Ethiopia Health Plan Review
Ethiopia Health Plan Review
TRANSFORMATION PLAN
HSTP II (2020/21 – 2024/25 (GC)
(2013 – 2017 EFY)
MID-TERM REVIEW
VOLUME I
COMPREHENSIVE REPORT
Core Members of the 2013 MTR Review Team with their funding agencies
The independent team of this MTR was composed of 5 international and 9 national consultants, supported
by 2 resource persons from WHO and African Resource Center. They were selected by the JCCC on
the basis of their professional expertise and participated in their individual capacity. Bill and Melinda
Gates Foundation, DFID, UNICEF, UNFPA, USAID, Netherlands Embassy and World Bank funded the
involvement of these consultants. As an independent review team, the opinions and suggestions in this
report are solely the responsibility of the authors and do not in any way commit or imply the agreement
of the MOH or any of the other stakeholders operating in the Ethiopian health sector.
Donna Espeut Service delivery [email protected] +251-901 003 539 Gates Foundation
Kate Tulenko Human resources [email protected] +1 202 460 9919 World bank
The leadership and coordinating role of the MTR support team was paramount and without which the
process would have not been successful. In this regard, we would like to the thank Dr Ruth Negatu,
Naod Wodndirad, Tsedeke Matheos, Ketema Muluneh and Shegaw Mulu for their commitment and full
support during the entire process. The MTR team would also like to thank the MTR core group and
the Joint Core Coordinating Committee (JCCC) for their guidance by reviewing the inception and draft
reports and providing constructive comments for improvement.
We would like also to thank the MTR team members, the experts from government, development and
implementing partners, for their technical support in undertaking this review.. We would also like to
acknowledge the team leaders of all the regional MTR field teams for their commitment despite security
and other challenges they faced while generating the necessary evidence at all levels of the system,
without which the quality of the MTR report would not have taken this shape.
We would like to thank the various funding agencies, AMREF, Africa Resource Centre, The Bill & Melinda
Gates Foundation (through American International Health Alliance), Netherlands Embassy, UNICEF,
UNAIDS, USAID, World Bank and WHO for their support to recruit the consultants.
Finally, we would like to acknowledge and thank all the stakeholders at the federal, regional, zonal,
woreda and facility levels that were very open and constructive when they provided their views and
recommendations to the MTR team.
HSTP II has five Transformation Agendas (top priorities), one of which is quality and equity. As a result
of the efforts made in the last 2.5 years, there is evidence showing declines in disease incidence,
prevalence, mortality (e.g., maternal mortality, some communicable diseases). The institutionalization
of quality improvement (QI) practices, rolling out new services, especially specialty and sub-specialty
services (mental health, home based clinical care, noncommunicable diseases, etc.) and the adaptation
of service delivery models in response to emerging crises (e.g., COVID-19, conflict) are some of the
achievements during the last two and half years. The best practices in this regard include deployment
of 63 mobile health and nutrition teams to respond to conflict, pre-positioning of essential commodities,
as well as evidence-based targeting of services to enhance the coverage and reach of health services
to crisis-affected, vulnerable and/or marginalized groups. Improved outcomes that directly impact
cause-specific mortality (e.g., HIV viral load suppression; TB treatment success) are also evident.
The establishment of the multi-sectoral engagement support team at MOH, was a laudable decision by
leadership that promoted a whole government, whole society, whole business approach in responding
to emergencies. Some of the achievements in this regard include expanding testing, isolation, and
treatment capacity by creating makeshift centers (approximately 150) and engaging private sector.
Twinning of hospitals in conflict-affected regions with hospitals from other regions; mobilization, training,
and deployment about 2,000 volunteers and health care workers (HCWs) for responses to COVID-19,
conflict, and other emergencies; digitalization of the Public Health Emergency Management (PHEM)
system during COVID-19 response; expansion of Emergency Operations Centers (EOCs) at national,
regional, and sub-regional levels; and the establishment and operationalization of national and regional
PHEM call centers have all contributed to strengthening the resilience of the health system.
There is also progress in implementing the information revolution (IR), as evidenced by the initiation
of the Model woreda strategy implementation in over 200 woredas, of which 10 are verified model
woredas; institutionalization and local capacity built around the District Health Information System 2
(DHIS2) customization and deployment ; scaling of a digitized community health information system to
over 8,000 health posts; and increased investment in telecommunications and information technology
infrastructure and equipment. These has been driven by the development of the national digital health
As part of the motivated, competent and compassionate workforce transformation agenda, Ethiopia has
invested in pre-service education that increased availability of health workforce. Also, investment has
increased to improve the quality of the health workforce through continuing professional development
(CPD), as well linking CPD to license renewal. There has been an improved stock of health workforce.
The total number of health workforce increased from 219,386 in 2012 EFY, to 342,889 in 2014 EFY,
resulting in an increased health professional density from 1.16 in 2013 EFY to 1.23 in 2014 EFY. There
is also a concerted effort to improve the capacity of existing workers, as evidenced by the effort of
CPD integration into license renewal with 205 CPD providers and 37 CPD accreditors, as well as the
establishment of professional standards for 31 professions. Progress has also been made towards
standardizing curriculum and school accreditation, the development of draft motivation and incentive
packages in consultation with health workers (pending approval), and the implementation of a national
license examination.
Another transformation agenda for which the MOH has made significant strides is in health financing.
