a l t h sy s t e m s

C h a p te r 1 : H e
a nd h e a l t h p o l i c y

oh a m m ed Hu ssien (MPH/HSM)
By: M
Wollo University
Chapter Objectives

After completion of this chapter, students will be

able to:
 Identify existing and emerging challenges in health care

system
 Analyze key health system building blocks and their

interactions
 Analyze health system strengthening frame work

 Apply systems thinking approaches for health systems

strengthening
 Describe national health policy

 Analyze the national HSDP and national health care

delivery model
 Discuss primary health care practice in Ethiopia

 Comply with national health policies, strategies and

2
initiatives
Current and emerging health issues
& trends
 The challenges that health institutions currently
face are complex and changing,
 the need to improve access to and quality of

health services and reform processes

 emerging diseases, the lack of resources or

new resource streams, and new donor priorities

 Patterns of disease, care and treatment are
changing
 In developing countries such as Ethiopia, the
range of diseases and health problems with a
growing magnitude include:
 infectious diseases,
 non-communicable diseases,

 neglected tropical diseases and

 road traffic injuries 3

Current and emerging health
issues...
 Although some diseases have been effectively

controlled with the help of modern technology,

yet new diseases are constantly appearing
 Several ‘old’ infectious diseases, including
tuberculosis, malaria and cholera have proven
unexpectedly problematic, because of increased
antimicrobial resistance, weak public health
services and activation of infectious agents (e.g.
tuberculosis)
 these issues have accelerated the need to learn
new ways of leading and managing to achieve
results
 Adapt our leading and managing practice to the
4
changing environment
Existing vs. Emerging Issues
 Emerging issues we will say are trending since
after or around the last ten years
 Existing issues have been around since before
 Major existing pandemics include:
 HIV/AIDS

 Malaria

 Tuberculosis

 Malnutrition

 Non-communicable diseases

 Avian influenza (or other influenza)

 Acute respiratory syndrome

5
Existing vs. Emerging Issues...

Emerging macro health issues

 Climate change, environmental degradation
and deforestation
 Changing industrial and agricultural practices
 Water development projects (i.e. dams)
 Inappropriate or excessive use of antibiotics
 Substance abuse
 Changing life style
 Human Trafficking

6
Health system building blocks

 What is a health system?

 A health system consists of all organizations,
people and actions whose primary intent is to
promote, restore or maintain health
 This includes efforts to influence determinants
of health as well as more direct health-
improving activities.
 A health system is therefore more than the
pyramid of publicly owned facilities that deliver
personal health services.

7
Health System Building blocks...

 It includes, for example,

 a mother caring for a sick child at home;
 private providers;
 behaviour change programmes;
 vector-control campaigns;
 health insurance organizations;
 occupational health and safety legislation.

8
Health System Building blocks...

 Six health system building blocks or functions

that together constitute a complete system
(WHO)
 The six building blocks of the health system
are:
1. Leadership and governance

(stewardship).
2. Health workforce;

