HSS Training for USAID DLIs

1. HSS Training for USAID DLIs Health Systems Strengthening Efforts:The Case of Ethiopia Nejmudin Bilal Health Systems 2020 Abt Associates (August 28, 2011)

2. Objective To see a country case on HSS efforts to make it responsive to the needs: Ethiopia

3. General Background • Population: 80 million • Population growth rate: 2.7% /year • Rural population:84% • Geographic size: over 1.1 million Km. Sq. • GDP $220/capita • U5 mortality: 123/1000 • MMR 470/100,000

4. Challenges and HSS interventions: Before and After Decentralization Facility Governance and HCF Reform Health Extension Programme

5. 1. Decentralization of Health System • 4 tier health system organization • Prioritized primary health care • MOH –policy direction and resource mobilization • Regional Health Bureaus, District Health Offices---managing service delivery • Community participates and strengthens CHS

6. Decentralization of Health…. Decentralization set the stage for the results I share in the next two reforms

7. 2. Governance and Health Care Financing Reform-Five Components • Health facility governing boards • HFs user fee revenue retention and utilization. • Systematizing the fee waiver system and exemption scheme • Outsourcing of non-clinical services. • Establishment of private Clinics/wings in public hospitals

8. Facility governing boards play critical management role • Ensure proper implementation of the reforms • Review and approve plans • Approves budget and follow up on utilization • Ensure that the activities of the hospital are carried out with transparency and accountability

9. 86 hospitals and 1,600 HCs have established facility governing boards • Improved responsiveness to local needs • Increased accountability to public funds • Improved resource mobilization • Increased role of local community ---good governance • Created sense of ownership by management

10. Governance and Health Care Financing Reform-Five Components • Health facility governing boards • HFs user fee revenue retention and utilization. • Systematizing the fee waiver system and exemption scheme • Outsourcing of non-clinical services. • Establishment of private Clinics/wings in public hospitals

11. Revenue retention led to improved quality of care • Foundation for all health care financing reform agenda • Facilities' ownership to control leakage • Generates additional resource • Invested strictly on quality improvement

12. Safe water Supply for health facility: WolaitaSodo HC After the reform Before the reform

13. Uninterrupted supply of medicine

14. New Microscope: improving diagnostic capacity of health institutions

15. Modern Dental equipment: ArbaMinch Hospital

16. Beautiful Environment motivates staff and encourages patients to use health institution: Awassa HC

17. New Generator: ensuring safe storage of medicine and uninterrupted functioning of diagnostic equipment Shashemene Hospital

18. Health Care Financing and Governance Reform • Establishment and operation of governing boards. • HFs user fee revenue retention and utilization. • Systematizing the fee waiver system and exemption scheme • Outsourcing of non-clinical services. • Establishment of private Clinics/wings in public hospitals

19. Fee waiver is a key to financial risk protection for the poor • Screening by Village Committees • Criteria for poverty certificate • Waiver system reform is step for health insurance-SHI and CBHI

20. 2 Health Care Financing and Governance Reform • Establishment and operation of governing boards • HFs user fee revenue retention and utilization. • Systematizing the fee waiver system and exemption scheme • .Outsourcing of non-clinical services. • Establishment of private Clinics/wings in public hospitals

21. Non-clinical services are outsourced Outsourcing enabled health facilities to: • Focus on core competencies • Tapping into external expertise • Improved Quality • Reduce and control operating costs. Overview of outsourced gardening: MizanTeferi Hospital /SNNPR/: .

22. Health Care Financing and Governance Reform • Establishment and operation of governing boards • HFs user fee revenue retention and utilization. • Systematizing the fee waiver system and exemption scheme • .Outsourcing of non-clinical services. • Establishment of private Clinics/wings

23. Private wings motivated staff and provided treatment options for patients • Established in public facilities • Higher payments than the normal fee • Amount of time in private wing is limited • Staff and health institution share the revenue

24. 3. The Health Extension Programme (HEP)

25. HEP is an evidence based intervention • Poor utilization = 30% • Children < 6 months, exclusively breastfed: 32% • Children with diarrhea given ORT: 37% • Delivery attended: 6% • Children with fever/cough brought to a health facility: 17% • Low immunization coverage Due to • Limited knowledge of optimal care practices at the family level • Limited physical access to health services in rural communities

26. HEP tackles the major causes of ill-health in Ethiopia • 2 HEWs/village • On 16 packages of health interventions in 4 major areas • Disease prevention and control (Malaria, HIV/AIDS, TB etc) • Family Health (FP, ANC, DS, PNC) • Hygiene and Environmental health services (personal and env hygienic, rodent control ..) • Information Education Communication • Salaried employees • House to house (75%)

27. Why are they all female?

28. Support structure for HEWs---strengthening the system • 1 HP/village- equipped • 1 supervisor/10 HEWs • Community based HMIS • 1 HC/5 HPs for technical and logistic support • Village council-leadership

29. Health Outcomes Associated with Health Systems Strengthening

30. Maternal Health service coverage

31. Child Health service coverage

32. Results Achieved… (HIV/AIDS & Malaria) Malaria

33. Increasing Expenditure in Health

34. Partnership with USAID’s in HSS • Health Financing and Governance Reform • Supported the training and deployment of HEWs and Health Officers • Supply Chain Management System • Design and scaling up of HMIS and DHS

35. Thank you