There is concerted effort to mobilize additional domestic resources through co-financing, establishment
of innovative financing (draft Resilience and Equity Health Fund (REHF)) and revising the list, costing
and financing of exempted health services. The FMOH was able to mobilize 3.23 billion ETB during
2014 and 2015 EFY through co-financing with engagement of MOF. Nutrition (Seqota Declaration),
immunization, HIV and Malaria have benefitted from co-financing from the federal government
allocation. The ministry was also able to mobilize more than US$ 400 million for COVID response
from government, development partners and the private sector. Furthermore, there are now resource
mobilization units in 7 regions (e.g., Addis Ababa, Amhara and Oromia regions). A best practice has
emerged in Oromia, where health center government budget allocation for drugs increased from
ETB 180,000 to ETB 300,000. Risk assessment on the Sustainable Development Goal (SDG)-pooled
fund (PF) was conducted and SDG PF Joint Financing Agreement (JFA) revised. Community-based
Health Insurance (CBHI) implementation has also progressed substantially. The federal government
has approved the CBHI proclamation that shifted membership from voluntary to mandatory. Due to
high political commitment and community ownership in most regions: (1) CBHI coverage expanded
(84% of 980 woredas) and 12.2 million households are covered (enrolment rate of 81%); (2) there is high
membership renewal (93%), despite COVID and security challenges in some areas; (3) general subsidy
increased from 10% to 25%; and (4) the CBHI benefit package revision is in the final stage. There
are best practices in increasing indigents coverage through mobilization of community, cooperatives,
development associations, and others to complement government subsidy, as well as integration of
PSNP and CBHI program in indigents selection in Addis Ababa.
As part of pharmaceuticals and medical devices, Demand-based forecasting and supply planning has
been launched and rolled out at hospital level, which enforces the payment of costs on time. There
is also a good indication that the management and coordination structure improved as the Pharmacy
and Medical Equipment (ME) Directorate was promoted to Lead Executive Office (PMDLEO) in the new
MOH structure; also, a Pharmacy and ME advisory board and supply chain steering committee were
established. Overall, strategies and policy directions are being revised (e.g., Medicine Policy is under
revision; Pharmaceutical and Medical Equipment roadmap is also under development; supply chain
protocol was developed; Ethiopian Pharmaceutical Supply Service (EPSS) draft proclamation in final
stages of development). The availability of essential medicines by level of health care is reported to be
at 76% against its MTR target of 84%-90% performance. Availability of program essential medicines is
reported to be 94%, while availability of revolving drug fund (RDF) essential Medicines was 84%.
The Ethiopian Food and Drug Administration (EFDA) focuses on products (food, medicine and medical
devices) regulation, and the MOH is undertaking regulation on health providers and health workforce.
EFDA’s new organizational structure was approved, with an improved human resources and structure
and establishment of a center of excellence (Kality) and Vaccine lab (Hawassa). The Development of
guidelines for emergency use authorization of medicines for public emergency situations; medicines
waste management and disposal directive; medicine donation control directive; and pharmacovigilance
directive are some of the achievements. The system is being supported through an electronic regulatory
information system (e-RIS). There is also improved Adverse Event reporting and the Agency is working
towards achieving WHO’s Maturity Level III (from Level I) to ensure vaccine production in Ethiopia.
The health professionals and health/health related facilities regulation processes harmonized and its
structure is upgraded to LEO level, 4 Desk, which is now better staffed. Addis Ababa, Gambella and
Somali regions have independent regulatory structures; Addis Ababa City Administration regulatory
office is reporting to the Mayor’s Office, and is well budgeted and staffed. Some regions are enforcing
regulations in registering and licensing health facilities: a license is required for health facilities to get
supply of medicines and medical equipment in Amhara; in Dire Dawa, if facilities do not have a license,
there will be no service provision. Overall, the proportion of HFs adhering to the minimum standard
have been raised from 43% to 62% well beyond target of 48%.
Priority investment areas for public private partnership (PPP) in the health sector were identified and
registered by the Ministry of Finance and Economic Cooperation (MOFEC), e.g., diagnostic services,
medical gas plant, and oncology, and feasibility studies were conducted. PPP training was also provided
The effort to promote traditional medicine is also showing some progress under HSTP II. There is
now a Traditional Medicine structure at desk level in the MOH. Progress is being made in developing
the following: a Traditional Medicines directive; Traditional medicines clinical trial guidance; Traditional
medicine 10 years roadmap and Draft policy. Three traditional medicinal products are under clinical trial.
Although five transformation agendas were identified as high-level strategic priorities, the MTR team
identified a major gap in terms of developing an implementation plan for the transformation agenda
that can be implemented and monitored at all levels of the system. There was also a need for revisiting
the transformation agendas in light of the multiple crisis and shocks experienced since the start of the
HSTP II.
The shortfalls in basic quality (e.g., basic services, electricity, improved water, diagnostics), a suboptimal
culture of evidence for action, and gaps in critical health system building blocks (e.g., financing,
workforce, infrastructure, commodity supply) remain impediments that compromised health qualiy
and equity, Suboptimal data quality (subpar timeliness (only 65%), low private health facilities reporting
rate (35%); discrepancies in performance assessed via surveys and routine data), low birth (69%) and
death (4%) notifications, irregularity of routine data quality assessments (RDQA)) coupled with low
culture of information use has affected the levels of evidence-based planning and decision-making.
