Health System Decentralization the Case of Ethiopia

1. Health System Decentralization the Case of Ethiopia Kenya National Health Leadership Management and Governance Conference Nejmudin Kedir Bilal, P. Health Economist, AfDB January 29, 2013

2. Outline • Background • How was decentralization conducted? • Why decentralization in Ethiopian health system? • Key health systems aspects of decentralization • Lessons learnt

3. Background • A coalition of rebel forces under the Ethiopian Peoples’ Revolutionary Democratic Front defeated the socialist government of Mengistu Haile Mariam in May 1991 • Ethiopia’s first popularly chosen national parliament and regional legislatures were convened in May and June 1995 • The current government of Ethiopia was established in August of 1995 • Since then the government has promoted a policy of ethnic federalism, devolving significant powers to subnational authorities.

4. The process of Decentralization • Part of broader government decentralization • Phased approach • 1996 to Regional States • 2002 to Woredas (and Zones) • Not one size fits all approach • Some with strong zones • Some with lessor role for zones • Some with no zones • 9 regional state governments, • 2 city adminis • Zones, • More than 850 districts • 15,000 Kebeles

5. Health Systems Decentralization was one of the key reforms triggered by multiple challenges Health service Delivery reform Decentralization Health Planning & HIS reforms Governance and Financing Reform Pharmaceuticals reform

6. Health System Decentralization • 4 tier health system organization • PHCU (health center + 5 health posts) (25,000) • District hospital (250,000) • Zonal hospital (1 million) • Specialized hospital (5 million people) • Health Extension Programme 2003/2004

7. Roles of different levels of the health system was defined • MOH –policy direction, setting standards and resource mobilization • RHBs, ZHDs and WorHOs set health priorities, deliver services, and determine budget allocations • WorHOs manage personnel issues, health facility reconstruction, and procurement at PHCU • Regions and woredas get block grants

8. Health Human resources management was one of the key decentralized functions • Major universities under MoEducation • Regional collages midlevel and low level health workers • RHBs, ZHDs and WorHOs can hire and fire • WorHOs are charged with HCs and HPs • Challenge: inter regional transfer

9. Health Planning Challenges in early phase of decentralization • Global and national commitments vs decentralized decision • Challenge of getting priorities across • Multiple plan documents • Historical budgeting not relevant to the local contexts

10. The “One plan” initiative • Priorities are set every 5 years and every year • The main Principe is ensuring vertical and horizontal linkage of priorities and targets • Led by government via steering committees at all levels • Combination of top down and bottom up process • Sharing and consulting with stakeholders • Endorsing the strategic and annual plans at joint sector meeting • Joint monitoring on annual basis

11. Centralized and fragmented information system required reform Data collection Too much data items 400 at HCs, 500 at WorHo. Irrelevant Reporting problems Incomplete, Untimely Redundancy, parallel= administrative burden Data analysis Not done at point of collection Uncoordinated initiatives Poor institutionalization

12. Key principles were set to reform and decentralize health information system • Standardize Indicators & definitions Disease list for reporting & case definitions Client / patient flow & data elements Recording & Reporting forms Procedure manual Information use guidelines 2. Simplify Reduce data burden Streamline data management procedures 3. Integrate Data channel Client / patient information at facility (integrated folder) 4. Institutionalize

13. Not only collection but use information at all levels FMOH Compiled and used RHB WoHO Compiled and used/reported HF Compiled and used/reported Weekly Weekly Weekly Monthly Monthly Monthly Quarterly Quarterly Quarterly Service delivery report

14. Health Service challenges: Preventable health problems as major causes of morbidity and mortality (60%-80%) • Only 1% of households had ITNs (<18% insecticide treated) • Only 40% of the population within 10 KM of health institution • 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 • Poor institutionalization of PHC

15. HEP: Innovative approach to deliver Preventive and Promotive Health Services Hygiene and Environmental Sanitation Disease Prevention and Control MNCH Health Education

16. HEP: Process & Roles defined for Training, Deployment & Support on Implementation

17. Capacity building: Accelerated scaling up of HRH and infrastructure to support HEP

18. Decentralized 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

19. Key Lessons • Part of broader government decentralization • Sequencing decentralization makes it more effective • Continuous and demand based capacity building • Some things are better kept at higher levels • Devolution does not mean no accountability! • Be ware of interrupting ongoing programmes