Overview of the Ministry

Health Sector Development Programme (HSDP) (2010/11-2014/15) gives an overview of the performance of the health sector in the Ethiopian Fiscal Year (EFY) 2006(2013/2014), examining the progress made, the efforts that are underway and the challenges faced by the sectorin the promotion of health, and in the implementation, financing and governance of health services.
As in previous years, the development process of the Annual Performance Report for EFY 2006 was widelyconsultative, involving Regional Health Bureaus (RHB), the various Directorates of the Federal Ministry ofHealth (FMOH), and agencies accountable to the FMOH as well as Development Partners (DP).

The report highlights the major achievements and challenges of the health sector in EFY 2006, under the three Strategic Themes:
(i) Health Service Delivery and Quality of Care;
(ii) Leadership and Governance; and
(iii) Health


HEALTH SERVICE DELIVERY AND QUALITY OF CARE
This Strategic Theme comprises of the Health Extension Program (HEP), maternal and newborn health services, child health services, national nutrition programme, prevention and control of communicable and non-communicable diseases, public health emergency preparedness and response, and quality of health services.

The performance of the sector during EFY 2006 was as follows:

1.Health Development Army (HDA) implementation has started in EFY 2003, with progress being made inthe organization and network formation over the past three years. In EFY 2006, 29,849 Women Development Groups (WDGs) were established in Tigray, with the formation of 149,245 one-to-five networks. Similarly, in Southern Nations, Nationalities and Peoples Region (SNNPR) a total of 84,129 HDA groups with
626,953 one-to-five networks were formed, while Amhara Region established 118,625 HDA groups and 572,802 one-to-five networks, and Oromia Region a total of 195,864 HDA groups and 880,975 one-to-five networks. A total of 10,407 HDA groups with 41,561 one-to-five networks were established in Addis Ababa in EFY 2006. In Harari, 1,613 HDA groups with 5,510 one-to-five networks were established, while 2,286
HDA groups with 12,695 one-to-five networks were established in Dire Dawa. Therefore, at the national level, a total of 442,773 HDA groups with 2,289,741 one-to-five networks were formed in EFY 2006.

2.Many hygiene and environmental health activities were carried out in EFY 2006; with regard to Open Defecation Free (ODF) kebeles, a total of 3,655 kebeles were declared as ODF kebeles in EFY 2006.

3.The Ethiopia Mini Demographic Health Survey (EMDHS) 2014 was carried out in the fiscal year, showing a steep increase between 2011 and 2014 in Contraceptive Prevalence Rate (CPR) from 28.6% to 41.8%, and a decrease in Total Fertility Rate (TFR) from 4.8 to 4.1. A remarkable progress was also observed in the percentage of skilled birth attendance (reflecting the performance over the five year period before the survey) from 10.0% in 2011 to 14.5% in 2014, ranging from 6.6% in Afar to 86.0% in Addis Ababa.
Of note is the fact that this 2014 estimate, referring to the five-year period before the survey, is not directly comparable with the 2014 HMIS estimate, but with HMIS estimates of the skilled birth attendance (SBA) over the same period (i.e. ranging between 17% and 23%), showing relatively
moderate discrepancies between the two sources.

4.Concerning maternal health services, antenatal care (ANC) coverage (at least one visit) increased from 97.4% in EFY 2005 to 98.1% in EFY 2006, postnatal care (PNC) coverage increased from 50.5% to 66.2%, while the percentage of deliveries attended by skilled health personnel increased from 23.1% in EFY 2005 to 40.9% in EFY 2006. Conversely, clean and safe delivery coverage by Health Extension Workers (HEW)
declined from 11.6% in EFY 2005 to 8.8% in EFY 2006; this decline was due to the expansion of Health Centers (HC) and the strengthening of HC-Health Post (HP) networks, with subsequent focus on provision of skilled care at birth in the catchment areas and increase in SBA coverage. Contraceptive acceptance rate (CAR) slightly increased from 59.5% in EFY 2005 to 63.0% in EFY 2006. The proportion of pregnant
women counselled and tested for prevention of maternal to child transmission (PMTCT) of HIV increased from 54.9% to 57.0%.