Performance Monitoring Teams (PMTs) lack rigor beyond conducting meetings, suggesting a gap in
their effectiveness in monitoring and evaluating the performance of health programs. Only 5% of health
institutions have a sufficient number of health information system (HIS) personnel, indicating a shortage
of skilled workforce in health information management. This is also affected by high turnover of staff
due to dissatisfaction and demotivation. Weak governance of HIS and digital health, especially at the
woreda (district) and lower levels; the maturity level of most digital health systems is still at an early
stage in terms of their functionality, usability, and interoperability; weak engagement of the private
sector in HIS strategy development and governance are the challenges identified in this report.
Despite previously mentioned strides, progress in domestic resource mobilization was low, especially
with the government budget allocated for health at the federal level. The share of general government
expenditure on health remains very low at national level (8.2%). The contribution of development
partners has also decreased from its level of US$ 388.2 million in 2013 to US$ 316.2 million in 2014 EFY,
this even worse for the SDG PG as it has decreased from US$ 87 million in 2013 to US$ 44 million in
2014 EFY. There is also slow progress in increasing CBHI coverage in developing regional states. The
flat CBHI contribution rates remain regressive. The Social Health Insurance program for civil servants
and pensioners hasn’t started, mainly due to fiscal space-related challenges the country face due the
current context.
Challenges in procurement and custom clearance, weak emergency LSCM (Logistics & Supply Chain
Management) capacity compromised the efforts made to improve the quality and effectiveness of the
health system. EPSS is overburdened, consequently has difficulty to provide equal and appropriate focus
The major challenges related to product regulation is related to (i) inadequate ability of EFDA to attract
and retain experienced regulatory staff; (ii) existence of different structures at federal and regional
levels making enforcement of EFDA’s regulations in the regions and the lower-level structures difficult;
(iii) lack of established regulatory system for safety and quality of blood, blood products , human
tissues and organs and (iv) only 5 (42%) of local manufacturing companies are cGMP compliant. On
the other hand, the major gaps in the health professionals and health and health related institutions
regulatory include; (i) lack independency as it is organized in the MOH and diverse structures across
regions, most lacking independence; (ii) absence of legal framework to implement regulations and the
delay in establishing Health Professionals Council limiting the opportunity to have effective and an
independent regulatory body; (iii) weakness in inter-sectorial collaboration especially with Ministry of
Trade, Tourism, Environmental and Forestry, Customs, and Police to enforce regulatory measures; (iv)
inadequate capacity to regularly inspect CPD centers and enforce quality of course content, trainers,
training venue and infrastructure and (iv) existence of two sets of rules for regulating private and public
HFs, with the former being more stringent.
There is fragmentation and duplication of efforts in many of the health system building blocks that
requires effective coordination and leadership. These include service delivery fragmentations,
leadership and other capacity building efforts, digital health initiatives (rollout of multiple systems with
questionable functionality), and traditional medicines. Many efforts were compromised by delays in
endorsing the legal frameworks/policy directions by the senior management of MOH. There is lack of
health infrastructure structures in some RHBs that compromised the quality and effectiveness of the
construction activities. There is also a sharp decline in budget hence the plan to construct 300 HCs did
not materialize.
Health facilities do not have adequate human resource (HR) as per standards and motivation packages
have not been equally implemented in all the regions. Competency assessments have not been fully
implemented and there were gaps in the implementation of competency-based training that include
inadequate skill labs, reading corners, and preceptors in hospitals. Unforeseen events such as conflict,
COVID-19, and infrastructure issues have also influenced the implementation of the integration of
CPD with licensing renewal, an effort that has not yet started in Benishangul Gumuz, Afar, and Amhara
regions. The transition of the Integrated Health Information System (iHRIS) from the development stage
to implementation stage is struggling. There is a gap in developing a clear roadmap to implementation
of the national eHealth architecture. The HIS system is faced with inadequate health IT human resource
capacity (skill mix, numbers, and skill), weak device management and tracking system. The management
of different software systems in the supply chain is complex, and there is a high dependency on
A major recommendation for next three years to enhance quality and equity are investing in the design
and implementation of ‘catch-up’ initiatives to rebound from service disruptions and the effect of health
shocks; Revisit the design of health service delivery architecture by setting measurable service norm/
standards (e.g., infrastructure, financing, HR) for each level of care and modality (e.g., static site, outreach,
mobile health services, home visits/home-based care, telehealth) and develop PHC investment plan to
implement revised EHSP and enhance the private sector investment and public-private partnerships
to expand the availability and quality of health services and promote medical tourism is recommended
to be a priority investment area.
MOH should work more to align its digitization efforts with and to leverage the potential of the broader
digital Ethiopia strategy (national identification (ID), mobile payments, government connectivity); the
functionality of the Information Revolution (IR) governance structures; develop and implement a
structure that ensures competitive compensation, career development opportunities, and supportive
working environments to attract and retain skilled HITs; Establish and enforce a robust legal and policy
framework for the security, privacy, and confidentiality of patient-level data; developing and implementing
a strategy (including the role of CMBP universities) on digital and AI-enabled healthcare approaches
to enhance healthcare service delivery, diagnostics, decision support, and patient engagement; and
work towards transitioning from electronic health information that encompasses interoperable systems,
telemedicine, mHealth applications, and data analytics. This should be supported by developing a
national data analytics platform; elevate the national data access and sharing guideline to a regulation
level; strengthen integration of Quality Improvement (QI) and Performance Monitoring Teams (PMTs)
at the health facility and enduring regularity of data verification processes. These should be supported
by prioritized investment on digital health that include establishing effective partnerships with other
government agencies such as Ethio-telecom; strengthening effective governance with engagement
of regions and programs in the design and implementation; prioritizing investment in telemedicine,
teleradiology, and other remote health service delivery mechanisms to enhance access to healthcare
services; enhance the monitoring of the functionality of digital health systems and infrastructure and
utilizing the data; expanding IT infrastructure at government health facilities, including the provision of
computers, LAN, and connectivity; and invest on unified, integration and interoperability digital supply
chain system with good maturity level. Government should ensure that all health facilities have the
number of health workers as per standards and also design and implement incentives for CPD centres
and accreditors to improve quality.
