency (EPSA)
implemented different strategies such as cyclical procurement, category management system,
framework agreement, to improve pharmaceuticals forecasting, quantification, procurement and contract
management. With this regard, in EFY 2013, the availability of vital and essential pharmaceuticals at national
level was 85% and 83% respectively.

EPSA has procured a total amount of ETB 17.01 Billion worth of pharmaceuticals and medical supplies in 2013
EFY. The amount of pharmaceuticals and medical supplies procured in the last five years has consistently
increased from ETB 4.5 Billion to 17.01 Billion in 2013 EFY (figure below).

Pharmaceuticals procured amount, in Billion Birr

18 17.01
16
14.14
14 13.23

12
10.11
10
8
6 4.8
4
2
0
2009 EFY 2010 EFY 2011 EFY 2012 EFY 2013 EFY

Figure 46. Trend of pharmaceuticals procured, amount in Billion Birr (2009 EFY to 2013 EFY)

Regarding distribution of pharmaceuticals, EPSA has distributed pharmaceuticals and medical supplies worth
of ETB 27.6 Billion to health facilities (ETB 4.2 Billion Revolving Drug Fund (RDF) and 23.4 Billion worth of health
program). Trend of pharmaceuticals and medical supplies distributed in the last five years shows that it has
increased consistently over the years as shown in the figure below.

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Pharmaceuticals distribution trend of five year

2009 2010 2011 2012 2013

13.36 Billion 16.22Billion 17.02 Billion 18.03 Billion 27.61 Billion

Pharmaceuticals Distribution has increased over the past five years

Figure 47. Trend of pharmaceuticals distributed, amount in Birr (200 EFY-2013 EFY)

In order to improve the availability of pharmaceuticals at health facility level, the MOH, EPSA and RHBs in
collaboration with partners implemented quick-win initiative. The quick-win initiative is a platform that
increases regular communication, information exchange and stock redistribution among EPSA warehouses
and health facilities. With this regard, Fill-ifs initiative training was provided to staffs of 113 hospitals. The
quick-win initiative increased availability of all pharmaceuticals at hospitals and minimize the stock difference
among central warehouses, hubs and health facilities.

By implementing framework agreement and strengthening placement strategy, EPSA was able to minimize
interruption in availability of supplies and reagents. Using framework agreement, 276 health facilities were
equipped with medical equipment, supplies and reagents were supplied regularly during the fiscal year.

The annual inventory turnover rate of pharmaceuticals and medical supplies at the warehouses was 1.15%,
which indicates that stocks are at least revolved more than one time in the budget year. The wastage rate of
pharmaceuticals and medical supplies in the pharmaceuticals supply chain system was 2.32% in 2013 EFY.

In 2013 EFY, customer and stakeholder satisfaction surveys were conducted and the findings showed that the
satisfaction levels as 67.8% and 72.5% respectively. Local pharmaceuticals manufacturing gap assessment
was studied in collaboration with the manufacturers’ union and other stakeholders and implementations
of interventions has been started to improve their performance. Pharmaceuticals suppliers’ performance
assessment was also conducted and presented to suppliers in a conference. Directions were given in that
suppliers will be notified their performance results periodically and the results of the evaluation will be
considered as an input for procurement decisions of the Agency.

By an eased clearance process and lean operation, EPSA has saved about birr 58.3 million that would be paid
if operated in the previous way of inefficiencies and wastefulness. This was achieved by implementing “Zero
Demurrage” initiative. This has big potential in reduction of unit cost of medicine.

EPSA developed and implemented different soft-wares which include web based Lambadina application for
its fleet management, electronic fixed asset information management system and SMILER for data capturing,
analyzing and interpreting tools for evidence-based decision.

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7.2. Medical equipment and Pharmaceutical Services

Auditable Pharmaceutical and Transaction Service (APTS)

As per Ministry of health plan to implement APTS in 80 health facilities in 2013 fiscal year, a financial support
of 264,891.00 USD was provided to regional health bureaus. In addition to financial support, the Ministry has
provided on-site technical support on pre-initiation, training, initiation and post implementation activities to
the health facilities. Accordingly, the system was initiated in 107 health facilities, which is more than a 100%
achievement against the annual target. This adds up with the 217 health facilities that implemented APTS
before the current fiscal year to give a cumulative number 324 number of health facilities.

Medical Equipment Maintenance

Data was collected on 30,500 Medical equipment on the assessment conducted in 198 hospitals to assess their
functionality status. Accordingly, medical equipment that are functional and non-functional were identified.
Based on the assessment findings, an installation and maintenance campaign was undertaken in which 32
medical equipment importers and partner organizations were engaged and different spare parts used for
installation and maintenance.

Figure 48. Medical Equipment Installation and maintenance campaign

With rigorous collaboration and coordination with RHBs and other key stakeholders, totally 9,045 medical
devices are maintained and made functional and 4,092 medical devices are installed and made ready for
service in the fiscal year. Through the campaign, more than 960 million USD worth of resource was able to
be saved. In addition to maintenance repairs, necessary spare parts have been identified for 1,468 medical
equipment and procurement process has been initiated.

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NUMBER OF MEDICAL EQUIPEMENT MAINTAINED

Campaign Routine Total

9045
7989

1056

Figure 49. Number of Medical Equipment Maintained in 2013 EFY

NUMBER OF MEDICAL EQUIPEMENT INSTALLED

Number of Medical Equipment Installed

4092

2590

1502

Campaign Routine Total

Figure 50. Number of Medical Equipment installed in 2013 EFY

Medical Equipment Distribution

During the fiscal year, a total of 41.7 million USD worth medical equipment was distributed to strengthen
COVID response, to initiate new services and to equip health facilities. Health post and health center kits, spare
parts, ambulance medical equipment, mechanical ventilator, oxygen cylinder, mobile x-ray, ICU package, and
ECG Machine are among the distributed supplies.

Digitalizing Pharmaceutical and Medical equipment Management

Medical Equipment Management Information System implementation was among the major initiatives that
is used to manage the procurement, installation, maintenance, and inventory of medical equipment in health
facilities and which has crucial role in establishing standardized and uniform medical equipment management
system. In 2013 EFY, the Ministry has planned to implement the system in 75 health facilities and enable to
initiate it in more than 100 health facilities.

On the other hand, different capacity building and technical supports were carried out in collaboration with
key stakeholders to revitalize and implement a web-based DAGU in health facilities. Data synchronization and
data visibility dashboard was designed and launched to hospital managers. After testing the dashboard in
selected health facilities, 50 facilities have utilized and to improved health commodity data exchange with
Ethiopian Pharmaceutical supply agency (PFSA).

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Antimicrobial resistant (AMR) prevention and containment

Several activities were performed to strengthen the antimicrobial resistance prevention and containment
nationally including the revision of National Antimicrobial resistance (AMR) prevention and containment
strategy. Awareness creation on AMR prevention and containment was provided to the public through radio
and television. Besides, as part of institutionalizing AMR prevention and containment activities, in 2013 fiscal
year more than 30 health facilities have initiated the antimicrobial stewardship program (ASP). This adds up
with the 30 health facilities that implemented ASP before the current fiscal year to give a cumulative number
of 60 health facilities.