3. Information;

4. Medical products, vaccines and

technologies;
5. Financing; and

6. Service delivery; 9
 Health System Building blocks...

1. Leadership and governance (stewardship):

 involves ensuring strategic policy frameworks
exist and are combined with effective oversight,
coalition building, regulation, attention to
system-design and accountability
 is arguably the most complex but critical building
block of any health system
 is about the role of the government in health and
its relation to other actors whose activities
impact on health
 Involves overseeing and guiding the whole
health system in order to protect the public
interest
10
Health System Building blocks...
2. Health workforce
 Health workers are all people engaged in actions
whose primary intent is to protect and improve
health
 A country’s health workforce consists broadly of
health service providers and health management
and support workers
 private as well as public sector health workers;
 unpaid and paid workers;
 lay and professional cadres.
 a “well-performing” health workforce is one which is
available, competent, responsive and productive.
11
Health System Building blocks...
3. Health information systems: ensuring the
generation, analysis, dissemination and use of
reliable and timely information on health
determinants, health systems performance and
health status;
4. Medical technologies: including medical
products, vaccines and other technologies of
assured quality, safety, efficacy and cost-
effectiveness, and their scientifically sound and
cost-effective use;
5. Health financing: raising adequate funds for
health in ways that ensure people can use
needed services, and are protected from
financial catastrophe or impoverishment 12
 Health System Building blocks...
6. Service delivery
 including effective, safe, and good quality health
interventions that are provided to those in need,
when and where needed, with a minimal waste of
resources;
 Effective provision requires trained staff working with
the right medicines and equipment, and with
adequate financing
 requires an organizational environment that provides
the right incentives to providers and users
 The service delivery building block is concerned with
how inputs and services are organized and managed,
to ensure access, quality, safety and continuity of
care
13
Definition of terms
 Access: lack of geographic, economic, socio-
cultural (including gender), organizational, or
linguistic barriers to services
 Effectiveness : the degree to which desired
results or outcomes are achieved
 Efficiency: the appropriate use of resources to
produce effective services
 processes and institutions produce results that

meet the needs of society by making the best use

of resources
 Sustainability: continuity of positive results
 Coverage: Services reaching more people or target
group
14
Definition of terms…
 Equity: equity means fairness
 Equity in health means that people’s
needs guide the distribution of health
services and opportunities for health and well-
being
 Quality: “the proper performance (according to
standards) of interventions that are known to be
safe, that are affordable to the society in
question, and that have the ability to produce an
impact on mortality, morbidity, disability, and
malnutrition
 Safety: the degree to which the risks of
injury, infection, or other harmful side
15
effects are minimized
 Health System Building blocks...
 Management systems are connected
 The building blocks alone do not constitute a

system
 It is the multiple relationships and interactions

among the blocks – how one affects and

influences the others, and is in turn affected by
them – that convert these blocks into a system
 Changes in one system can trigger changes in

another
 intervention targeting one building block will

have certain effects (+/-) on other building blocks

 Improvements in one area cannot be achieved

without contributions from the others

 Interaction between building blocks is essential
16
for achieving better health outcomes.
building block interactions

17
Health System Strengthening

 WHO (2007) defines health system strengthening,

as: improving the six health system building
blocks and managing their interactions in ways
that achieve more equitable and sustained
improvements across health services and health
outcomes.

 If all six components function effectively and

deliver their intended results, the assumption is
that the entire health system is strong

18
 A framework for people-centered
health systems strengthening
 People: those who lead, manage, and use the
systems – are the central element for health system
strengthening,
 On one side are the nurses, doctors, midwives,
health officers, laboratory technicians, pharmacists,
and health facility administrators who lead and
govern; manage human resources, financial
resources, supplies, and information; and deliver
health services
 On the other side are the people in the cities, towns,
and rural areas who need information and
community support to engage in health-seeking
behaviors
 The goal of providing quality health care cannot be 19
People-Centred Health Systems Strengthening
Framework

20
A framework for people-centered…
 The figure illustrates how the various health
systems work in concert to provide the critical link
between health-seeking and health-generating
behaviors on the one hand (demand) and the inputs
provided by the various actors in the overall health
system
 The six key health system building blocks in the
outer circle are the focus of the interaction among
critical stakeholders: government, health care
providers, clients, and communities
 It is so obvious that people run a health system that
we sometimes overlook this critical fact
 much attention is devoted to the process aspect of
systems 21
A framework for people-centered…
 Often ignored are those who develop or improve
processes and procedures to foster the smooth
flow of information, money, medicines, and people
within the overall health system
 The Framework for People-Centered Health
Systems Strengthening attempts to remedy this
imbalance
 Health systems strengthening is an empty exercise
if we forget the people at the center of it all
 The people in the “people-centred” framework are
those who develop the systems, use the systems to
do their work, and benefit from strong systems
22
A framework for people-centered…

