Partnership for Prevention and Care: Africa Health Conference

1. Partnership for Prevention and care Africa Health ConferenceThe World Bank’s contribution to Ethiopia and other African countries to achieve the health related MDGs GebreselassieOkubagzhi, Dr. med Senior Health and HIV/AIDS Specialist World Bank, Consultant

2. World Bank Support to Healh Development in Africa • The World Bank has for years been supporting African Countries to improve the health status of their populations using different instruments. The support took the form of technical assistance, material and financial support • The world Bank strongly supports the MDGs and made available funds to countries to accelerate the implementation of MDGs based on the belief that achievement of MDGs will facilitate the improvement of Health status of populations in general and the poor in particular. • The World Bank support is usually based on proper assessment of needs and changing environments.

3. A Changing African Context • Economic growth in Africa averaged 5 percent per year in the past decade • Poverty rate has been falling by 1 percent per year • Private sector is attracting more investment • Robust market oriented, pro-poor reforms • Africa on the brink of an economic takeoff • Greater diversity among countries: • Middle income countries increasing – from IDA to IBRD • Fragile states: lack of security, low capacity, humanitarian needs

4. African successes in health • Child mortality reduced from 180 to 129 (2009-2010) • Maternal mortality declined between 40 and 50% from 1990-2008. • HIV prevalence showed a declining trend in many African countries and mortality due to HIV has shown reduction since the introduction of ARV Treatment • Malaria mortality down, interventions up, rapid progress in scaling up insecticide treated net use among children across all African countries • DPT 3 coverage rate has increased with marked difference between countries

5. Going ForwardIn lending the Guiding Principles lead to the following priorities: • Maintain long-term trend in overall lending for HNP, while continuing recent improvements in existing portfolio quality indicators • Invest in health systems for outcomes to strengthen country systems, creating enabling environment for impact of single-disease partnerships • Use innovative approaches such as Results Based Financing to increase the quantity and quality of health services • Focus on health systems aspects of priority disease control and reproductive health interventions, and expand regional focus in disease control, using recently developed regional framework • Expand collaboration with IFC to further expand PPPs • Invest in scaling up new technologies in eHealth and mHealth interventions beyond pilot phase

6. Going ForwardIn partnerships, the Guiding Principles lead to the following priorities: • Collaborate with disease and health systems partnerships, and with technical agencies (UN Specialized Agencies, bilateral institutions) to tap into expertise in disease control, M&E, and country specific knowledge as part of strengthening lending and AAA • Internally, expand collaboration with other sectors and PREM, as well as IFC • Strengthen partnerships with Africa based institutions (African Union, NEPAD), as well as regional economic groups, regional health communities (ECSA), and academic and research institutions • Develop new partnerships with private sectors in countries (ie, malaria) Work with the International Health Partnership (IHP+) on joint support to single country-led national health strategies, and with the Harmonization for Health in Africa (HHA) partnership to strengthen capacity in areas of health

7. Going ForwardIn knowledge the Guiding Principles lead to the following priorities: • Built on successful model of Dakar and Nairobi Hubs in providing just-in time expert technical assistance to countries and Bank teams in areas of health systems strengthening • Synthesize and disseminate lessons learned from evaluations of health service delivery innovations implemented in RBF operations • Develop capacity for countries to foster synergies between disease control and health systems • Collaborate in multisectoral analyses in areas such as service delivery, governance, population, and nutrition • Disseminate and expand work on M&E, including results chains, targets setting, and tools for improving project M&E

8. Going ForwardThe Results Framework Once priorities are agreed, the Results Framework will provide indicators with benchmarks at three levels: • Tier 1: shows country-level development health outcomes. These are determined by the actions in many sectors, the overall macroeconomic environment, and technological change. The Bank, and the HNP sector, contributes to health outcomes, but attribution is not feasible; • Tier 2: shows indicators measuring Bank outputs and outcomes that jointly with the activities of countries and other partners lead to better coverage with interventions that are known to contribute to health outcomes. Where feasible, indicators in this tier will be disaggregated by poverty quintile, urban-rural, and gender; • Tier 3 indicators measure the efficiency, quality, and effectiveness of AFTHE activities in lending, analytical work, and partnerships

9. Short Historical Perspective of Public-Private Partnership in Ethiopia • The history of International partnership within the health sector in Ethiopia can be traced to July, 1896 (Ethiopian calendar) when a Russian Medical Team arrived in Addis Ababa to provide health care for war victims during the battle of Adwa. • No agreement was signed between the provider and recipient country and the sole factor was humanitarian concern and international solidarity. T • The Russians also established a 20-bed provisional hospital at the present site of Menilik II hospital.

10. Short Historical Perspective Conti…. • Similarly, the history of Human Resource Development goes back to the 1950s, When the British Red Cross and the then United Nation’s Relief and Rehabilitation Administration (UNRRA) supported the training of auxiliary health workers and sanitary inspectors respectively, and sent ten students for physician training of 6-8 years in Kampala, Alexanderia and Beirut. • The Ethiopian Red Cross Society established a School of Nursing in 1949 and operated a blood bank being a sole provider and a living example of privately delivered but governmentally funded model of Public-private Partnership. • The Norwegian missionaries have a long history of health service provision in the country and used to run Yirgalem, Arbaminch and Gidole Hospitals and were engaged in the training of frontline health Workers.