COVID-19 and Emergency activities

Various supports and facilitations were conducted for natural and man-made disasters response. A total of
50.2 million USD worth of pharmaceuticals used for COVID-19 prevention and control were facilitated to be
imported in duty-free. Total Cost of 4.3 million USD worth pharmaceuticals were distributed to regions and
health facilities for law enforcement campaign. Moreover, more than 739,000 USD cost of emergency and ICU
pharmaceuticals were distributed for potential risks associated with elections.

Other activities

 Acetic acid solution preparation for visual inspection of cervical cancer was initiated at health facilities’
compounding pharmacy by adopting standard operating procedure and providing theoretical and
practical orientation to health facilities and RHBs, which enables to improve the screening performance
and quality of the diagnostic chemical.
 Activities to improve the monitoring and evaluation of pharmacy service, pharmaceutical supply chain
management, medical equipment management through capacity building works and strengthening
report and feedback system were undertaken
 The revision of national standard treatment guideline (STG) was finalized
 National traditional medicine management guideline was finalized. This is expected to clear
stakeholders’ engagement and facilitate their communication in standardizing the traditional
medicine practice. Based on the guideline, training materials was developed and training was provided
to stakeholders (including traditional healers). In addition, traditional medicine strategy was drafted
 National essential medical supplies list was prepared
 The development of quantification tool, which enables to undertake 2015 EFY pharmaceuticals
quantification exercise by all federal and regional hospitals, which in turn used to standardized
quantification and improve forecast accuracy
 Various capacity building was provided for pharmacy and biomedical engineering professionals of
health facilities and RHBs on warehouse and inventory management, reverse logistic, ART pharmacy
service, AMR and DAGU-2
 To improve maintenances capacity, skill based training on MCH, OR and laboratory equipment have
been provided to all federal and regional health bureaus biomedical engineers/technicians

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Challenges

 Poor preparation of sites for installation of medical equipment by health facilities

 COVID-19 related logistic activities affect the routine activities
 Interruption of DAGU-2 compromises the pharmaceutical management system in health facilities
 Low budget allocation by RHBs to improve the pharmaceutical and medical equipment management
system

Way forward

 Allocating sufficient budget for the maintenance campaign and strengthening site preparedness
follow up for medical equipment installation.
 Providing appropriate support for antimicrobial resistance (AMR) prevention and containment and
improving traditional medicine practice
 Advancing warehouse and inventory management system in health facilities
 Strengthening web-based eAPTS, DAGU and MEMIS implementation at all levels

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 CHAPTER

HEALTH FINANCING
 MINISTRY OF HEALTH

CHAPTER 8: HEALTH FINANCING

8.1. Resource Mobilization and utilization

Transformation in health financing is one of the five transformation agendas/priorities identified in the second
Health Sector Transformation Plan (HSTP-II). Its major focuses include proactive mobilization of adequate
resources from domestic and international sources, performing resource allocation and prioritization of health
systems for efficient use of resources, strengthening bilateral partnership and implementing public-private
partnership to meet the national and global commitments. The HSTP-II has undergone interventional costing,
resource mapping and financial space analysis of resources for its implementation. The analysis showed that
there is a 28% budget gas based on the base case scenario costing. Mobilizing adequate resources, improving
efficiency, and implementing different innovative financing strategies are some of the strategies recommended
to fill the financing gap of HSTP-II.

In this section, the major activities and achievements regarding resource mobilization and utilization that are
performed in the first year of HSTP-II implementation are described.

1. Health care financing reform implementation

The Government of Ethiopia approved a health financing reform strategy in 1998 EC that aimed to raise
additional resource for the health sector, enhance efficient allocation and utilization of resources, improve
quality and coverage of health service delivery and ensure the sustainability of the health financing system.
The reform began with what is now referred to as “first generation” reforms, which includes the following major
components: (i) Revenue retention and utilization (RRU); (ii) Institutionalization of health facility governance
system; (iii) User fee setting and revision; (iv) Outsourcing of non-clinical services at public hospitals; (v)
Establishing and operationalizing private wings at public hospitals; (vi) Systematizing the fee-waiver system;
and (vii) standardizing the package of exemption services. The major activities and achievements of the health
care financing reform in 2013 EFY are as follows:

- Health Care financing reform components have been implemented at 96% of health centres and 99%
of public hospitals. These health facilities have established a governing board that includes members
from the community, they have their own autonomy for their operation and being managed through
their respective governing boards
- Almost all health centres and hospitals that are implementing health care financing reform components
have been retaining and utilizing their internal revenue (RRU). Retaining and utilizing internal revenue
has become an important source of health facility operational budgets to improve the quality of health
services
- Exempted health service and fee waiver system are implemented at public health facilities to ensure
equity of health services and enable the poor to access health services without incurring a cost at
the time of seeking health care. In 2013 EFY, more than 22 million ETH Birr was reimbursed to health
facilities (for both exempted and fee waiver services provided).
- At the end of 2013 EFY, 135 hospitals were outsourcing one or more of the non-clinical services and 83
hospitals had established and operationalized private wings
- User fees are currently expected to reflect the cost of delivering services as well as the ability and
willingness to pay of the service users. User fee setting, and revision exercise is based on the cost-
sharing policy of the government. Some regions have exercised user fee setting and revision done at
some hospitals and health centres. User fee for federal and university hospitals was set and revised
and endorsed by the Council of Ministers and published on Federal Negarit Gazette, regulation No
477/2021

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- Institutionalizing first generation health care financing reforms: Since the HCF strategy has been
implemented for long, the reform components have matured and progressed well. Thus, the Ministry
of Health (MoH) initiated to institutionalize the first-generation health care financing reforms at seven
regional health bureaus, namely, Amhara, Oromia, SNNP, Tigray, Diredewa, Harari and Addis Ababa
City Administration. To facilitate the transition and institutionalization process, MOH has developed
an action plan for institutionalization of the first-generation reform and shared to the regional health
Bureaus. Based on the action plan the following key activities were carried out:

o Establishment of Organizational structure: A prototype organizational structure

is developed, roles and responsibilities for each position is defined and monitored the
customization and endorsement of the structures at regional level.
o Revision of HCF legal framework and implementation manuals: A prototype health care
financing implementation manual is developed and shared to regions. RHBs started to revise
their regulation, proclamation, directive and implementation manuals based on their gaps
and needs
o Preparation of training manuals: a standardized prototype comprehensive HCF training
materials such as Health Facility Governing Body (HFGB), Health Facility Management
Committee (HFMC) and Health Facility Finance Staff (HFFS) were developed
o Capacity building activities: Facilitation skill training was provided for master trainers

2. PUBLIC PRIVATE PARTNERSHIP IN HEALTH (PPP)

Enhancing private engagement in health is one of the fourteen strategic directions of HSTP-II. To enhance private
engagement in health, one of the engagement platforms is creating a partnership between the public and
private sectors. The PPP proclamation states that the objective of PPP is to improve the quality of public health
services by creating a favourable framework for promoting and facilitating the implementation of privately
financed projects. The Ministry of Health has established PPP team under the Partnership and Cooperation
Directorate (PCD), which is responsible for coordinating the overall implementation of PPP project initiation,
appraisal, implementation, and evaluation. At a federal government level, there is a conducive environment
for the implementation of PPP as there is public private partnership policy and strategic framework including
proclamation, directive, and guideline. The Ministry of health is also developing operational manual on PPP.