 It is critical to focus on the people who need the

skills and support to integrate and use the six
building blocks and management systems to
deliver high-quality health care
 Recognizing that no system can operate without
skilled and motivated staff, you should always put
people first when designing, modifying, or
improving a health management system
 Recognize, support, and reward the staff
members who take on the management and
leadership roles that make the health system
work every day, at every level

23
A framework for people-centered…
The People at the Centre of Health Systems are:
 Health managers and administrators who have the

knowledge, skills, responsibility, and authority to

build and maintain the management systems
needed to deliver health services;
 Personnel at all levels, including health care

providers and administrators, who use the

management systems to address challenges and
achieve results;
 Communities and families that are educated and

empowered to promote their own health and

demand quality services;
 Clients who have adequate information to use

health services appropriately and are not impeded

by poor quality, high fees, gender disparities, or
24
other forms of discrimination
Systems thinking
 “Systems thinking” is an approach to problem
solving that views "problem" as part of the wider,
dynamic system (WHO, 2009)
 It involves more than a reaction to present problems
 involves more than “fixing” a problem - quick-fixes
that are likely to backfire
 It is a forest thinking approach; a shift from
the usual approach of tree-by-tree thinking
 It demands a deeper understanding of the linkages,
relationships, interactions and behaviours among
the elements that characterize the entire system

25
a) Interventions with system-wide
effects
 all health interventions have system level
effects to a greater or lesser degree on one
or more of the systems building blocks
 simple interventions or incremental changes
to existing interventions may not have
system-wide effect
 not all interventions will need a systems
thinking approach
 E.g. Adding vitamin ‘A’ to routine EPI
 more complex interventions can be expected
to have profound effects across the system –
thus require a systems thinking approach
 e.g. Scaling-up of ART has effects across the
health system 26
b) System-level interventions

 “System-level interventions” target one or

multiple system building blocks directly or
generically for all health problems, rather than
specifically
 Given their effects on other building blocks,
“systems-level interventions” strongly benefit
from a systems thinking approach
 E.g. paying-for-performance is a “system-level
intervention” as it will affect almost all other
building blocks of the health system

27
System-level interventions …
 It will present governance challenges around the
accountability and transparency concerning
bonus payments dispensed to staff in health
facilities;
 affect the information system in tracking the
conditions triggering payments;
 strongly influences service delivery by changing
staff behaviour, increasing utilization, or possibly
crowding-out other services;
 it may also shape human resources by
improving (or eroding) provider motivation

28
 e v e l o p m e n t
Historical d
of health s erv i c e s i n
E t h i o p ia
Historical development of health
services
 Major historical advents in the development of health
services in Ethiopia are arbitrarily divided into 6 periods
 Period I: Period of introduction(1500-1900)
 Period II: Period of Ethiopianization(1900-35)
 Period III: Italian occupation(1935 -1941)
 Period IV: Period of Restoration and Basic Health
Services (1941 – 1974)
 Period V: The primary health care period (1974 –
1991)
 Period VI: The Sector Wide Approach Period(1991
onwards)
30
 Period I: Period of introduction (1500-1900)

 During this period modern medicine was introduced

into Ethiopia by different groups of people
 religious and diplomatic missions , travelers,

traders, invaders and warriors

 Most of these people were not medical doctors

 The few actual medical doctors confined their

practice to the royal circles

 the large mass of the Ethiopian population drew

little benefit during this period

 However, there were also preventive medical

activities practiced by Westerns that included

measures to control cholera in the army of
Emperor Theodros and smallpox vaccination
during the time of Emperor Yohannes IV.
31
Period II: Period of
Ethiopianization (1889-35)
 Major undertakings during this period were:
 The Rassian mission established the first hospital
(the Russian Red Cross Hospital in A.A – 1897)
 The first government sponsored health facilities
were established in Harar (Ras Mekonnen Hospital)
and Addis Ababa (Menelik II Hospital) by 1909
 The government formally assumed responsibility
for the provision of health services with the
establishment of Health Department within the
Ministry of Interior in 1908

