Equity and CBHI

Submitted by admins on Wed, 10/16/2019 - 12:17



Equity and CBHI Report






  1. 1.Key areas raised/discussed under the sub theme 
  • Equity and CBHI in terms of all six building blocks and community engagement
  1. Major challenges raised/discussed  

Equity related

  • Infrastructures (power source, water, road and Connectivity, etc)
  • Poor access to health services and low physical health coverage
  • Instability and high turnover of staff including leaders
  • Inadequate budget allocation and poor utilization
  • Transportation problem (Inaccessibility)
  • Security problem
  • Frequent occurrence of epidemics
  • Leadership lacks the profound knowledge (huge skill gaps in understanding the system) and so can’t beer the roles and responsibilities vested on them.
  • Implementing similar policy, strategy, regulation and guides at all levels that have different settings (urban, agrarian, pastoralist areas)


  • Voluntary scheme
  • Low population coverage
  • Low coverage of indigents
  • Fragmented woreda scheme
  • Flat rate premium
  • Passive purchasing (absence of mechanism for proper negotiation)
  • Financial sustainability (some woredas are in difficulty to cover their expenses)
  • Poor service quality (shortage of drugs, medical supplies, reagents, and diagnostic services)
  • Weak private sector engagement
  • Poor data management (paper based data management and reporting)
  • Difficulty in photographing and ID distribution particularly for the poor
  • Skill gaps among care providers
  • Difficulty in serving referred client particularly when the client referred to health facility outside of the zone.
  1. Consideration for EFY 2012 implementation and beyond to be considered in the next HSTP (in the following four categories)
  • Intervention/s that need to be dropped: _____________________________________________
  • Intervention/s that need to be modified: _____________________________________________
  • Intervention/s that need to be continued as is: _______________________________________
  • Intervention/s that need to be newly added: __________________________________________


  1. Community engagement through contextualizing the existing informal and formal community structure (eg. Gada system in Borena, ‘Fema’ in Afar, WDA)
    • Identifying the informal organization and strengthen and engage them accordingly, if no organize and capacitate them to fully participate in the all process
    • Follow bottom-up planning approach
    •  Implement community score card
    • Ensure shared tasks and decisions among stakeholders
  2. Leadership, governance and accountability through
    • Participation
    • Availing monetary and/or non-monetary incentives
    • Mutual accountability. For instance, availing logistics and any necessary resources for mobile or outreach services (currently, there are health facilities without perdiem for field work but allocated budget for night duty)
    • Legal enforcement to ensure leadership commitment and accountability
    • Capacity building
    • Establish system to manage pastoralist related issues separately  (Plan, implementation, monitoring performances) in big regions  as it has been done in emerging regions
    • Restructuring the system from higher to lower levels to deploy multi-sectoral approach like that of woreda transformation agendas 
  3. Service delivery
    • Develop or revitalized programs contextually (context governs the services). Eg . revitalize HEP to the pastoralist context, task shifting as HEWs may be burn out due to fatigue for serving long time
    • Develop and implement locally appropriate service provision modality (eg. Outreach, mobile, periodic intensification, etc)
  4. Integration and coordination (multi-sectoral approach)
    • Coordination within the health sector (manage pastoralist areas differently). A need to restructure and share tasks among Directorate, department, case teams based on the administrative levels.
    • Enabling the condition that the community can get comprehensive services (encourage settlement)
    • Integrated services: Health, water, school, water services
    • Productive safety net may help this approach
  5. Repositioning the HSTP agendas
    • Service outsourcing for remote areas to private health facilities and/or social organization)  while the government needs to focus on regulatory and monitoring
  6. Human Resource management
    • Intensive work on capacity building particularly the health managers
    • Revise and customize the human resources management policy in context to the pastoralist areas to encourage employment and retain experienced care providers. For instance:  incentive packages (financial and/or non-monetary incentives)
    • Create convenient living and working places for the care providers
    • Assess Introduce based financing
  7. Strengthen regulation and monitoring system
    • Regulate service quality and cost both in public and private health facilities with impartiality  
  8. Involve Universities in pastoralist areas
    • Human capacity building
    • Research and services
  9. Develop comprehensive  joint plan in consultation with the key stakeholders and make it practical


  • Continuous community sensitization and mobilization till the expected level of community awareness assured (Ensure full enrolment and continuous renewal)
  • Engage care providers in community level works
  • Community engagement (problem identification, planning, implementation and monitoring)
  • Recognition for best performing staff
  • Enhance the commitment of leadership from higher to lower levels as performances depend on the commitment level of the leaders.
  • Legal binding
    • A need to change the voluntary to compulsory scheme
    • Enforce the administrative bodies to allocate adequate budget for the indigents
  • Attention to address the indigents issues (currently very low coverage) that leadership commitment to allocate adequate budget sustainably)
  • Ensure reasonable services quality  (availing drugs, medical supplies, reagents, and diagnostic services, and skilled care providers)
  • Socio-economic constraints (eg. Opportunistic cost  and family support) should be addressed through multi-sectoral approach
  • Revision of premium rate and assign premium rate based on the households’  income
  • Higher level pulling fund should be in place to maximize cross-subsiding (currently, limited at woreda  or zonal levels)
  • Efficient use of collected money
  • Reboot medical audit
  • Design and implement provider payment scheme
  • Establish proper data management system, digitalizing the data management including reporting
  • Establish public and private health facility partnership  to avail quality health services (create access to drugs, laboratory and diagnostic services)
  • Strengthen the structure of Health Insurance agency at all levels (Regional, Zona and woreda)
  • CBHI should be political agendas and setting its performance as evaluation criteria for the leaders. 
  • Service provider and purchaser should be separated (re-organize the Health Insurance agency and its structures outside the health sector)
  • Conduct assessment on service utilization among CBHI members to identify determinants of service utilization



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