In collaboration with the Ministry of Finance and stakeholders, the PPP team at PCD has conducted feasibility
study of Medical Gas Plant Placement and Diagnostic services (laboratory, Pathology, and Imaging services).
In addition, pre-feasibility study on oncology service was conducted and the findings of the studies were
submitted to Ministry of Finance for technical review. These projects were presented for the PPP board for
approval and the Ministry succeeded in registering the projects as pipeline.

In 2013 EFY, the PPP team at PCD has participated in series of capacity building activities and all the team
members are currently certified in public private partnership professionals. This is a prerequisite for the
contracting authority to design and implement PPP projects.

3. Civil Society Organizations (CSO) Coordination

In the budget year, 40 new project proposals were appraised, all of which (100%) were endorsed for
implementation as they were found to comply with the minimum requirement of MOH. On the other hand, a
mid-term evaluation was conducted for six organizations and the findings of the evaluation was distributed to
the concerned bodies. Two rounds of partnership forums were conducted in the fiscal year.

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4. COVID-19 Pandemic Response Resource Mobilization in 2013EFY

Ministry of Health in collaboration with development partners has been working in the COVID-19 pandemic
responses. In order to respond it effectively, the MOH has mobilized and allocated resources (in kind and
in cash) from the government, development partners, CSO and Private sectors locally and internationally
through proactive resource mobilization. Totally, 411,627,213 USD was mobilized from development partners
(207,544,678US$), Ministry of Finance (86,952,524 US$) and other sources (117,180,011 US$).

Development Partners’ Contribution to the health sector

The government of Ethiopia allocates budget for the health sector, but additional financing is required as the
allocation from the government treasury is not adequate. Development partners contribute to the financing of
the health sector through different financing channels. In 2013 EFY, a total amount of 473,449,951.95 USD was
committed from development partners (DPs) and a total amount of 388,255,856.43 USD (82%) was disbursed.

Regarding SDG performance fund, 87,176,789.92 USD (22.4%) of the total disbursed budget from DPs was
disbursed via the SDG performance fund. The major contributors of SDG performance fund were FCDO (57%)
followed by GAVI (12%) and EKN (12%).

Table 25. Amount of fund committed and disbursed by development partners, 2013 EFY

Commitment (in Disbursement in Percentage of

S.N Source of Fund
USD) in 2013 EFY USD in 2013 EFY Disbursement

1 SDG Performance Fund      

  FCDO 24,676,506.71 49,782,848.00 202%
  EKN 10,725,067.07 10,621,960.00 99%
  Irish Aid 5,824,000.00 6,182,790.92 106%
  Spanish 1,082,939.02 1,170,800.00 108%
  UNICEF 500,000.00 500,000.00 100%
  UNFPA 50,000.00 50,000.00 100%
  WHO 50,000.00 50,000.00 100%
  Italian Coop SDG PF 5,600,000.00 6,064,409.00 108%
  GAVI 8,271,646.00 10,378,982.00 125%
  WB 36,230,000.00 1,875,000.00 5%
  KOICA 500,000.00 500,000.00 100%
  Total SDG performance Fund 93,510,158.80 87,176,789.92 93%
2 Bilateral Partners      
  CDC-Atlanta 3,000,000.00 2,900,000.00 97%
  Afr CDC -WB 40,000,000.00 11,453,574.43 29%
  COVID-19 Emergency Response - WB 117,940,175.00 101,520,827.62 86%
  EU 2,537,227.56 0 0%
Italian Cooperation (for Developing
  2,816,000.00 1,500,000.00 53%
Regions)
  Total bilateral partners 166,293,402.56 117,374,402.05 71%

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3 UN Organizations      
  UNICEF 9,766,133.00 9,284,879.00 95%
  UNFPA 5,868,854.00 5,842,686.99 100%
  WHO 8,368,418.00 4,347,671.64 52%
  Total UN organizations 24,003,405.00 19,475,237.63 81%
4 Global Fund (GF)      
  GF-Malaria 24,586,158.81 12,167,384.00 49%
  GF-TB 19,894,538.84 8,637,921.00 43%
  GF-HSS 21,250,766.16 11,506,627.00 54%
  GF-HAPCO 80,091,299.00 79,992,392.00 100%
  Total GF 145,822,762.81 112,304,324.00 77%
5 GAVI      
  GAVI-DATA QUALITY 2,445,934.00 2,262,288.85 92%
  GAVI-HSS 23,500,000.00 23,500,000.00 100%
  GAVI-PRI 3,500,000.00 0 0%
  Total GAVI 29,445,934.00 25,762,288.85 87%
6 Foundation      
CIFF(SURE, Deworming, Gashero, SCI,O.
  9,586,213.30 8,432,708.44 88%
Sight&End Fund)
  BUFFET 3,000,000.00 15,719,946.00 524%
  IPF 527,000.00 475,890.52 90%
  One Wash 222,281.30 47,326.50 21%
  Sekota Declaration 1,038,794.18 1,486,942.52 143%
  Total (Foundations) 14,374,288.78 26,162,813.98 182%

  Grand Total 473,449,951.95 388,255,856.43 82%

8.2. Public Budget allocation

Percentage share of government health budget from the total government budget

The federal government of Ethiopia allocates an annual budget to regions and city administrations to support
the implementation of health programs. The 2001 Abuja declaration urges African Union states to allocate
at least 15% of the total government budget to the health sector. In 2013 EFY, 13.2 % of the total government
budget was allocated to health, which is better than last year (which was 12%). Regions that allocated at least
15% of their budget to health include Gambella (19.5%), Harari (16%) and Sidama (15.4%). The other regions
have allocated less than 15% of their total government budget to health. The lowest share of government
budget to health was allocated in Addis Ababa city administration, with only 2% of the total government
budget allocated to health. Compared to the previous fiscal year (2012 EFY), three regions have reduced the
percentage share in 2013 EFY. These regions are Amhara, Benishangul Gumuz and SNNPR.

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Table 26. Share of Total health budget (%) from total government budget in 2013 EFY

Share of Total health budget (%) from total government budget

Region
2012 EFY 2013 EFY
Tigray 10% 10.4%
Afar 13% 13.9%
Amhara 15% 12.7%
Oromiya 13% 14.5%
Somali 11% 14.4%
Benshangul Gumuz 15% 14.3%
SNNP 17% 14.8%
Sidama  NA 15.4%
Gambella 14% 19.5%
Harari 10% 16.0%
Dire dawa 12% 12.6%
Addis Ababa 6% 7.0%
Total 12% 13.2%

Financial Management and utilization

The sector has been financed from both government and donors. MOH have been working to ensure the
appropriate and efficient utilization of resources in compliance with the Ethiopian government’s financial
and other resources administration rules and regulations. Grant budgets from different donors have been
transferred to regional health bureaus for different health programs and projects. In 2013EFY more than 3.6
Billion ETB budget from different grants was transferred to regions, from which 48% of it was liquidated.
For a grant that was transferred to regions in the last two years (Hamle 2011EFY to Sene 2013EFY), 65% was
liquidated. This shows that there is a challenge in utilizing and liquidating grant budget timely, which calls for
a stronger grant management system to improve timely utilization and liquidation of grant budget.