32
Period of Ethiopianization…
 Although this under-funded department did not
accomplish much beyond maintaining curative
services in the capital, commercial clinics
flourished in several regional capitals
 In 1930 the first medical legislation to regulate
the work of medical practitioners and pharmacies
was released
 A start was made in 1935 in the field of health
human power development by enrolling students
for auxiliary medical training, although the
Italian occupation interrupted some of these
activities
33
 Period III: The Italian occupation
(1935 -1941)
the Italian Government had
 destroying the limited medical services

organized for the Ethiopian troops and civilians

affected by the battle
 made aggressive precaution measures to

protect the Italian troops from infectious

diseases such as malaria, venereal diseases,
cholera, typhus by
 distributing prophylactic medicines

 providing extensive vaccination against

typhoid & cholera

 introducing sanitary and personal hygiene

measures
34
The Italian occupation…
 There was expansion of health facilities, but
almost all hospitals were designated for the
exclusive use of the white population
 The health care stipulated for the Ethiopian
population was to provide preventive health
services primarily to curtail the transmission of
infectious diseases from the Ethiopians to the
Italians and other Europeans
 To this effect, regulations to enforce exercises of
preventive health care were issued and
implemented
 Despite increased number of health facilities and
physicians in the country, this period had
insignificant benefit to the Ethiopian population35
 Period IV: Period of Restoration
and Basic Health Services (1941 –
1974)
 In this period, the activities of the health sector

were concentrated on restoration and

establishment of what was demolished or taken
away by the Italians
 Some of the major developments during this
period were
 Restoration and overtaking of the health care

by Ethiopian Government
 A separate Ministry of Health was established in

1948
 In 1949, the first health personnel training

school was established at the Red Cross

36
Period of Restoration and BHS…
 Ethiopia became member of WHO in 1949
 There were (1952) 38 hospitals and 80 physicians
(all foreigners) throughout the country
 Gondar Public Health College, the first of its kind, was
established in 1954 and started training of health
professional
 Ethiopia became one of the pioneering countries in
implementing basic health services approach
 The “Health Center Team Training Program” was

launched in 1954 produced new cadre of health

professionals (HOs, community nurses and
sanitarians)
 The era of “basic health services” since 1954 in
Ethiopia is considered as one of the success stories
37
Period V: The primary health care period
(1974 –91)
 Before PHC period, the approach used to provide
health care to the underserved was BHS by:
 establishing health centers, health stations
 training auxiliary health workers
 The BHS approach was also combined with vertical
communicable diseases programs
 The BHS were designed to provide preventive,
promotive and curative health services
 In 1974, 20 years after the adoption of BHS
approach, the health facilities in the country were
inadequate and also mal-distributed in favor of few
cities with only 5% of the country’s population

38
The primary health care period…

 Many countries including Ethiopia realized that

they have failed to reach the underserved
majority of their populations through basic
health services approach
 1977 the World Health organization set a goal of
“health for all by the year 2000”, and the
following year, PHC was declared as the key
approach to achieving this goal.
 Since 1980, PHC has been the main strategy on
which the health Policy has been based

39
The primary health care period…
 Generally, during this period, there was growth of
health facilities, but the overall achievement was far
less than anticipated in the plan
 Other remarkable events during the period between
1974 & 1984 (10 years health plan) include
conversion of the Gondar Public Health College to
medical school, establishment of a 3rd medical
school in Jimma, and opening of two additional
hospitals
 Modern health care during this period was
structured into a 6-tier health system
 The 6 tier health system consists of: Referral
(central) hospital, regional hospital, rural hospital,
health center, health station and community health
service. 40
 Period VI: The Sector Wide
Approach Period (1991
 onwards)
The Ethiopian health system is currently being
reformed and the main program being
implemented is the Health Sector Development
Program (HSDP)
 HSDP is implemented as part of reformation
process in the framework of the government’s
Sector Wide Approach (SWAp)
 SWAps were introduced by the World Bank in the
late 1980s and strongly promoted in the early and
late 1990s
 They are seen as ways of delivering agreed upon
health policies and manage domestic as well 41
SWAp Period…
 SWAp - Characterized by a formalised process
for donor coordination and harmonisation of
donor procedures for reporting, budgeting,
financial management and procurement
 The HSDP was launched in 1998 in response to the
prevailing and newly emerging health problems in
Ethiopia and in recognition of weaknesses
observed in the existing health delivery system
 The initial HSDP which was drafted in1993/94 was
designed for a period of 20 years, with a rolling
five-year program period