The major investments in both product and health professionals and facilities regulation is harmonization
of the structures and enforcement between the federal and regional levels; develop and implement
capacity development and retention plan to strengthen the capacity and human resource mix and
numbers especially at lower level. In terms of product regulation, there is need to strengthen the regulatory
harmonization with countries in the region (African Medicines Agency, IGAD, EAC) to expand suppliers
base. In terms of health professionals and health facility regulation, there is a need to (i) formulate legal
framework (ii) support regions to develop a more standardize regional regulatory structures; (iii) work
towards an independent regulatory body (iv) in collaboration with the MOE, encourage pre-service
training of medical professionals shift towards skill and competency-based approach.
The is a need to undertake a concerted leadership effort to improve advocacy at all levels, especially at
the federal levels, for increased buy in at higher level political leaders for better allocation of resources
to the sector as part of Program Based Budgeting and endorse the revised exempted service financing
mechanism and implement an innovative Resiliency and Equity Health Fund (REHF). The Ministry,
in collaboration with development partners, should mobilize the required funds from domestic and
external sources as per the national reconstruction and recovery plan launched by the Ministry of
Finance. Government and partners need to implement the harmonization and alignment action plan to
address the gaps on alignment, resource utilization, reporting and accountability. There is also a need
to developing an investment and implementation plan for EHSP after revision of norms and standards.
Work towards accelerate the coverage of the poor Using PNSP system to identify the very poor; devise
strategies to operationalize mandatory CBHI membership; develop a tailored CBHI strategy for emerging
regions and conflict affected area. MOH/EHIS may also consider conducting a comprehensive political
economy analysis of SHI implementation, especially on the feasibility of implementing SHI.
The Ethiopian health sector has developed and implemented successive sector wide plans-referred as
health sector development or health sector transformation plans since 1997. The latest plan is referred
to as second Health Sector Transformation Plan (HSTP II) and has been implemented since July 2020.
The overarching objective of HSTP-II is to improve the health status of the population through; (i)
accelerated progress towards universal health coverage; (ii) protecting people from health emergencies;
(ii) woreda transformation and (iv) improve health system responsiveness. HSTP II set 76 targets to
be realized; of which 73 of the have midterm targets. The plan has five transformation agendas-top
priorities- and 14 strategic directions with 323 strategic initiatives to be realized, as reflected in Table 1.
Enhance provision of equitable and quality comprehensive 193; 17 programs with their own specific
1
health service strategic initiatives (58%)
Total 332
Ethiopia developed six five years health sector strategic plans over the last 25 years and conducted a
5 midterm review (MTR) for each of the sector strategic plans. This review builds from the experience
gained so far in terms of process as well as timing.
b) Assess the relevance and progress of implementation of HSTP-II strategic directions and
initiatives;
d) To assess the effect of conflict and emergencies on the performance of the health system;
The Terms of Reference (TOR) sets out in four phases of MTR deliverables:
a) Inception report: A report that includes all the preparatory phases of the evaluation, including
design of methods and data collection tools
b) Regional reports: A report that includes quick analysis and key findings of each region for all the
seven sub-teams/thematic areas;
The TORs also set out the different processes and phases that the MTR team should follow in undertaking
this review as outlined in figure 1.
The specific data collection methods proposed for this evaluation include:
a) Comprehensive desk review – the desk review assessed a broad range of policy, strategy and
planning documents related to the HSTP II. The team reviewed the HSTP II and its transformation
agenda roadmaps, the 2013, 2014 annual and 2015 EFY six months review reports, other
assessments and studies carried out in each thematic areas by government and its partners.
The document review also included program level strategies, innovations and performance
assessments and reviews carried out in the last two and half years. This assessment was
supported by the review of relevant surveys and literatures including the DHIS2 data at different
levels. In order to capture recent information on the performance alignment, the MTR team
used the recent alignment diagnostic assessment report and did not request MOH and the DPs
(through the HPN) to fill in the standard questionnaire used in earlier MTRs for that purpose.
c) Questionnaire – The MTR Questionnaire provided guidance for the interviews to be held with
specific questions for each of the 14 Strategic directions and the 5 Transformation Agenda’s for
federal, regional, zonal, woreda, hospitals, health centers, community (including Health Post).
The questionnaire assessed and verified to what extent HSTP II is relevant and on track to
achieve its MTR targets and how far the Strategic Initiatives, as mentioned under each of the
14 SDs, have been able to contribute to the realization of targets set in the HSTP II. The tools
helped to explore factors behind successes or the lack of it as well as strategic interventions
to accelerate progress at all levels of the government structure to and generate evidences
that will inform the draft three years Health Sector Development and Investment Plan (HSDIP).
Another important aspect of the review is to document lessons learned that could be shared
nationwide with other Regions.