Integrated Financial Management Information System (IFMIS) implementation

Integrated Financial Management Information System (IFMIS) has been implemented since 2006 EFY.
Taking lessons from the pilot implementation, the ministry has expanded the use of the IFMIS system to the
management of grants, and expanded to federal hospitals and MOH agencies. In 2013 EFY, Monthly, quarterly
and annual reports have been prepared and submitted to the Ministry of Finance with the IFMIS system

8.3. Health Insurance

One of the objectives of the second health sector transformation plan (HSTP-II) is accelerating progress towards
universal health coverage (UHC). Achieving UHC requires improvement in service accessibility, utilization and
financial risk protection. In order to avoid financial barriers for health care and protect people from financial
risk, Ethiopia has been implementing various health financing strategies, including implementation of health
insurance system. Community Based Health Insurance System (CBHI) is one of the mechanisms that has
been implemented to improve health financing in the health sector. The Ethiopian Health Insurance Agency
(EHIA), one of the seven agencies of the MOH, is responsible for the planning, implementation, monitoring
and evaluation of health insurance program in Ethiopia. The Ethiopian Health Insurance Agency has been
implementing CBHI related initiatives mainly focusing on four objectives: Expansion of CBHI services, improving
equitable and quality service utilization, improving mobilization of financial resources for health insurance

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services and capacity building to implement health insurance services. In this section, the implementation
status of the community based health insurance system and its major achievements are discussed.

Expansion of Community Based Health Insurance Program

Community based Health Insurance was started in 2004 EFY as a pilot in some selected Woredas and its
implementation has then been expanded to cover many Woredas and households at the end of 2013 EFY. At
the end of 2013 EFY, 834 Woredas in Ethiopia have started CBHI scheme and health services using CBHI. From
the total 834 Woredas providing CBHI service in 2013 EFY, about 100 of them have started the service in the
fiscal year.

Table 27. Number of Woredas that started CBHI implementation and services, 2013 EFY

Number of Woredas that have start-

 Region Remark
ed providing health care via CBHI
There is no status report in 2013 EFY
Tigray - from Tigray ( At the end of 2012 EFY,
36 Woredas already started CBHI)
Afar 3
Amhara 178
Oromia 325
Somali 1
Benishangul-Gumuz 3
SNNPR 160
Sidama 31
Gambella 3
Harari 9
Dire Dawa 1
Addis Ababa 120
Total 834 This doesn’t include Tigray region

Membership status and CBHI fee Collection

In the 834 Woredas where health care service provision with CBHI is started (excluding Tigray region), 8,700,359
(61%) of the total eligible households were enrolled into the CBHI program. From the total 8,700,359 household
members, 7,038,647 (81%) were paying members and 1,661,712 (19%) were indigents that received subsidy
from the government. Household membership in 2013 EFY has increased from 49% in 2012 EFY to 61% in 2013
EFY.

Regarding fee collection, more than 2.02 billion ETB was collected from paying members, from which 1.86
billion ETB (92%) was deposited to bank. For indigent members, 147,086,643 subsidy was expected to be paid
to Woredas but 137,533,737 ETB (94%) was paid.

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Table 28. CBHI membership and fee collection in Woredas that have started CBHI service, 2013 EFY

No. of Woredas that Member households (No. of households

have started provid-  
Region enrolled to CBHI)
ing health care via Enrollment rate
CBHI Paying members Indigents Total
Tigray  -  - -  - - 
Afar 3 6,782 2,370 9,152 40%
Amhara 178 2,154,903 508,220 2,663,123 67%
Oromia 325 3,499,964 774,585 4,274,549 61%
Somali 1 9,930 5,655 15,585 31%
Ben. Gumuz 3 13,095 3,394 16,489 40%
SNNPR 160 1,065,394 227,497 1,292,891 57%
Sidama 31 94,370 48,710 143,080 33%
Gambella 3 10,083 1,963 12,046 43%
Harari 9 19,043 7,353 26,396 55%
Dire Dawa 1 12,206 9,208 21,414 46%
Addis Ababa 120 152,877 72,757 225,634 76%
Total (excluding Tigray) 834 7,038,647 1,661,712 8,700,359 61%

Other major Insurance related activities and achievements in 2013 EFY

- In 2013 EFY, conducting audit was expected in 642 Woredas, but audit was conducted in 539 Woredas
(84%). The other Woredas are on the process of auditing.

- Regarding CBHI ID card distribution, 88% of new household members in new and existing CBHI Woredas
were provided CBHI identification card.

- In the fiscal year, 830,533,836 ETB was reimbursed to health facilities that provide health services to CBHI
members. From the total pay, 53% was reimbursed to health centers, 36% was to hospitals, 5.4% to third
party insurance and 5.6% for other payment

- The average pay per CBHI member was 29 birr per person at health centers and 116.55 birr per person at
hospitals

- A readiness assessment was conducted in 312 health facilities in 2013 EFY. The plan was to conduct the
assessment in 400 health facilities.

- Capacity building trainings were provided to health extension workers, kebele management members,
CBHI staff, health workers and other individuals

- A 10 years strategic plan preparation is in the final stages. It will soon be completed

- Monitoring and evaluation manual is prepared and a training is provided to regional health bureau staff

- The preparation of the following documents is completed: Medical audit manual, CBHI communication
strategy, third party insurance agreement manual, CBHI members compliant handling management
system and other documents

- Social mobilization and awareness creation activities were performed through social media, workshops,
meetings, trainings, media and other mechanisms

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Challenges

- CBHI proclamation is submitted for approval but not yet approved

- Lack of adequate human resource and structure
- Lack of comprehensive health services in some health facilities
- Shortage of medicines in health facilities and referral of CBHI members to private health facilities
- Shortage of medicine at health facilities that affect the quality of care to CBHI members
- COVID-19 has created a challenge in social mobilization and other CBHI services
- In some Woredas, the amount of CBHI resource collected is low and does not cover payment to health
services provided
- Shortage of budget to cover CBHI payment to in some Woredas

Way forward

- Follow the approval process of CBHI proclamation

- Preparation to initiate social health insurance system for the formal sector employees
- Digitalize CBHI information system
- Conduct social mobilization and awareness creation activities
- Strengthen resource mobilization activities
- Expand CBHI implementation by starting the scheme in new Woredas
- Take appropriate actions based on CBHI audit findings

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PUBLIC HEALTH EMERGENCY

PREPAREDNESS AND RESPONSE
ANNUAL PERFORMANCE REPORT

CHAPTER 9: PUBLIC HEALTH EMERGENCY

PREPAREDNESS AND RESPONSE

T
he global health system has been challenged due to different disease outbreaks, man-made and
natural disasters which predominantly affect the health systems. Thus, to respond to a crisis,
be it a disease outbreak or other disruption resulting in a surge in demand for health care, both a
vigorous public health response and a highly proactive and functioning health-care delivery system
are required. The Ethiopian public health institute (EPHI) has been implementing public health emergency
activities intensively in response to the increasing public health crisis. Public Health Emergency Management
(PHEM) aims to improve how the health system deals with existing and evolving disease epidemics, as well as
natural disasters of national and international concern. It is designed to ensure rapid detection of any public
health threats, preparedness related to logistic and fund administration, and prompt response to and recovery
from various public health emergencies. 

In 2013 EFY, the Ethiopian health system was challenged by different types of public health emergencies,
including the COVID-19 pandemic. This section of the report summarizes major activities related to public
health emergency management in 2013 EFY, which include epidemic prevention and response and responses
to conflict areas.

9.1. Epidemic Prevention and Control

During 2013 EFY, about 348 public health alerts were reported and 93% of those alerts were confirmed within
48 hours. About 324 (93%) of them were outbreaks, and the remaining were other public health rumors. Of
those public alerts, 40% were for acute watery diarrhea (40%), Guinea worms (20%) and the remaining were
for Arbovirus and common cold-related diseases.