42
 SWAp Period…
Other key events during this period are:
 The development of current national health
policy of the country (1993)
 A change in the health service delivery
structure from 6 – tier to a simpler 4 – tier
system (during the first HSDP)
 Re-structuring of the 4 – tier health service
delivery system to 3 – tier delivery system
(during the 4th HSDP)
 The development of the Health Service
Extension Package (HSEP initiative); which
seeks to provide health promotion and
extension services to communities (2nd 43
Primary Health Care (PHC)

 International conference, organized by WHO and

UNICEF, was held in Alma-Ata in 1978 on the
theme of ‘HEALTH FOR ALL’
 The Alma-Ata Declaration stated that
 “health is a basic human right,
 governments are responsible to assure
that right for their citizens and to develop
appropriate strategies to fulfill this
promise”

44
Primary Health Care…
 Gross inequalities in the health status of people,
are of common concern to all countries
 between developed and developing countries
 within countries
 The Conference
 Stressed the right and duty of people to
participate in the planning and implementation
of their health care
 Advocates the use of scientifically, socially and
economically sound technologies
 In order to attain these targets Primary Health
Care (PHC) is taken as the appropriate method
45
 Definition
 PHC is an Essential Health Care based on
practical, scientifically sound, and socially
acceptable methods and technology made
universally accessible to individual and families
in the community through their full participation
and at a cost that the community and country can
afford to maintain at every stage of their
development in the spirit of self reliance and self
determination.

 the primary, or first contact, level – usually in

the context of a health district – acts as a
driver for the health care delivery system as a
whole 46
 Definition…
The basic terms in the definition are:
 Essential Health Care:
 Group of functions essential for the health of the

people given at lower level of health service.

E.g. Medical care, MCH, referral, school
health, environmental health, health
education, control of communicable
diseases etc…
 Methods & technology:
 Scientifically sound: scientifically explainable

and acceptable
 Socially acceptable : intervention should

consider the local value, culture and belief

47
Definition…

 Universally accessible:
 Because of the inequitable distribution of the
available resources, the services are not
reachable by all who need them
 Only a few can afford or within the reach
to use them
 Therefore, PHC bring health care as
close as possible to where people live
and work

48
PHC Principles
 Six principles of Primary Health Care
1. Intersectoral collaboration
2. Community participation
3. the use of appropriate technology
4. Equity
5. Focus on prevention and health promotion
6. Decentralization

49
1. Intersect oral Collaboration
 It means a joint concern and responsibility of
sectors responsible for development in identifying
problems, programmes and undertaking tasks that
have an important bearing on human well being
 Health has several dimensions that can be affected
by other sectors
 The causes of ill health are not limited to factors
related to the health sector
 Education for literacy, income, clean water,
sanitation, improved housing, construction of roads
and water ways, enhanced roles of women, are
changes that may have substantial impact on
health
50
2. Community involvement
 is the process by which individuals and families
assume responsibility for the community and develop
the capacity to contribute to their health and the
community's development
 Is a means by which communities can play a more
influential role in health development, in which the
emphasis is on strengthening the capacity of
communities to determine their own needs and take
appropriate action
 Communities should not be passive recipients of
services
 Everybody should be involved according to his/her
ability
 The community should be actively involved in51
3. The use of Appropriate
Technology
 Take account of both the health care needs and