5.The percentage of HIV-positive pregnant women who received ART to prevent Maternal to Child Transmission (MTCT) of HIV has been estimated at 60.6% in EFY 2006, with an increase from 42.9% in EFY 2005. According to the 2013 UNAIDS Report, Ethiopia is one of the few "rapid decline" sub-Saharan African countries, with a reduction by 50% of new HIVinfections among children between 2009 and 2012.

6.The EDHMS 2014 showed a decrease in stunting prevalence from 58% to 40% among under 5 childrenbetween 2000 and 2014, while the proportion of children underweight declined from 41% to 25%, and the prevalence of wasting from 12% to 9% in the same period.

7.Concerning child health services, a general increase in immunization coverage was observed between EFY2005 and EFY 2006 for pentavalent 3 vaccine (from 87.6% to 91.1%), pneumococcal conjugate vaccine(PCV) 3 (from 80.4% to 85.7%), measles vaccine (from 83.2%, to 86.5%), as well as for the percentage of fully immunized children (from 77.7% to 82.9%). The new rotavirus vaccine has been introduced into the routine immunization schedule in EFY 2006. The cumulative number of HCs providing Integrated Management of Neonatal and Childhood Illnesses (IMNCI) increased from 2,373 in EFY 2005 to 2,967 in EFY 2006. Concerning neonatal care, out of the total 850 HCs with established newborn corners, 313 were
implementing the service, while the number of hospitals providing neonatal intensive care unit services has increased from 27 to 30 in EFY 2006.

8.The national VAS coverage among children aged 6-59 months in EFY 2006 was 71.7%, below the performance in the previous year (93.1%) as well as the target set for EFY 2006 (96.0%); wide differences were observed across regions, ranging between 2.0% in Gambella to 96.5% in Oromia Region.

9.In EFY 2006, the de-worming coverage of children aged 2-5 years (82.4%) was lower than in EFY 2005 (91.4%) and the annual target (97.0%) for EFY 2006, ranging between 5.8% in Gambella Region to more than 100% in Afar Region.

10.HIV/AIDS is one of the top priorities of HSDP IV. There was a steep increase in the number of facilities providing HIV Counselling and Testing (HCT), PMTCT and Antiretroviral Therapy (ART) services: the increase was from 3,040 in EFY 2005 to 3,447 in EFY 2006 for HCT, from 2,150 to 2,495 for PMTCT, and from 880 to 1,047 for ART in the same period. The number of HCT services decreased from 11,965,533 in
EFY 2005 to 9,664,519 in EFY 2006.

11.A linear increase has been observed in the number of People Living With HIV/AIDS (PLWHA) ever enrolled, ever started and currently on ART over the past years; in particular, there was an increase between EFY 2005 and EFY 2006 from 744,339 to 805,948 for PLWHA ever enrolled in HIV/AIDS care (+61,609), from 439,301 to 492,649 for those ever started (+53,348), and from 308,860 to 344,344 for those currently
on ART (+35,484).

12.In EFY 2006, the distribution of 19,866,625 Long Lasting Insecticide-treated Nets (LLIN) was planned in malaria-endemic areas; however, 11.7 million LLINs were actually distributed, increasing the cumulative number of distributed LLINs to 58,676,866. With regards to vector control, the revised plan was to implement IRS in 5,111,694 households in EFY 2006; however, a total of 3,930,604 households in malaria endemicareas were sprayed, below EFY 2005 performance (5,032,693 households) and target for the current year(with a target achievement of 76.9%). In EFY 2006, 2,627,182 laboratory confirmed plus clinical malaria cases were reported, with a decrease with respect to the number of cases (3,862,735) reported in EFY
2005. The percentage of laboratory confirmed cases in EFY 2006 (84.1%) was higher than the percentage (73.8%) estimated in EFY 2005. A total of 213 deaths were recorded in EFY 2006, with a Case Fatality Rate (CFR) of 0.01%.

13.Between EFY 2005 and EFY 2006, only fluctuations were observed for TB treatment success rate (from 91.4% to 92.1%) and TB cure rate (from 70.3% to 69.1%), while TB case detection rate decreased from 58.9% to 53.7%: all these indicators were below the target set for EFY 2006. In EFY 2006, additional 13 Multi-Drug Resistant TB (MDR TB) centres started treatment services, increasing the total number of MDR TB treatment centers to 32 country-wide, while a total of 332 health institutions were providing follow-up services. A cumulative total of 1,559 MDR TB patients were enrolled in second line drug (SLD) treatment and, out of them, 598 MDR TB patients were enrolled in SLD treatment in EFY 2006.