About 91% of disease alerts and unusual public health events were crosschecked at points of rumors using
public health experts in the health system. The details of each disease are described below.

1. Anthrax

In 2013 EFY, 152 anthrax cases were reported from Gamo zone (SNNPR), but with no death report. The
timeline of anthrax cases in Gamo Zone is described in the figure below.

Figure 51. Anthrax outbreak cases in Arbaminch town, SNNPR, May-June 2021

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2. Suspected Cholera

In 2013 EFY, 8,495 cases and 96 deaths from suspected cholera were reported from Oromia, Sidama, Gambella,
and SNNP regions (see figure below). Since April 2019, a cumulative of 19,844 cases (124.3 people per 100,000)
and 327 deaths (with a case fatality rate/CFR of 1.6%) have been reported across the country from the beginning
of the outbreak. There has been no recent active cholera outbreak in the last two months.

To control the outbreak, the government has implemented disease surveillance activities such as early case
detection, case management, and the prepositioning of medical and laboratory supplies. About 1,632,461
population groups with 97.3% coverage were vaccinated in targeted woredas in Oromia, SNNP, Gambella,
Sidama, and Somali regions.

Table 29. Regional distribution of suspected Cholera cases, deaths and CFR in Ethiopia, 2013 EFY

Region No. of affected Woredas No. of Cases No. of deaths CFR (%)
AA 12 18 0 0.0
Afar 6 365 2 0.5
Harari 2 15 0 0.0
Oromia 25 1177 13 1.8
SNNPR 19 5303 53 1.7
Somali 10 1609 28 1.7
Tigray 5 8 0 0.0
Total 79 8495 96 1.6

3. Acute flaccid paralysis/Polio

In 2013 EFY and previous years, a cumulative of 67 (60 circulating and 3 VDPV2) cases were reported. The last
case was reported on March 16, 2020 in the SNNPR region, Hadiya zone. As part of the response, 8,216,768
children were vaccinated with a first dose and 8,660,434 eligible children were vaccinated with a second round
vaccine. All used and unused MOPV2 vials have been retrieved and destroyed to replace it with nOPV2.

Table 30. Total number of children vaccinated in response to polio outbreaks

Response Target Round # Vaccinated Cov.(%)

R1 6,966,751 103%
Response 1 6,746434
R2 7,364,457 109%
R1 1,250,017 94%
Response 2 1,333,280
R2 1,295,977 97

4. Measles

A total of 730 cases and 13 deaths of measles were reported in 22 woredas of five regions in 2013 EFY (figure XX).
The measles outbreak was reported from Amhara, Somali, SNNPR, Oromia, and Harari regions.

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Measele outbreaks by Epi.Weeks

150

100
# of Cases

95 Suspected
Confirmed
61 56 65
50 48 44 41
29 30 31
17 22 15 19
0 2 4 7 7 6 9 6 1 0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Epi.Weeks
Figure 52. Measles outbreaks in Ethiopia, by Epi Weeks: Week 01-24, 2021

Most of the measles outbreaks were managed with response through enhancement of the surveillance
system, reinforcing the routine immunization, case management including supplementary immunization
activities (SIAs), and advocacy, social mobilization, and community engagement. Measles outbreak SIAs were
conducted in 16 kebeles in the Karat and Segen zones and a total of 19,396 children were vaccinated.

Table 31. Measles Outbreak Response from 2017 to 2021

Indicators Target 2017 2018 2019 2020 2021

Annualized rate of investigation of sus-
>=2 4.8 3.6 3.1 2.9 4.7
pected measles cases per 100,000
Non-Measles Febrile Rash Rate >=2 2.3 1.9 2.4 3.2 1.2
Proportion of Woredas with ≥1 case per
>=80 76 63 69 70 80
100,000 with a blood specimen (%)
Proportion of reported measles cases with
>=80 42 100 100 100 96.9
blood specimen (%)

Proportion of measles IgM+ (%) <10 49 40 18 13.2 25

5. Dengue fever

Dengue fever outbreak declared in the dire Dawa city in August 2020 and bout 577 dengue fever cases were
reported. Similarly, on December 10, 2020 suspected outbreak of dengue fever was reported from Somali
region, Dollo zone, Warder Woreda. Accordingly, about 36 samples were collected and 6 were positive for
dengue fever virus. There was no death report

6. Yellow fever

Yellow fever outbreak occurred in Gurage zone, SNNPR in February 2020. On March 03, 2020, a report was
received from St. Paul hospital that two patients with symptoms concurrent with Yellow fever infection and one
of them died. Yellow fever reactive mass vaccination campaign was conducted SNNP and Oromia and 651,811
target population groups were vaccinated in 15 Woredas and 189 kebeles through a vaccination campaign.

7. Dracunculiasis

A total of 17 cases and infections were reported between Hamle, 2012 to Yekatit, 2013, including 5 human cases,
8 cat infections, 2 dog infections, and 2 baboon infections. All cases were handled using all response pillars,

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including community conversation (CCC), vector Control, active case surveillance, and frequent supervision
visits from the Ministry of Health, EPHI, RHB and key partners.

9.2. Health Emergency response in conflict affected areas

9.2.1. Health Emergency response in Tigray region
Following the conflict in Tigray region, MOH in collaboration with its stakeholders has established a national
emergency task force to respond for health emergency in the conflicted affected areas in the country. In this
section, summary of the major emergency response and recovery activities conducted in Tigray region, from
December 2020 to June 2021 (until the withdrawal of ENDF from Tigray)

Leadership and governance

• The ministry of health established a national task force and advisory group that meet weekly to
monitor the health emergency response.
• Comprehensive Tigray health system recovery plan was prepared in coordination with Tigray RHB and
shared for stakeholders
• Two Review meeting conducted at Mekele and Addis Ababa, in the presence of MoH senior
leadership, directors, and the Health bureau management
• 129 health professionals including senior specialist were mobilized and deployed to hospitals in the
conflict areas
• Senior Technical staffs were deployed to support the region and frequent visit was made by MoH
senior leadership to the region.
• Different capacity building trainings in program implementation was provided for the RHB and health
facility staffs

Health service delivery

There were only 4 Hospitals and 17 Health centers that were functional and providing service actively to
the community when the MOH and the interim government started to activate the regional health system.
The Ministry and all stakeholders devise mechanism to ensure provision of essential health service using
functional health facilities, mobile health and nutrition team and establishing temporary clinics in IDPs with
high population volume. With the emergency response team, the following results were documented:

 The number of functional health centers and hospitals increased to 118 and 25 respectively
 65 mobile health and nutrition team with 6 to 8 health workers were established to provide essential
health service in areas where health facilities are damaged and inaccessible due to security
 More than 93% of health professionals re-started their regular work at health facilities
 Essential services such as OPD service, maternal and child health services resulmed at health facilities
 Blood banks were reactivated and distributed ready blood to health facilities as per the demand from
health facilities

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COVID-19 Response

 Six COVID-19 treatment centers were reinitiated for admission and treatment of patients
 COVID-19 testing was re-initiated and 4,358 covid-19 suspected cases were tested, 1,411 (42.4%) of
them were positive.
 150 Oxygen cylinders were distributed to the region and budget requested to initiate oxygen and
waste treatment plant for Ayder Hospital
 National COVID-19 vaccination launched at Mekele at the presence of H.E. the Minster, Tigray RHB
Head and other stakeholders
 128,000 COVID-19 vaccine was distributed to the region and more tha 89,535 people were vaccinated