the socio­economic context of a country

 All levels of health system have to review their
methods, equipment and techniques using
appropriate criteria
 To be appropriate, a technology must be:
 Effective - meet its objective
 Culturally acceptable and valuable
 Affordable i.e. Cost effective
 Locally sustainable: we should not be over
dependent on imported skills and supplies for its
continuing function, maintenance and repair
 Environmentally accountable: the technology
should be environmentally harmless or at least
minimally harmful
52
4. Equity
 This is to close the gap between the haves and
"have not's" which will help to achieve more
equitable distribution of health resources
 Universal coverage of the population with care
provided according to need is the call for equity
 If all cannot be served, those most in need
should have priority
 These principles may come into conflict with
efforts to promote cost effectiveness, because
those most in need may be more costly to reach
 Trade-off between equity and efficiency

53
 5. Focus on prevention and
promotive health services
 Such an approach sees health as a
positive attribute, rather than simply" the
absence of disease”
 One of the important tasks of the planner
is to redress the imbalance in
allocation of resources to preventive
and curative care, enhancing the role of
resources available to prevention and
promotion

54
6. Decentralization

 Decentralization, reflecting the two key

principles of community participation and
multisectoralism
 Decentralization away from the national or
central level brings decision making
closer to the communities served and to
field level providers of services, making
it more appropriate
 There is also a greater potential for
multisectoral collaboration at the lower
service-delivery level
55
Decentralization…

 Decentralization may enhance the ability to

tap new sources for financing health care-
greater efficiency in service provision
 May lead to geographical inequalities in
resource availability and technical quality
 Planners should, therefore, consider whether
specific strategies and decisions will
enhance or hinder the achievement of PHC

56
The components of PHC
 Essential health care consist 8 elements
1. Health education
2. Food supply and proper nutrition
3. Provision of safe water and basic sanitation
4. Maternal & child health care, including
family planning
5. Immunization
6. Prevention and control of endemic disease
7. Treatment of common diseases and injuries
8. Provision of essential drugs
57
The components of PHC…

Additional elements incorporated after

Alma-Ata
1. Oral Health
2. Mental Health
3. The use of traditional Medicine
4. Occupational Health
5. HIV/AIDS
6. Acute Respiratory Infection (ARI)

58
PHC in Ethiopia
 Ethiopia has adopted the declaration of “Health for
All” using the PHC strategy
 Since 1980, PHC has been the main strategy on
which the health Policy has been based
 The current Health Extension program is designed
based on the principles of PHC
 PHC review was done in the country in the period
of August 1984 - January 1985
 According to the review
 there were limited achievements regarding

intersectoral collaboration and community

involvement
 there was over-ambitiousness in setting plans &

goals 59
 PHC in Ethiopia…
 Major implementation problems of PHC
 Absence of infrastructure at the district level

 Difficulty in achieving intersectoral collaboration

 Inadequate health service coverage and

inappropriate distribution of available health

services,
 Inadequate resource allocation

 Absence of clear guidelines or directives on how

to implement PHC
 Presence of culturally dictated harmful traditional

practices of unscientific beliefs and practice

 Absence of sound legal rules to support

environmental health activities

60
 Weak community involvement in health
Health Policy, Strategy
and Reform in Ethiopia
Policy, public policy and health
policy
 A policy is a set of clear statements that
defines the intention of a community,
organization or government’s goals and priorities.
 Policies outline the role, rules and procedures
 They create a framework within which the
administration and staff can perform their
assigned duties
 A policy involves agreement or consensus
on the following main issues:
 Goals and objectives to be addressed,