Analysis Methods
The gathered information and data were analyzed, triangulated and crosschecked for validity of
findings. The MTR team developed different analysis tools to ensure a rigorous and systematic analysis
of quantitative and qualitative information. The core outcome and output targets indicated for each of
the 14 SDs and 5 TA’s of the HSTPII provided the quantitative basis for the MTR, and the information
was generated from the routine sources of information. This was crosschecked whenever possible
with survey data. In addition, the quality and reliability of this routine information was reviewed on the
ground as part of this process. Furthermore, the more qualitative information coming from the interviews
at the various levels was used to verify the validity of the quantitative information. The Strategic Affairs
Executive Office filled in the figures for the three remaining columns (the achievement of the last two
years and six months of this financial year). If no information is available, NA will be included, but the
indicator was not removed. The team used three approaches to analyze data during the evaluation.
First, the team explored and undertook different aspects of quantitative analysis (trend, percentages,
shares, unit costs, etc.). Second, the team carried out a rolling analysis of the qualitative data generated
from national, regional and woreda level interviews and the sample visits. At the end of each day of
fieldwork the team members were meeting to review the field notes and develop an on-going tally
sheet to log key findings. The team then discussed new findings and trends that may have emerged
during the day and place them in to a findings, conclusions and recommendations matrix that was
developed on an on-going basis during the fieldwork. Finally, the team conducted a joint analysis to
systematically identify preliminary findings, conclusions and recommendations for all the key evaluation
questions before leaving the region and share the findings to the regional level decision makers.
The MTR team visited all regions. In the three bigger regions (Amhara, Oromia) two zones (one well
performing and another less well performing) were selected. Within these zones, one well performing
woreda and one less performing woreda was subsequently selected. The team also visited well
performing and less performing facilities and communities within each woreda. In the other regions,
while all other sampling frame remains the same, there was no visits to specific zones. In each region,
two woredas were visited. The selection of the zones, woredas and health facilities was carried out
by the regional teams in consultation with and guided by the achievements in the HMIS data (woreda
transformation indicators). The regional visits followed the division of roles as outlined in Table 2.
Region 1 Region 2
Limitations
Ethiopia’s health sector has been impacted by multiple, overlapping shocks that disrupted services.
Hence, any assessment of performance on the Transformation Agenda on Quality and Equity must
interpret progress and shortfalls, both planned and unexpected, through the lens of navigating the
challenges in delivering equitable, quality health care in the midst of complex emergencies. The
following table indicates performance against HSTP II targets related to quality. There are no specific
HSTP II indicators that relate directly to health equity, although disparities in HSTP II indicators can shed
light on key inequities in health care. This is examined further in a subsequent section.
Performance
(% achieved)
against MTR
Data Source
Target 2022
Color Rating
End Target
(2024/25)
Mid- term
Indicator
Baseline
Targets
2022
Performance
(% achieved)
against MTR
Data Source
Target 2022
Color Rating
End Target
(2024/25)
Mid- term
Indicator
Baseline
Targets
2022
Proportion of health
facilities implementing
0.53 0.65 0.8 0.62 0.95 6 month parliament report
compulsory Ethiopian
health facility standard
Proportion of patients with
33% 42% 54% 79% >100% 6 month parliament report
positive experience of care
Institutional mortality rate 2.20% 1.90% 1.50% 2.74% 24.5% DHIS2 -Six Months Data
Availability of essential
ANNUAL PERFORMANCE
medicines by level of 79.2% 84.0% 90.0% 76.0% 90% REPORT 2014 EFY (2021/22)
health care
Health Security Index 0.63 0.7 0.78
One of the major achievements during the last two and half years is the Institutionalization of Quality
Improvement (QI) practices within health facilities. This is primarily driven by the development and
implementation of key guidelines (e.g., Ethiopian Primary Health Care Clinical Guidelines [EPHCG],
Ethiopia Hospital Services Transformation Guidelines [EHSTG]) and development and implementation
of QI directives/initiatives, often utilizing internal revenue within health facilities. Given the context,
the sector was also able to introduce some crisis adaptations (in response to COVID-19, conflict, etc.)
strengthened service delivery, as evidenced by the enhanced clinical care capacities (e.g., emergency
care, ICU, laboratory) and accelerated rollout of different service delivery modalities and innovations
(e.g., multi-month dispensing of medicines; adaptation of differentiated service delivery models to
facilitate equitable access in conflict-affected settings). Under HSTP II, there has been a proliferation
of activities and initiatives to address quality in health care. however, shortfalls in basic quality (e.g.,
basic services, electricity, improved water, diagnostics, suboptimal culture of evidence for action, and
gaps in health system building blocks (financing, workforce, infrastructure, commodity supply etc.) have
limited the translation of QI efforts into quality transformations that ultimately result in improved health
outcomes. The above shortcomings are particularly apparent in conflict-affected areas and Emerging
Regions. Nonetheless, existing guidelines are driving service delivery improvements that not only
expand the availability of some health services, but enhance quality. For example, as confirmed during
regional field visits for the MTR (e.g., in Harari and Oromia), the EHSTG are informing the delivery of
tertiary-level care and cancer services.
It is difficult, however, to explore quality transformations when available evidence reveals major
shortfalls in the most-basic aspects of quality of care. All basic client services—maternal and child health
services, family planning (FP) services and services for adult sexually transmitted infections (STIs)—are
only available in 20% of all health facilities in Ethiopia.1 There is minimal urban-rural difference in this
regard (22% and 20%, respectively). The 2021–22 ESPA also revealed another important difference
between public and private facilities: there is a major disparity in the availability of basic client services
in public versus private facilities. Across the country, only 1% of private facilities offer all basic client
services, compared with 24% of public facilities.2 Although the availability of basic client services is
1
Ibid., Table 3.3.