14.Concerning prevention and control of Neglected Tropical Diseases (NTD), mapping the geographical distribution of trachoma and leishmaniasis has been completed, while mapping of lymphatic filariasis,schistosomiasis and soil-transmitted helminthiasis is still incomplete. A total of 7,482,414 people (out of the planned 8.4 million) received Ivermectin treatment for onchocerciasis in EFY 2006, while 1,422,298 people received preventive therapy (Ivermectin and Albendazole) for lymphatic filariasis. Furthermore, 1.4million tablets of Praziquantel and 8 million tablets of Mebendazole have been given to school-children as part of the schistosomiasis and soil-transmitted helminthiasis prevention and control, respectively.

15.The National Strategic Plan for Control, Elimination or Eradication of Non-Communicable Diseases (NCD) was completed in EFY 2006. Progress was made in different areas, such as development of population- based cancer registry, prevention and control of mental diseases and tobacco control.

16.For the epidemic prone diseases under surveillance, the number of cases reported in EFY 2006 was as follows: 24,493 suspected measles cases (CFR=0.5%); 268,353 suspected dysentery cases (CFR=0.02%); 1,783 suspected meningococcal meningitis cases (CFR= 3.8%); 868 suspected anthrax cases (CFR=1.5%); 3,062 suspected rabies cases and exposures (CFR=1.4%); and 4,754 suspected relapsing fever cases (CFR=0.4%). Furthermore, the non-polio Acute Flaccid Paralysis rate was estimated at 3.2 per 100,000 children under 15 years, above the WHO standard; ten polio cases were confirmed in EFY 2006 from Dollo Zone in Somali Region, and appropriate response was undertaken. A total of 31 suspected yellow fever
cases were reported from South Omo Zone of SNNPR in EFY 2006; furthermore, 12,238 cases of dengue fever were reported, mainly from Dire Dawa, Gode in Somali Region and Adaar Woreda in Afar Region,with almost all cases being reported from urban kebeles.

17.In relation to quality of health services, the Ethiopian Hospital Reform Implementation Guideline (EHRIG) has been implemented in EFY 2006, resulting in improved service delivery at public hospitals. The institutional mortality rate was 4% (better than the national target of 5%), the bed occupancy rate
reached 60% (below the national target of 75%), the average surgical waiting time was estimated at 10 days,
while the patient satisfaction reached 77%.

18.The Auditable Pharmacy Transactions and Services (APTS) Initiative aimed to improve the quality of pharmacy services and increase the availability of specialty drug to 70% and the availability of essential drugs to 100% in 22 high load university hospitals in EFY 2006. A number of undertakings have been performed in improving emergency care, including the implementation of the emergency services strengthening project in Addis Ababa.

19.In EFY 2006, the number of functional regional blood banks increased from 12 to 25, with 30 mobile teams collecting blood from the communities on a daily basis. A total of 87,685 units of blood were collected in EFY 2006, with a 46% increase from 60,090 in the previous year, while the proportion of voluntary blood donors increased from 54% to 70% in the same period.

20.In EFY 2006, a total of 30,927,623 outpatient department (OPD) visits were provided with an average of 0.35 OPD visit per person per year; this performance was slightly higher than the achievement in EFY 2005 (0.34).

21.Concerning the national laboratory system, trainings were given for laboratory professionals as well as equipment was provided to health facilities to improve the quality of the laboratory system in the country. As part of the on-going laboratory quality assurance mechanism, 156 laboratories have participated in these activities through use of quality control samples.

LEADERSHIP AND GOVERNANCE
The Leadership and Governance chapter comprises of evidence-based planning, monitoring, evaluation, policy formulation and implementation. It also includes the development and implementation of the regulatory framework. Different activities had been performed in EFY 2006.