 Priorities among those objectives and

 Main directions or strategies for achieving them

62
Continued…..
 Public policy is “a set of interrelated decisions
taken by a political actor or group of actors
concerning: the selection of goals and the
means of achieving them within a specified
situation where those decisions should, in
principle, be within the power of those actors to
achieve” (Jenkins, 1978)
 When a government takes a decision or chooses
a course of action in order to solve a social
problem and adopts a specific strategy for its
planning and implementation, it is a public
policy (Anderson 1975)
63
Continued…..
 A health policy is a set of clear statements and
decisions defining priorities and main directions
of improving health and health care in a country
 health policies are ‘networks of interrelated
decisions which together form an approach or
strategy in relation to practical issues concerning
health care delivery’ (Barker 1996)
 Examples of health policies include seat belt
policies, and policies for smoke-free public places
such as schools and workplaces
Networks of interrelated decisions
64
National Health Policy of
Ethiopia
 The 1993’s health policy of Ethiopia is one among
the prominent developments of the country
 The policy envisioned the health care sector
development (HSDP) for the next twenty years
 It reorganized the health services delivery system
so as to contribute its own to the overall socio-
economic development.
 The policy principally focuses on fiscal and
political decentralization, expanding the PHC
services to all segments of the population and
encouraging partnerships and the participation of
nongovernmental actors
65
General theme of the policy…1
1. Democratization and decentralization of the health
service system.
2. Development of the preventive and promotive
components of health care.
3. Development of an equitable and acceptable standard
of health service system that will reach all segments of
the population within the limits of resources.
4. Promoting and strengthening of inter-sectoral activities.
5. Promotion of attitudes and practices conducive to the
strengthening of national self-reliance in health
development by mobilizing and maximally utilizing
internal and external resources.
6. Assurance of accessibility of health care for all
segments of the population.

66
General theme of the policy…2
7. Working closely with neighbouring countries,
regional and international organizations to share
information and strengthen collaboration in all
activities contributory to health development
including the control of factors detrimental to
health
8. Development of appropriate capacity building
based on assessed needs.
9. Provision of health care for the population on a
scheme of payment according to ability with
special assistance mechanisms for those who
cannot afford to pay.
10. Promotion of the participation of the private
sector and nongovernmental organizations in 67
Health Sector strategies in
Ethiopia
 The Health Sector Development Program
(HSDP) which was launched in 1998 is the main
health sector strategy of Ethiopia since then.
 It was adopted in response to the prevailing and
newly emerging health problems in Ethiopia
and in recognition of weaknesses observed in
the existing health delivery system.
 The HSDP was designed for a period of 20
years, with a rolling five-year program period.

68
Health Sector strategies...
 Three main goals of HSDP:
 Build basic infrastructure,
 Provide standard facilities and supplies and
develop
 Deploy appropriate health personnel for realistic
and equitable primary health care delivery at
the grassroots level
 four phases of Health Sector Development Plans:

69
HSDP I (1997/98–2001/02)
 Prioritized disease prevention
 A change in the health service delivery
structure from 6 – tier to a simpler 4 – tier
system
 The main change is to replace health
stations (popularly known as ‘clinics’)
with PHCUs: with each PHCU having a
health center surrounded by five Health
Posts, each serving a population of 5,000
for a total of 25,000 for the PHCU
 The four-tier system comprised of PHCU,
District hospital, Regional hospital and
specialized hospital.
70
 The three one’s principle and harmonization
HSDP-II (2002/03–2004/05)
 Introduced the Health Service Extension Program
(HSEP)
 Innovative health service delivery system
 Health Extension Programme (HEP) in Ethiopia
was embarked in 2003 and is hence a sub-
component of the HSDP since then.
 “It is a package of basic and essential promotive,
preventive and selected curative health services,
targeting households in the community, based on
the principles of primary health care to improve the
health status of families with their full
participation, using local technologies and the
skill and wisdom of the communities”
71
Health Extension Programme

 HEP is similar to PHC in concept and principle,

except HEP focuses on households at the
community level, and it involves fewer facility-
based services
 The philosophy of HEP is that if the right
knowledge and skill is transferred to households
they can take responsibility for producing and
maintaining their own health
 The overall goal of the HEP is to create a healthy
society and reduce rates of maternal and child
morbidity and mortality.