Sexual and Gender based violence and Mental health service

 Mobilized 57 health professionals (Psychiatrist, clinical psychology, Physicians, Nurses, Gyn and Obs.
from university hospitals
 Established one stop centers in Mekele, Axum, Adigrat, shire, Adwa, and wukuro to provide service
for victims; Logistic support and RH kit provided for the one stop centers
 8983 Toll free golden line was launched to report and seek any service for clients with SGBV and /MH
problem
 Standby ambulances were assigned for any referral of the victims to the nearby centers
 Standardized Assessment checklist developed and used to screen patients with mental health
problem
 Individual Counseling, Group Counseling, Psycho-education and Psychiatric Services provided for
patients with mental health
 Simple screening tools used to identify SGBV cases mass Education provided in the SGBV
prevention, Integrated with MHNT to identify, and refer the SGBV victims

Pharmaceuticals and Logistics

 A total worth of 103,392,925.15 million RDF and program drugs were distributed to Tigray region
Health facilities from Dessie, Gonder and Semere hubs and 260,501,889 Million worth drugs and
supplies were distributed from shire and Mekele.
 In addition, different medical equipment such as mechanical ventilator, X-ray machines, patient bed
were distributed to Tigray region.
 Other logistics such as health center kits (worth 4.2 million), desktop computers (worth >2.8 million
Birr), 20 ambulances (12 from MOH and 8 from Regions), 25 refrigerators and 2 cars were provided

9.2.2. Emergency Health Response to Other conflict affected areas

It is to be recalled that considering the unwanted war the government was forced into since October 2013 EFY
and the current situation in the Tigray region, the government implemented a unilateral ceasefire decision in
June 2013. However, this unilateral ceasefire decision did not bring the desired result but rather the situation
escalated into violence in the neighboring Amhara and Afar regions, as well as in other regions of the country.

In the face of such conflicts, the health care system and service delivery is one of the most highly affected and
pressured systems. Over the past three months, especially in the two regions (Amhara and Afar), there has been
widespread displacement of healthcare workers, shortages of medical supplies and equipment, water and

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power source outages, and other health facility infrastructures have been destructed. As a result, efforts are
being made to reduce the impact of the situation, number of illnesses and deaths by strengthening the health
service delivery system in a way that will address the current situation. Minister of Health is collaborating and
coordinating with regional health bureaus as well as other partner organizations to provide Critical support in
health emergency response.

Health facilities in the conflict zone have been shut down and severe damage has been incurred on their
infrastructures. Even though the depth and extent of the damage have not yet been fully investigated so far, we
have learned from the reports we have received, many health facilities, healthcare workers and ambulances
have ceased providing service. Ambulances that were purchased at a high cost to reduce maternal mortality
were robbed and injured, and most are out-of-service. Accordingly, 49 in Amhara, 16 in Afar, 9 in Oromia, 6 in
Benishangul-Gumuz and 6 in Somali 6 (86 ambulances in total) were looted or destroyed.

In general, many health facilities and ambulances have been forced to stop providing services, and the closure
of health facilities has led to the displacement of healthcare professionals. In addition to disrupting the health
service delivery in the area, this has put a strain on other health facilities. Thus, 7629 in Amhara, 108 in Oromia,
and 340 in Afar (8,077 professionals in total) have been displaced. Great efforts are being made to respond
at all levels in collaboration with the regional health bureaus. In addition, the extent of the damage will be
assessed and explained in detail by experts consecutively.

Activities on availing essential health services and support for IDPs 

All the necessary and versatile support is being provided to the regions to provide essential health services to
those displaced by the conflict and to communities living in the conflict zone. So far, according to local reports,
there are a large number of IDPs in various shelters. In the Amhara region alone, there are more than 1,837,642
million IDPs, of whom 256,070 of the IDPs are under the age of five and 71,641 are pregnant and breastfeeding
mothers. There are also 112,000 IDPs in Afar region, 193,040 in Benishagul Gumz, 559,122 IDPs in Oromia, of
which 56,880 are children under the age of five, and 19,880 are pregnant and lactating mothers.

Efforts are being made to provide health services to IDPs in the shelters, while mobile health and nutrition
groups (MHNT) are being set up and deployed to reach the inaccessible portion. So far, 9 teams and 14
temporary clinics in Amhara as well as 5 temporary clinics and 13 teams in Afar are providing services and are
working to organize and deploy additional teams based on the demand.

Activities on nutritional assessment 

In Amhara Region, Nutritional Screening was performed for 16,419 children under the age of five, among which
4,137 were MAM and 1,929 were severe acute malnutrition (SAM) cases. 8,242 pregnant and lactating mothers
were screened and 940 were diagnosed with moderate acute malnutrition (MAM). Children with malnutrition
are being treated.

In Afar, 9,000 children under the age of five were diagnosed with malnutrition, 3,457 with moderate acute
malnutrition (MAM), and 2,425 with severe acute malnutrition (SAM). Nutritional assessment was done for
21,345 pregnant and lactating mothers as well. Nutrition supplementation and treatment are being provided
for these people.

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Human resource support 

Health professionals have been sent to the affected areas to provide professional support. So far, 350 for
Amhara, 54 for Afar, and 45 professionals for referral health facilities that provide service related to the conflict,
which makes a total of 449 professionals have been assigned. Following the request of the regions, the
necessary preparations are being made to send more professionals, and it is understood that there is a great
desire from health professionals to be there and support on the ground.

Medical supplies and equipment Support

Health facilities in the conflict zone are overwhelmed. To respond to the situation  medical supplies and
equipment  are being distributed from the Ethiopian Pharmaceutical Supply Agency hubs. Accordingly, in
addition to the support provided before June 2013, the following support has been provided in the last few
months alone (until September 2021). Medical supplies worth more than 397 million Birr was supported to
conflict affected facilities in Amhara, Afar, Benishangul Gumuz and Oromia regions. In addition to the regular
distribution and support to facilities, the stockpile of EPSA branches is constantly being filled to prevent Stock
outs.

Blood donation and supply

Following a national call, young people and volunteers are donating blood locally and the collected blood is
being distributed to health facilities.

Cash Support

MOH transferred large sums of money to the regions for support of regular health activities. In addition to
the regular support, more than 12 million birr to Amhara, more than 3.5 million birr to Afar, and 3 million birr
to Oromia, a total of 18.5 birr million has been transferred for support during this conflict. In addition to the
support provided by our Ministry, MOH agencies are also providing significant financial and in-kind support.

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COVID-19 AND ITS RESPONSE

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CHAPTER 10: COVID-19 AND ITS RESPONSE

Note: This chapter includes mainly for the period October 1, 2020-August 2021. Comparison of
this period with the overall COVID-19 trend is also described.

Number of infections and deaths due to COVID-19

Between October 1, 2020 to August 31, 2021, 1,967,064 tests were conducted, from which 232,767 cases were
detected, with positivity rate of around 11%. The majority of cases in the last 12 months were reported from
Addis Ababa, followed by Oromia and SNNP. Since COVID-19 was reported in Ethiopia in March 2020, an overall
3,301,802 tests were conducted, among which 319,101 cases were detected with an overall positivity rate of
9.7%. (Figure below).