22.The status of implementation during the fourth year of HSDP IV was monitored by the FMOH and regions using various monitoring and reporting mechanisms. The FMOH held regular Joint Steering Committee (JSC) meetings with Regional Health Bureaus (RHB) every two months, and bi-weekly Executive Committee Meetings with agencies. FMOH also held quarterly Joint Consultative Forum (JCF) meetings with Development Partners (DP), and bi-weekly Joint Core Coordinating Committee (JCCC) meetings. In addition, the FMOH developed the maternal, newborn and child health (MNCH) scorecard and, from mid-EFY 2006 onwards, progress in the maternal, neonatal and child health programs can be monitored
every quarter using the MNCH scorecard for accountability and action purposes.

23.The FMOH conducted a mid-year inspection, involving members of the parliament and other government sectors, to verify activities that had been undertaken at grass roots level. The inspection was conducted in all regions, 26 zonal health departments , 52 WorHOs, 52 HCs as well as in kebele administration offices and one-to-fivenetworks. The result of inspection has shown the strengths and weaknesses during the preparatory and implementation phases, and based on the inspection's results, measures were taken, particularly to strengthen the HDA and thereby the overall health system.

24.One of the major planning activities performed during EFY 2006 was the finalization of the Woreda-based Core Plan for EFY 2007. Furthermore, the draft Health Sector Transformation Plan was prepared for thecoming five-year period (EFY 2008-2012) as part of the 2035 vision of the health sector.

25.Concerning the Health Management Information System (HMIS), the revision of the list of the HMISindicators was completed; training was conducted in 3,338 (97.4%) public facilities and 4,175 (69.9%) private facilities, making a total of 7,513 (79.9%) public and private facilities being already trained. In
addition to training, sufficient amount of printing materials were distributed directly to districts, and Tigray, Afar and Somali Regions have already started using the revised tools for recording and reporting.

26.The Community Health Information System (CHIS) is being implemented, with a cumulative number of 25,569 HEWs being already trained (78.6% of the total). CHIS implementation coverage increased from 40% in EFY 2005 to 64.5% in EFY 2006 country-wide, ranging from 2.5% in Somali Region to 99.0% in SNNPR. Amhara, Tigray and Oromia Regions showed an intermediate coverage (94.0%, 79.8% and 43.8%,
respectively).

27.A Joint Review Mission (JRM) was conducted in EFY 2006, in collaboration with DPs, to review the level of achievement of the strategic objectives of HSDP IV, identify challenges, document best practices, and forward recommendations to improve future governance, management and implementation of activities to meet HSDP IV goals.

28.In EFY 2006, the operational research focused on HIV/AIDS, TB, malaria, immunization, traditional medicine, nutrition, and policy. In particular, the analysis of 2011/2012 data from antenatal care-based HIV surveillance sites was completed and released this year, estimating the HIV prevalence among pregnant women at 2%; a survey on the prevalence of the first line anti-TB drug resistance was completed, with estimation of MDR TB prevalence among new and re-treatment cases.

29.The regulatory system has been strengthened, and a number of activities related to Inspection and Quality Control of "Products", "Premises", and "Professional Practice" had been accomplished. In EFY 2006, 17,183 new health professionals were registered and licensed at federal and regional levels, while the registration was renewed for 8,963 health professionals. Import permits were given for pharmaceuticals, food products, and tobacco products, while export permits were given for drugs and food products. Inspection and licensing were carried out on a number of facilities, including food import and distribution enterprises, pharmaceuticals import and distribution enterprises, cosmetics importers and distributors, tobacco
products importers and distributors, and health facilities.

30.With respect to gender mainstreaming, several activities have been implemented, including the launching of the Gender Mainstreaming Manual, with orientation meetings being organized with RHBs and federal level sector offices on this subject. The National Gender Training Manual and Standard Operation Procedures for the response and prevention of sexual violence were also developed in EFY 2006.


HEALTH INFRASTRUCTURE AND RESOURCES

In EFY 2006, a total of 203 new HPs were constructed, making a cumulative number of 16,251 HPs. During the year, a total of 305 HPs were equipped with medical kits.

32.According to the Service Provision Assessment (SPA) survey on the availability and functionality of health facilities carried out in EFY 2006, the total available HCs were 3,335, and, out of these, 3,315 (99.4%) were functional. A total of 257 HCs were equipped with necessary materials.