72
Components of the Health Extension
Package
 The HSEP intends to provide communities

with four essential packages of services:

A. Disease Prevention and Control

1. HIV/AIDS and other sexually transmitted

infections (STIs) and TB prevention and
control
2. Malaria prevention and control

3. First Aid emergency measures

B. Family Health
1. Maternal and child health
2. Family planning
3. Immunization
4. Nutrition
5. Adolescent reproductive health 73
Components of the HEP…

C. Hygiene and Environmental Sanitation

1. Excreta disposal
2. Solid and liquid waste disposal
3. Water supply and safety measures
4. Food hygiene and safety measures
5. Healthy home environment
6. Control of insects and rodents
7. Personal hygiene
D. Health Education and Communication:
cross cutting
74
HSDPIII (2005/6-2009/10)
 The ultimate goal of HSDP-III is “to improve the
health status of the Ethiopian peoples through
provision of adequate and optimum quality of
promotive, preventive, basic curative and
rehabilitative health services to all segments of the
population.”
 Directly aligned with the health-related MDGs
 to improve maternal health
 to reduce child mortality
 to combat HIV/AIDS, malaria, TB and other
diseases
75
HSDP IV (2010 –2015)
 Developed as part of the National Growth
and Transformation Plan (GTP)
 The expression of the renewed commitment
to the achievement of MDGs
 Gives priority to maternal and child health,
nutrition, as well as the prevention and
control of major communicable diseases,
such as HIV/AIDS.
 Emphasizes the strengthening of Health
Service Extension Program to improve the
quality of PHC, human resource development
and health infrastructure.
76
HSDP IV...2
 Community empowerment/ownership
 Developed the three tier health delivery system
 Developed through two approaches:
 the strategic plans was developed using the
Balanced Scorecard (BSC) framework
 Costing of HSDP IV is conducted using the
Marginal Budgeting for Bottlenecks (MBB) tool
 MBB helps to look into the health system bottle
necks, high impact interventions and associated
costs of achieving results that have been
planned under the HSDP-IV

77
 Ethiopian Health Tier System

Specializ
ed
Hospital
Tertiary Level Health
3.5-5.0 Care
million
People

General Hospital Secondary Level Health

1.0-1.5 million people Care
Primary Hospital
40,000 People
Health Center

(60,000-100,000
people)
Health Center Primary Level
(15,000-25,000) People Health Care
Health Post
(3000-5000) People

Urban Rural

78
Health Sector Reforms in Ethiopia
 Many governments in the world are introducing
major changes in the health sector.
 International organizations, such as the World
Bank, are promoting ideas that would involve
significant reforms.
 These changes are commonly referred to as
Health Sector Reforms (HSR).
 Health sector reform is concerned with making
planned changes to health policies; and the
organizations, systems and culture by which
health policies are formulated and implemented

79
Health Sector Reforms...2

 We may refer to two definitions

 Health sector reforms are concerned with
changing health policy and the institutions
through which policies are implemented”.

 “Health sector reform is a substantial

change which aims to improve efficiency,
equity and effectiveness of the health
sector”.

80
Health Sector Reforms...3
 Ethiopia has implemented a series of health sector
reforms in response to a changing internal and
external environment.
 National Health Sector reform:- has been

defined as a sustained process of fundamental

change in national policy and institutional
arrangements led by government and designed
to improve the functioning and performance of
the health sector and ultimately the health status
of the population
 Business Process Reengineering: - leading to

a set of new approaches like benchmarking best

practices, designing new processes, revising
organizational structures and a selection of key
processes 81
Health Sector Reforms...4
 Decentralization as a principle and main
strategy
 Integration of Services
 Health Insurance Scheme
 Health Care Financing
 Joint Governance and Coordination
 Health Facility Governance
 Health management information system

82
Health Sector Reforms...5
Expectations of the health sector reform:
 The main expectation of health sector reforms is
health improvement or gain and that is to be
ascertained in the following areas of concern:
 Improved equity in health and health care services
 Increase and better management of health
resources
 Improved performance of health systems and
quality of care
 Greater satisfaction of consumers and providers of
health care

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