2
Ibid.
It should be noted that ESPA data collection was hampered by the conflict that emerged since the start
of HSTP II implementation. According to the 2022 Ethiopia Conflict Impact Assessment, 76% of health
posts, 50% of health centers and 83% of hospitals in Tigray damaged or destroyed. In Amhara, figures
are 49% of health posts, 52% of health centers, 46% of hospitals, plus 5 blood banks damaged and 124
ambulances looted or damaged (see Table 2 later in this chapter for more information).
The MTR confirmed that there have been several QI achievements, but public perceptions of quality
are mixed. According to the 2022 People’s Voice Survey, respondents on average rated the quality of
their last health care visit as ‘poor’ or ‘fair,’ with similar ratings assigned to elements of quality such as
‘care competence’ and ‘user experience.’4 A slightly higher proportion of respondents rated the overall
public health system as ‘excellent’ (35%), compared to 33% rating the overall private health system as
‘excellent.’5 The proportion of adults rating the health system as ‘fair or poor’ was also slightly higher for
the public health system than for the private health system (36% and 34%, respectively).6 Considering the
type/level of health facility, there are further public-private sector differences in perceptions of quality.
Private-sector secondary health facilities are most likely to be rated as ‘excellent’ (75%), compared to
only 46% of public secondary health facilities receiving such a rating. Quality ratings are far lower for
primary health care facilities than for secondary facilities; only 40% of 2022 PVS respondents rated
their last visit to a public-sector primary facility as ‘excellent.’7 The corresponding estimate for ‘excellent’
ratings for private-sector primary facilities is 53%.8
There are also differences in the public’s perception of quality of care for specific components of primary
health care. According to the 2022 PVS, delivery care was the PHC component with the highest share
of ‘excellent’ ratings, followed by care for children (39%), care for chronic conditions (24%) and mental
health care (20%).9
There major initiative helped to prioritize the implementation of enhanced equity in HSTP II period is the
development and finalization of the country’s National Health Equity Strategic Plan (2020/21–2024/25)
which has elaborated priorities and specific approaches. While there was a vision to cascade the plan
to all levels and ensure that it is reflected in annual operational plans using the Woreda-based health
sector annual plan, that vision was not fully realized at the time the MTR was conducted. Another
achievement is the rollout of ‘new’ services (e.g., mental health, geriatric, home-based clinical care,
3
Ethiopian Public Health Institute (EPHI), Ethiopia; Ethiopian Ministry of Health and ICF. 2022. Ethiopia Service Provision Assessment 2021–2022 Preliminary
Report. Addis Ababa, Ethiopia: EPHI; Ethiopian Ministry of Health, Addis Ababa; Ethiopia; and ICF, Table 3.3.
4
Under the domain of care competence, the PVS examined the following factors: provider skills, knowledge of past visits, explanations and equipment/supplies.
Under the domain of user experience, the PVS examined factors: respect, courtesy, joint decisions, visit time, wait time and scheduling time.
5
Ministry of Health. 2023. People’s Voice Survey: Ethiopia Country Brief 2022.
6
Ministry of Health. 2023. People’s Voice Survey: Ethiopia Country Brief 2022.
7
Ibid.
8
Ibid.
9
Ibid.
» Variations in regional focus, e.g., some regions have focused on service expansion, some are in
‘humanitarian’ mode and others in recovery/restoration mode
Despite this complex mix of drivers and determinants of inequities in health, existing data largely focus
on regional disparities and, to a lesser extent, gender disparities. The 2019 Mini Demographic and
Health Survey (Mini DHS) provides some insights on health inequities, with three particular types of
disparities observed across various health indicators (gender disparities; urban-rural disparities and
regional disparities).11 The National Health Equity Strategic Plan (2020/21–2024/25) highlighted that
huge disparities in health status and utilization persist across other equity dimensions such as agrarian
versus pastoralist lifestyle.12 While there are tailored approaches (e.g., mobile health services, tailored
strategies for TB detection and screening) for pastoralist, existing data systems such as DHIS2 are
not adequately tracking equity dimensions and their impacts on health service utilization and health
outcomes. Special assessments also shed light on a more-nuanced concept of equity. For example,
mental illness is a condition for which equitable access is limited. The 2022 People’s Voice Survey
revealed that only 8.4% of persons who reported having ‘poor’ or ‘fair’ mental health received mental
health care.13The PVS also provides insight on how ability to pay influences health care seeking and
perceptions of quality. According to the 2022 PVS, only 55% of adults reported that they ‘can afford
good quality care if very sick.”14
Socioeconomic background remains an important determinant of where (from which providers) adults
in Ethiopia seek care. As expected, a higher share of persons from higher socioeconomic strata seek
care from the private sector for the health care. The public sector is still the predominant source of
10
https://www.unicef.org/health/injuries
11
Ethiopian Public Health Institute (EPHI) [Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA:
EPHI and ICF.
12
Noted on p. 27 of the National Health Equity Strategic Plan (SWOT Table)
13
The 95% confidence interval for this estimate is 3.4 – 19.5%. SOURCE: Ministry of Health. 2023. People’s Voice Survey: Ethiopia Country Brief 2022.
14
The 95% confidence interval for this estimate is 48% – 61%. SOURCE: Ministry of Health. 2023. People’s Voice Survey: Ethiopia Country Brief 2022.