33.Similarly, according to the SPA survey, the total available public hospitals were 156 in EFY 2006, and, out of these, 150 (96.2%) were functional. On the other hand, ongoing construction of 123 hospitals was reported from seven regions.

34.With regard to Human Resource Development, 3,583 new medical students were enrolled in 27 public medical schools in EFY 2006, making the total medical students on training 14,290. The New Medical Education Initiative has been expanded to 13 medical schools, contributing to the increase in intake of medical students. The physician to population ratio improved from one physician per 26,943 population in
EFY 2005 to 1 per 20,970 population in EFY 2006.

35.The Integrated Emergency Surgery and Obstetrics (IESO) training aims at improving the provision of emergency obstetric care and surgical services at primary hospital level. So far, 163 health officers have completed the training and have been deployed in different health facilities, while, in EFY 2006, 130 IESO students were enrolled in 11 existing and new training institutions, with a total of 504 being under training.

36.Concerning Accelerated Midwifery Training, 1,240 midwifery students have been enrolled in EFY 2006, with 1,219 midwifery graduates being deployed to health facilities in the same year.

37.In EFY 2006, 96 Level V nurse anaesthetists and 94 degree graduates have been trained and deployed. A total of 115 nurse anaesthetists are under training in eight health science colleges (HSC), while 630 trainees are attending Bachelor of Science Program in ten universities in the same year.

38.To maintain two Health Extension Workers (HEW) per Health Post, 4,825 students were enrolled for level III training, while 2,123 HEWs graduated in Level IV Health Extension Service Training and 2,357 HEWs were enrolled for upgrading to Level IV in 19 training centres.

39.In the framework of the Ambulance Service and Emergency Care/Paramedics Training to improve pre- hospital emergency care in managing all emergencies, including maternal emergencies, 256 paramedics graduated, while 259 were enrolled in six training centres. Concerning the health information technicians (HIT) training, a total of 1,266 students were on training in HSCs in EFY 2006, while 433 were graduated and deployed to health facilities, increasing the cumulative total of HIT professionals deployed in health facilities to 2,532. In EFY 2006, a total of 4,520 health professionals were deployed, including 937 general practitioners, 94 anaesthetists, and 61 IESO officers.

40.Out of the planned procurement of pharmaceuticals and medical equipment worth of ETB 8.26 billion, the Pharmaceutical Fund and Supply Agency (PFSA) has procured pharmaceuticals worth of ETB 6.18 billion (74.8% of the target) in EFY 2006. Out of the planned distribution of drugs and medical equipment worth of ETB 10.87 billion, the agency has distributed pharmaceuticals and medical equipment worth of ETB 10.46 billion (96.2% of the target) in the same year. In EFY 2006 the construction of 17 warehouses and 11 cold chain systems was completed. An assessment revealed that 27 selected tracer drugs were available at the time of data collection in 89% of health facilities (90% of hospitals and 89% of HCs), while the long
term availability (during the previous 6 months) was 78% in health facilities (81% in hospitals and 78% in HCs). With regard to rational drug use, 37 health facilities have established Drug Information Services (DIS), while 267 health facilities have established Drug and Therapeutics Committees (DTC).

41.The Health Information Technology Initiative covers a wide range of applications, such as telemedicine,tele-education, mobile health (mHealth), electronic HMIS (e-HMIS), Electronic Medical Records,Geographic Information System, and Human Resources Information System. Concerning tele-education, three university hospitals (St. Paul's, Adama and Yirgalem) were connected via woreda-net in EFY 2006 to teach basic science courses for pre-clinical students. The number of facilities implementing eHMIS increased from 1,433 in EFY 2005 to 2,345 in EFY 2006.

42.The fifth round of the National Health Accounts (NHA) was carried in the year (based on 2010/11 expenditures) to estimate the flow of resources in the health sector. Per capita health expenditure increased from USD 16.1 per capita in 2007/08 to USD 20.8 in 2010/11, below the HSDP IV per capita spending target of USD 32. The "rest of the world" (including multilateral and bilateral donors and international non-governmental organizations) accounted for almost half (49.9%) of the health financing, households for 33.7% and Government for 15.6% (of whom, Federal Government for 5.2%, Regional and Local Government for 8.1% and Parastatals for 2.3%).