11. Health and Medical Care in EthiopiaThe Health sector • The history of Government organized medical services can be traced to the establishment of the first hospital (Menilik II Hospital) in 1909. A number of hospitals and clinics were established since then. When the Ministry of Public Health was established in 1947, there were 46 hospitals with 3400 beds and 92 clinics , 106 physicians (only two of them were Ethiopians) and 88 nurses

12. Health and Medical Care in EthiopiaThe Health sector conti… Number of Health Facilities and health workers • According to the information in the HSDP IV document, in 2009/2010 there were: • HSDP I (1994 E.C)* HSDP III (2001 E.C)* • Health Posts 76 14416 • Health Centers 412 2689 • Hospitals 87 195 • Medical Doctors 1888 2152 • Nurses (not including midwives) 11,976 20,109 • Midwives 862 1379 • Health Officers 30 3760 *Ethiopian Calendar year The above figures indicate massive increase of facilities and health personnel although the increase is modest in some categories of health workers such as medical doctors and midwives. The rural health services have enormously increased since the deployment of two female Health Extension Workers for each Kebele Health Post.

13. Health and Medical Care in EthiopiaThe Health sector conti… • A health Sector Strengthening scheme was adapted and resulted in the expansion of health facilities which are critical in expanding medical service delivery to unreached areas. As a result of this, • HCT providing facilities have increase from 658 in 2004/5 to 2184 in 2009/10. The rate of HIV positivity has declined from 12.5% in 2004/5 to 1.5% in 2009/10. • Concerted efforts by both public and private sectors have led to counseling and testing of 9.4 million people; • providing support to 104,399 People infected by HIV and 325,201 orphans and Vulnerable Children. • Clinics and hospitals operated by the private sector participate actively in the provision of routine counseling and testing

14. Health and Medical Care in EthiopiaThe Health sector conti… • At the end of 2004/5 a total of 8278 patients were receiving ARV treatment out of which only 900 used to get free treatment. • At the end of June 2010 cumulative number of patients who have ever started ARV treatment were 268,934 (61.8% coverage of the estimated total number (336,160) of positive patients that require the ARV treatment>), in line with the government measures taken to ensure access to universally, free ARV treatment as of 2004/5 both in government and non-government health facilities. • Among the mothers who were found HIV positive 6990 (53%) have taken ARV prophylaxis . The prevention of HIV transmission from mother to child during pregnancy, delivery and breast feeding was given serious consideration.

15. Health and Medical Care in EthiopiaThe Health sector conti… The World Bank Started supporting the health sector in Ethiopia with its first project of Family Health in 1989 and the total credit amount was US$33 million. The Second World Bank Financed Project was HSDPI in 1998 with a total credit of US$100. HSDP III was supported by the Multi Donor Trust Fund (MDTF) which was used to procure drugs, equipment and supplies for health facilities throughout the country Furthermore, the World Bank supports the “Private Sector Development Capacity Building Project” with a total amount of USD 24 million and an additional amount is being considered.

16. Health and Medical Care in EthiopiaThe Health sector conti… HIV/AIDS The World Bank started the first Multi-SectoraI HIV/AIDS Prevention and Control Program initially for two countries namely Ethiopia and Kenya and support to other countries followed. The first wave of MAPs in Africa were funded from USD 500 allocated for HIV/AIDS intervention to fight the expanding epidemic. When the initial allocation was used up additional resources were allocated for subsequent HIV/AIDS projects.

17. Health and Medical Care in EthiopiaThe Health sector conti… • The Bank allocated USD 59.7 million for the first HIV/AIDS project (EMSAP I ) and USD30 million for EMSAP II. • The Bank also supported analytic studies to understand the level and the factors associated with the HIV epidemic. Indications are the epidemic is showing stabilizing and declining tendency in Ethiopia due to unceasing efforts of the government and collaboration of partners including the private sector and active community involvement. In addition, the world bank has provided technical and material support to strengthen HIV/AIDS interventions around the business community.

18. Health and Medical Care in EthiopiaThe Health sector conti… • HIV/AIDS interventions by design provided a broader area of participation by the private sector. A number of CBO, NGO, Associations etc have participated and continue to participate in the implementation, supervision and evaluation of HIV/AIDS interventions. Some are recipients of GF, PEPFAR, bilateral, and multilateral including World Bank funds to mention a few. • The Community Response Component of HIV/AIDS interventions is a mechanism established to scale up HIV/AIDS related interventions among women, youth and other vulnerable groups (MARPs) which show high HIV incidence.

19. Health and Medical Care in EthiopiaThe Health sector conti… Conclusions • Historically the Private sector has played a pioneering role in the introduction of modern medicine in Ethiopia even before the establishment of a government health management structure. • The initiation of PHC strategy, Millennium Development Goals, Multisectoral HIV/AIDS and IHP demanded the enhancement of Public-Private partnership to achieve their objectives. • Given the present implementation status, the country is on track to meet most of the MDGs and may take a special effort to reach the Maternal Mortality MDG by 2015. • World Bank was actively involved in supporting the health sector including MDGs in Ethiopia and engaged in advocacy to enhance Public-Private Partnership.. • In Ethiopia health and medical care services have expanded and are contributing significantly to the achievement of MDG.