Figure 53. COVID-19 situation in Ethiopia: Total since the pandemic started versus October 1, 2020 to August 31, 2021

Since the start of COVID-19 pandemic until August 31, 2021, there were 4,830 deaths and 285,784 recoveries.
Among these, 3,436 of the deaths and 245,638 recoveries were reported from October 1, 2020 to August 31,
2021.

The source of confirmed cases during the past 12 months were from Community (88.42%), Contacts (11.03%)
and imported (0.55%). From the total COVID-19 patients admitted, 0.12% were asymptomatic, 62.1% had had
mild symptoms and the rest had moderate to severe illness.

Overall 77.2 percent of those who died are above 55 years old. During the past 12 months, most of deaths, were
in Addis Ababa (2099) followed by Oromia (515), Amhara (246), Sidama (151), Harari (138) and SNNPR (131).

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Figure 54. Number of deaths due to COVID-19 by region, from October 1, 2020 to August 31, 2021

Until August 31, 2021, overall 63,877 infected people were admitted to facilities for isolation or treatment
centers throughout the country, among which, 27,366 of the infected people were admitted in the last 12
months (October 2020 to August 31, 2021).

Figure 55. Summary of COVID-19 situation in treatment centers from October 1, 2020 to August 31, 2021

Overall, 235,514 cases were on home-based isolation and care (HBIC), among which 157,887 were in the past 12
months. Overall, 227,052 of those on HBIC were recovered and during past 12 months 171,793 were recovered.

Total death from HBIC was 38 and during the past 12 months 34 death were from HBIC. Total case transferred
to COVID-19 treatment center from HBIC were 981 and total case transferred from COVID-19 treatment center
to HBIC were 1992.

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Figure 56. Summary of COVID-19 situation in Home based isolation centers: Total since COVID-19 started and October 1, 2020
to August 31, 2021

Health care providers infection

A total of 3404 health care providers were infected with the virus since the pandemic started. From the total,
504 of them were infected in the past 12 months (October 1, 2020 to August 31, 2021). Overall, the majority of
the infected providers are from Addis Ababa (1407), followed by Oromia (501), and the lowest is from Sidama
region (96). From the total infected health care workers, 3298 were recovered as of August 31, 2021.

A total of 40 health care providers deaths were registered and 27 of them were during the past 12 months. Out
of the total deaths, 32% were nurses, 19.8% physicians including interns, 8% were health officers, 4.1% were
midwives and 6.2% were laboratory technicians.

Figure 57. Summary of COVID-19 in health care workers, august 31, 2021

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COVID-19 Preparedness and Response

Coordination

The national Public Health Emergency Operation Center (PHEOC) has been collaboratively working with
stakeholders, government agencies, partner organizations, UN agencies, embassies, hospitals, industrial parks
and others. With the intent of COVID-19 information sharing and response activity facilitation, morning briefing
of Incident Management System (IMS) has been conducted every day by core IMS staffs and key partners’
representatives. There has also been weekly joint meeting, every Tuesday, among the national and regional
Emergency Operations Centers COVID-19 response IMS to evaluate weekly COVID-19 situations, progress of
response strategies, challenges faced and way forwards. The virtual meeting of Joint Steering Committee
encompassing MOH, Agencies and RHB top leadership under the leadership of H.E Minister of Health has been
ongoing. This meeting is held either weekly or once in two weeks depending on the urgency of the situation
and need.

Emergency Operation center

The Emergency Operations Center has been functional facilitating every COVID-19 preparedness and response
activities 24/7 at national level.

Planning, Monitoring & Evaluation

The 2013 EFY Emergency Response and Plan has been prepared and shared at both national and regional
levels. Various initiatives and campaigns like Community Based Activities and Testing (CoMBAT), COVID-19
sero-survey, No Mask No Service initiative and COVID-19 response revitialization/Dagim Tikuret have been also
been prepared and monitored. Intra action review Conducted at national EOC, Task force and all regions.
COVID-19 response revitialization/Dagim Tikuret was launched on 17 May 2021 to revitalize COVID-19 at
multiple level. The national overall House-to-House visits performance was 30.9% with 15.4% at urban and
85.2% at rural. Even though the plan was to test 14000 test per day, only 35 percent of it was achieved.

Daily situational report (SitRep) all 365 days of 2013 EFY and 53 Weekly bulletin in all weeks of year has been
disseminated through EPHI website. Besides this, more than 33 different guidlinese has been developed and
disseminated. A new COVID-19 directive (directive 803/2021) which is a revised version of the former directive
30/2020 has also been developed and disseminated to the public and authorized legal entities.

Daily morning plan submission and afternoon report from all EOC section was undergoing and being monitored.

Logistic

There has been ongoing distribution of PPE, Viral Transport Media (VTM), swabs, pharmaceuticals and other
medical supplies to isolation and treatment centers. An estimated 2.03 billion worth supplies has been
distributed in 2013 EFY. There has also been Resource mobilization from governmental, Non-Governmental
organizations, Diasporas, individuals, and partners for COVID-19 response. Various activities has been
performed to equip COVID-19 treatment centers by human resource and infrastructure. Among these: ICU
training for 25 facilities (for 100 individuals), 124 MVs and 216 patient monitor and ICU beds and1453 moderate/
severe beds have been distributed to regions.

Laboratory activities

Laboratory service expansion has been one of the major activities done under the laboratory section increasing
daily surge to 25,000 tests. Eighty-four RT-PCR testing laboratories were established nationally (including
21 private & 1NGO). New testing technologies, Antigen Rapid Diagnostic Tests (Ag-RDT), were evaluated &

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verified to use in Ethiopia. Private Sectors has also started COVID-19 test for travelers and others. Starting from
September, 2021 COVID-19 negative result was communicated to clients though SMS

More than 160 professionals has been trained on COVID-19 sample collection while 147 laboratory professionals
received refreshment training on RT-PCR testing from zones, regional labs and Universities level. Ag -RDT
Training of Trainers (TOT) for 40 Laboratory professionals and basic training was provided to regions for 252
Laboratory professionals. Supportive supervision and mentorship has been conducted in regions by deploying
experts from the national level.

National capacity to conduct Genomic sequencing was built which enabled the country to detect the new
SARS-COV-2 variants, Alpha, Beta and Delta.

Quality Assurance was another major activity performed in the fiscal Year. Forty-seven actively working PCR
laboratories were enrolled in first round which was increased to 60 in the second round. Fifty Ag-RDT testing
facilities enrolled in Proficiency Testing panel program. To enhance the quality assurance of the laboratory
National testing strategy & algorithm developed & shared, national quality assurance guideline was drafted
and regular Turnaround Time (TAT) monitoring and feedback provision have been conducted.

Between October 01, 2020 and August 31, 2021, laboratory tests were performed with the positivity rate of
10.0%. The trend of laboratory test in weeks is shown below.

Figure 58. Trend of laboratory test from October 1, 2020 to August 31, 2021 by Epi-weeks

Epi Surveillance

A total of 392,776 rumors were received and 364,739 of them were investigated from October 1, 2020 to August
31, 2021. More than 332,681 contacts were traced, followed and linked to laboratory for testing. Guidelines
were revised based on existing scientific evidence. Over 30 high-risk sites assessment and five cluster cases
Investigations were conducted in the period.