43.One of the main challenges hampering health care access and quality is the lack of resources. To address this challenge and hence to mobilize adequate resources for the health sector, different resource mobilization activities have been implemented, including:

(i) revenue retention by health facilities for quality improvement;

(ii) implementation of fee waiver system for enhanced equity;

(iii) establishment of privatewings and outsourcing for better efficiency; and (iv) pilot and implementation of community based and
social insurance schemes for improved financial access to health services, avoiding payment at the point
of care delivery.

Revenue retention is additional to the block grant budget allocated from treasury, and it is
used strictly for quality improvement activities. Currently 2,849 health facilities (101 hospitals and 2,748
HCs) are retaining and utilizing internally generated revenues to improve the quality of health services.

44.To tackle financial barriers to health care access, the government has initiated and is implementing two types of health insurance systems, namely, the Community Based Health Insurance (CBHI) for the rural population and urban informal sector, and the Social Health Insurance (SHI) for the formal sector employees. CBHI is being piloted in 13 woredas of four regions (Tigray, Amhara, Oromia and SNNP), and a total of 157,553 households have been registered at the end of EFY 2006. The CBHI scheme has generated ETB 29,402,451.40 in EFY 2006, with a 39.5% increase as compared to ETB 21,065,786.62 in EFY 2005. In EFY 2006, the Ethiopian Health Insurance Agency (EHIA) Implementation Directive was endorsed, and
SHI scheme has registered a total of 20,390 out of 112,514 employees found in 127 federal level offices.

45.In EFY 2006, the percentage of total budget allocated in the health sector at regional level was 10.30%, which was higher than in EFY 2005 (9.75%), while the per capita health allocation was ETB 116.43, increasing from ETB 100.16 in EFY 2005. The regional block grant budget allocated to the health sector ranged from 5.6% in Harari to 15.6% in Gambella in EFY 2006. Although per capita allocation is increasing over time, the allocated budget for health in EFY 2006 was below the need of the sector for delivering quality care.This calls for enhancing implementation of the health care financing (HCF) reform and expansion of pre-payment schemes, such as community and social health insurance, as well as additional funds from
different sources.

46.One of the main sources of funding for the health sector is the contribution from DPs. In EFY 2006, a total of USD 558.33 million was committed by DPs and a total of USD 612.87 million (109.8%) was disbursed. A total of USD 234.68 million was disbursed to MDG PF with a 76.1% increment from EFY 2005 (USD 133.23 million). The MDG PF accounted for 38.3% of total DPs' disbursement in EFY 2006 (increasing
from 25.1% in EFY 2005).

With one year to go until the 2015 target date for achieving MDGs, substantial improvements have been documented on many health-related goals, with remarkable progress having been made in reducing child mortality, improving nutrition, and combating HIV, tuberculosis and malaria. Ethiopia has shared with other countries that have made progress towards achievement of MDGs common overarching elements of success, including leadership and partnership, evidence and innovation, development and implementation of dual short term and long-term strategies, and adaptation to change for sustained progress.
Despite these positive developments, the sector still faces formidable challenges. Decreasing the huge burden of maternal mortality remains the single most serious challenge to the sector. Even though appropriate strategies and initiatives are in place, there are serious shortages of the required trained human resources, and there are also cultural, social and economic barriers to be overcome. In particular, despite the high increase in the percentage of deliveries assisted by skilled birth attendants (from 23.1% in EFY 2005 to 40.9% in EFY 2006),

it is necessary to further strengthen the ongoing interventions to address the gaps in midwives, doctors and anaesthetists for provision of EmONC services, absence of 24 hours a day and 7 days a week service in most health facilities, rapid turnover of highly trained professionals, and inadequate availability of drugs, supplies and medical equipment. Such constraints should be tackled if the MDGs are to be achieved by the target date.

Furthermore, it is hightime to envision the future of the health sector beyond 2015, and this knowledge lays the foundation for an
integrative and transformative post-2015 sustainable development agenda. In this perspective, the FMOH isdeveloping the 20-year health sector vision to achieve the health outcomes that commensurate with lower-middle income country by 2025 and middle-middle income country by 2035.

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