A special investigation on equity of quality reproductive health services in Ethiopia (Dinsa et al., 2022)
found that overall quality of antenatal care (ANC) and family planning (FP) services were low, and there
was “little variation in the distribution of the quality of these services between poor and nonpoor areas,
urban and rural settings, or regionally.” (Dinsa et al., 2022).16 Further insights on the state of in-equity
can be found from the upcoming national equity survey conducted by MoH and EPHI, which was not
available during the HSTP II MTR.
Recommendations
i. Invest in the design and implementation of ‘catch-up’ initiatives to rebound from service
disruptions during the COVID-19 pandemic and other shocks (conflict, climate-related threats
such as drought) since the start of HSTP II implementation.
a) Strengthen regional capacity to ensure that regions can better align service delivery with
their realities/needs on evidence-informed, adaptive management to capacitate sub-
national stakeholders to better plan, manage & deliver services along the humanitarian-
development-peace nexus (emergency, recovery, restoration, resilience) in different
contexts throughout the country informed by an overarching Recovery and Rehabilitation
Plan (RRP) (as a high-level priority for the country) to enhance health system resilience.
ii. Revisit the design health service delivery architecture by setting clear, measurable service norm/
standards (e.g., infrastructure, financing, HR) for each level of care and modality (e.g., static site,
outreach, mobile health services, home visits/home-based care, telehealth) and develop PHC
investment plan invest on:
15
Ministry of Health. 2023. People’s Voice Survey: Ethiopia Country Brief 2022.
16
Girmaye D Dinsa, Ermias Dessie, Sarah Hurlburt, Yosef Gebreyohannes, Catherine Arsenault, Bereket Yakob, Tsinuel Girma, Peter Berman & Margaret E. Kruk
(2022) Equitable Distribution of Poor Quality of Care? Equity in Quality of Reproductive Health Services in Ethiopia, Health Systems & Reform, 8:1, e2062808,
DOI: 10.1080/23288604.2022.2062808
b) increased service availability (including slowly evolving services such as adolescent health,
NCDs, mental health) in existing facilities &
e) Strengthening referral services across the continuum of care nationally and at local levels
iii. Re-examine the health sector’s role in the Woreda Transformation model, with a focus on
multisectoral collaboration and collective leadership to achieve health goals.
a) Informed by a clear strategy on where and how to engage the private sector so that private
sector contributions are strategic, actionable and monitored for their relevance, effectiveness
and efficiency.
b) To achieve greater harmonization of quality and service standards among public- and
private-sector health facilities
c) Define private-sector entry points and accountabilities with a comprehensive national health
services map and real time referral systems
Midterm Target
HSTP-2 Target
Performance
Indicators
Baseline
Information use index 52.50% 67.10% 85.00% 60% IR report
Relevance of the transformation agenda/ strategic direction to be included in the next three year
plan
The need for the transition from the electronic health information era to digital health era is well
recognized as the main rationales for the development of the blueprint. However, digital transformation
was one of the missed opportunities as a result of overemphasis on digitizing the data and reporting
systems. Although major efforts have been made to align the digital health blueprint, the HIS strategy,
and the roadmap for the information revolution, the emphasis on the electronic health information system
still dominates the agenda for changing the health care industry. The major recommendation is that the
information revolution transformation agenda needs to be reframed as a digital health transformation
agenda and should encompasses both digital health interventions and health information systems. This
approach will help in better aligning it to the global strategic documents (WHO’s digital health strategy).
The country has an overarching digital Ethiopia strategy and all sectors, including health are aligning
their digital transformation efforts with this guiding national strategy. The health sector has done this
through the development of the digital health blueprint. Thus, the priority is very relevant but needs to
be reframed from information revolution to digital transformation.
The implementation of the IR model woreda strategy has been initiated in over 200 woredas (districts),
resulting in approximately 10 verified model woredas with the focus on introducing information and
communication technologies (ICTs) at the local level to enhance healthcare service delivery and data
management. This is facilitated by the commitment of the Ethiopian government and the engagement
of six local universities in the Capacity Building and Mentorship Program (CBMP- that provided technical
assistance, training, and mentorship to woredas. The second major achievement in the IR is the
institutionalization and local capacity development related to the customization and deployment of the
District Health Information System 2 (DHIS2). Concerted efforts have been made to build local capacity
to sustainably implement DHIS2 in Ethiopia, leading to improved data management and utilization at
There are also major challenges that require further attention and improvements to fully harness the
potential of digital technologies in the health sector. First, there is weak governance of HIS and digital
health. Although platforms have been established, they are not fully functional, and there is a lack of clear
governance structures at the woreda (district) and lower levels. This has resulted in poor local ownership
and hindered effective decentralization of HIS and digital health initiatives. Second, the financing of the
IR roadmap remains donor dependent and the share of government investment in these areas remains
low, although strategies have been developed and costed. The maturity level of most digital health
systems in Ethiopia is still at an early stage, requiring significant efforts and investments to strengthen
their functionality, usability, and interoperability. It is also noted that the existing and planned digital
health systems primarily focus on data collection rather than incorporating service delivery workflows.
While data collection is important, integrating digital health technologies into service delivery workflows
can streamline processes, improve efficiency, and enhance the quality of care.