Point of entry screening

Interventions implemented at Point of entry (PoE) aimed at the identification of ill travelers with symptoms
and signs of COVID19, identification of appropriate public health measures such as quarantine, isolation or

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treatment facilities at PoE, and provision of information to travelers on the public health risks and required
precautionary measures during travel. Standard operating procedures and COVID-19 health declaration
forms developed for PoE sites facilitated and enhanced health screening, information gathering and contact
tracing for arriving passengers. Isolation Center at Point of entry prepared and guidance prepared according to
Situation on quarantine and Requirement of entry. A total of 1,584,356 people screened and more than 55,674
returnees were received and tested at POEs

Case Management

A total of 333 COVID-19 treatment centers have been established and equipped by 653 ICU Beds, 279 MV,
16,000 beds, 4383 oxygen Cylinder and 950 oxygen Concentrators. The national oxygen production capacity
was increased from 1900m3/hr to 3091m3/hr. Fifteen Private health facilities are engaged in COVID-19 case
management 13 as treatment center and 2 HBIC follow up. Mobile based HBIC follow up system is in place in
Addis Ababa. Private ambulances are being utilized for severe & critical case referrals in Addis Ababa. Death
audit and assessment of quality care have been conducted in some treatment centers and COVID-19 case
management service-integration was implemented in 70 health facilities. Furthermore, field hospital and
millennium hospital were prepared and equipped to enhance COVID-19 patients’ care capacity.

Mental Health and Psychosocial Support (MHPSS) have also been given an intense focus in treatment center.
Accordingly, 28 MHPSS clinics were established and 52 Universities MHPSS team were formed.

Protection of Special group

In general 32836 old age at 26 geriatric centers, 150,000 homeless, 129,033 prisoners at 122 prisons, 938616
refuges and 50,000 women at different sites were reached. Health education and different support has also
been given. Screening for COVID-19 has been performed at special setting and capacity building for Workers
working in Disability associations, Prisons, IDP sites, Geriatric centers.

Infection prevention and Control

In the last fiscal year, regarding COVID-19 infection prevention and control, various guidelines and informative
video spots were prepared and shared to the public and capacity building trainings were provided for
health professionals. More than 30 SOPs and guideline developed on mass gathering, election, safe school
reopening, on rational use of PPE. Different Videos has been prepared on doffing and donning, hand washing,
chlorine preparation. 385 healthcare workers (HCWs) from all regional Health bureau & treatment centers
took comprehensive COVID-19 training for HCWs. Basic IPC training given for HCWs in High risk population
group(prisons, geriatrics centers, military camps daycare, IDPs, …), Federal police & Defense Force HCW,
Industries park & mega industry safety experts, University food handlers, cleaners & security, social organizations
and religious leaders.

Risk Communication and Community Engagement (RCCE)

One of the corner stone of COVID-19 response was risk communication and community engagement. The
EPHI and MOH have developed various COVID-19 Prevention Guides and RCCE strategies, daily updates to
Media on COVID-19 Situation all 365 days, media scanning and monitoring and different awareness creation
messages prepared and shared in different forms. Furthermore, RCCE technical working groups established
and relevant experts mobilized like Graphic Art Designers, RCCE, and Media. Audio-video messages developed
and aired for the public. Daily press statements developed and press conferences conducted by MoH and
EPHI higher officials. Targeted Social and Behavior Change (SBCC) materials developed, translated, printed
and distributed to regions and lower level. Besides these about 26,000 health extension workers and their
supervisors are trained on COVID-19 response activities using Mobile based training approaches.

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Digitalization

District Health Information Software 2 (DHIS2), a free and open source health management data platform,
has been used for COVID-19 aggregate data entry and contact tracing, managing laboratory Order/request,
admission and referral management, clinical follow up for case management and result dissemination /
e-messaging.

Different electronic applications like Health Facility Application, Home based Isolation and care, Traveler
Certificate Application, Call center Application, Community House to House Screening Application, Commodity
Management Application: DAGU 2.0, an inventory management system), have also been utilized.

Regional Support

Around 284 multidisciplinary experts deployed for response from national to region through contract. From
different organization, including MOH, around 1757 multidisciplinary experts participated in covid-19 response
at national Public Health Emergency Operations Center level. Different ICT materials including 968 tablets for
contact tracing &testing and 12 audio visuals conference device were distributed nationally for all regions.

School Reopening

Guiding documents were developed and cascaded with various school assessment conducted before and
after reopening. A total of 214 School assessments were conducted and feedback given. Training of trainers
was provided for 250 experts from universities, regional education bureaus and zonal education departments.

Research (Evidence generation)

Various researches have been facilitated by the MOH and EPHI. It includes; The First Few Cases investigation
(FFX): An Investigation of a Hundred COVID-19 Cases and Close Contacts in Ethiopia, factors that influence the
duration of symptom resolution in COVID-19 patients in Ethiopia, health workers exposure risk assessment and
management, community risk perception and Different Cluster & Outbreak investigations in the congregate
setting are some of the evidence generation researches conducted in the fiscal year. Furthermore, other 30
different studies are at different stages.

COVID-19 outbreak Projections

Existing COVID-19 forecasting models differ substantially in methodology, assumptions, range of predictions,
and quantities estimated.

The ministry has used around seven models to forecast the outbreak in Ethiopia up until now. However,
currently only two have regular updates, the IHME and EPHI models.

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Dec. 31, Jan. 21, Jan. 27, Jan. 30, Feb. 07, Feb. 11,
2019 2020 2020 2020 2020 2020

COVID-19 China alerts

WHO to several
WHO confirms
human-
PHEOC
activated for
WHO declares
Ethiopia
starts
WHO names
the novel

Timeline
pneumonia to-human 2019-nCOV laboratory
the outbreak corona virus:
cases of transmission preparedness test for
a PHEIC COVID-19
unknown cause of the virus and IM assigned COVID-19

Feb. 14, Dec. 31, Mar. 13, Mar. 15, Mar. 16, Mar. 20,
2020 2020 2020 2020 2020 2020

Prime Minister
Ethiopia 8335 toll Ethiopian
Egypt WHO declares of Ethiopia
Figure 59: COVID-19 reports free hotline Airlines
confirms the COVID-19 declared closure
the first upgraded to suspends flight
related events and Africa’s first outbreak a of schools
COVID-19 digital call to around 30
major activities case PANDEMIC and mass
case center countries
timeline gatherings.

Mar. 23, Mar. 25, Mar. 28, Apr. 01, Apr. 05, Apr. 08,
2020 2020 2020 2020 2020 2020

14-days PM of Ethiopia Ethiopia

launched The first COVID-19
mandatory The first declares
national COVID-19 recovered laboratory
quarantine for death state of
resource patient testing started
all travelers reported in emergency
mobilization reported in in AHRI and
arriving in Ethiopia to fight
committee Ethiopia NAHDIC
Ethiopia started COVID-19

Aug. 29, Oct. 26, Mar. 07, Mar. 13, July 13, Sept. 07,
2020 2020 2021 2021 2021 2021

General Ethiopia
School Ethiopia Alpha and
election in received Delta SARS-
reopening begins Beta SARS-
Ethiopia the first 2.2 COV-2 variant
commenced COVID-19 COV-2 variants
postponed due million doses reported in
in Addis vaccine reported in
to COVID-19 of COVID-19 Ethiopia
Ababa rollout Ethiopia
pandemic vaccine

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ANNUAL
PERFORMANCE
REPORT 2013 EFY (2020/2021)

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