Interoperability of digital health systems is another glaring gap identified in the mid-term review,
which hampers data sharing, collaboration, and the integration of health information across various
levels of the health system. The engagement of the private sector in HIS strategy development and
governance is another challenge identified in the mid-term review. Private sector involvement can bring
expertise, resources, and innovation to digital health initiatives. This has been evident in COVID-19
response. Many digital solutions for COVID-19 response were developed by private firms. Establishing
effective partnerships and collaborations with the private sector can contribute to the development
and implementation of sustainable and scalable digital health solutions in Ethiopia. There is a lack of
evidence regarding whether the implementation of digital health strategies is bringing about cultural
transformation (a shift in the mindset and behaviors of healthcare providers and stakeholders) in data
use. Lastly, there are gaps in the motivation and retention of Health Information Technicians (HITs) who
play a vital role in managing and maintaining digital health systems. Insufficient motivation and limited
career development opportunities for HITs is reported to have resulted in workforce shortages and
turnover, negatively impacting the sustainability and effectiveness of digital health initiatives.
i. Align with and leverage the potential the broader digital Ethiopia strategy such as the national
identification (ID) program, mobile payments, government connectivity, and hosting infrastructure
to strengthen synergies, resources can be maximized, and interoperability between different
digital systems can be enhanced. Also leverage the national ID program for Master Patient
Index (MPI) and implementing national health shared records to enables the seamless flow
of patient information across healthcare settings, enhancing continuity of care and improving
health outcomes.
ii. Strengthen the functionality of the Information Revolution (IR) governance structures, particularly
by increasing the capacity of the Ministry of Health (MoH) to mobilize resources and coordinate
HIS efforts at the national level. This should be supported and facilitated by Introducing
accountability mechanisms around the quality of reported data and the outcomes with clear
performance metrics, feedback mechanisms, and incentive structures.
iii. Foster and support decentralization and local ownership of HIS and digital health initiatives
including woreda and health facility-level personnel, to take ownership of digital health
initiatives fosters sustainability, adaptation to local contexts, and responsiveness to community
needs. As part of capacity building, develop and implement a structure that ensures competitive
compensation, career development opportunities, and supportive working environments to
attract and retain skilled HITs.
iv. Establish and enforce a robust legal and policy framework for the security, privacy, and
confidentiality of patient-level data, learning from best practices of other countries, to ensure
the protection of sensitive health information and maintain public trust in digital health systems.
v. Develop a Total Cost of Ownership (TCO) for major digital systems, to have comprehensive
understanding of the financial implications and requirements, with a particular focus on the
electronic Community Health Information System (eCHIS) and Electronic Medical Records (EMR),
assessing the full lifecycle costs of implementing and maintaining digital systems, including
infrastructure, software, training, and support.
vi. Developing and implementing a strategy (including the role of CMBP universities) on digital
and AI-enabled healthcare approaches to enhance healthcare service delivery, diagnostics,
decision support, and patient engagement.
vii. Work towards transitioning from electronic health information that encompasses interoperable
systems, telemedicine, mHealth applications, and data analytics. This should be supported by
designing and implementing analytic platforms as well as build capacity that enables visualization
of health data and leverage digital health technologies to enhance patient-centered care and
improve health outcomes. Prioritize investment on building and deploying systems that promote
remote data access, findability, use, reuse, and interoperability.
viii. Leverage the potential of the private sector (expertise, innovation, and resources) in digital
health systems development, implementation, and support by working more on public-private
partnerships and creating an enabling environment for private sector engagement.
The HSTP II plan set two targets for Human Resources for Health (HRH). One was the density of health
workers and the other was the retention of health workers. Data for retention of health workers were
not available at the national and the regional levels. The recent Federal Ministry of Health annual
performance report of 2014 EFY indicated that nationally there were 13,117 General Practitioners,
including specialists and sub-specialists, 70,246 Nurses, 21,993 Midwives, and 16,452 Health Officers
(Table 5).
Table 5: Selected Health Workforce (Core Health Workers) Distribution by Region in Ethiopia, 2013 EFY – 2014 EFY
The 2014 EFY Federal Ministry of Health annual performance report indicated that nationally one Doctor
(General Practitioner, Specialist, or Sub-specialist), one Nurse, One Midwife, and One Health Officer was
expected to serve 7,576; 1,415; 4,519; and 6,041 people, respectively (Table 6).
Table 7: Health workers’ density at regional and national level in Ethiopia, 2013 EFY – 2015 EFY
1 Tigray 1.74 -
2 Afar 0.84 1.10
3 Amhara 1.04 1.12
4 Oromia 0.75 0.76
5 Somali 1.02 1.36
6 Benishangul Gumuz 2.16 2.12
7 SNNP 1.22 1.54
8 Sidama 1.34 1.54
9 South West Ethiopia - 0.83
10 Gambella 2.86 2.66
11 Harari 2.44 2.49
12 Dire Dawa 1.50 2.66
13 Addis Ababa 4.35 4.67
National 1.0 1.6 1.16 1.23
Note:
• Ethiopia’s health professionals’ density (for core health professional categories) considers
Doctors, Health Officers, Nurses, and Midwives per 1000 population.
• The baseline for health workers’ density is 1.0/1000, the target for Mid-Year 2015 EFY is 1.6/1000,
and for 2017 EFY 2.3/1000.
The mid-term evaluation of HSTP II revealed that progresses has been made regarding a motivated,
competent, and compassionate health workforce (MCC). The progress included an increment in the
availability of the health workforce in the labour market due to a good focus on developing the health
workforce through investment in pre-service and CPD, standardizing curriculum and training institution
accreditation, and linking CPD with licensing renewal in most regions. Efforts to redesign/revise existing
motivation/incentive packages/ mechanisms and implementation of national license examination were
also some of the achievements made due to the implementation of HSTP II.
The mid-term review identified a number of challenges in ensuring the availability of an adequate
number and mix of quality health workforce that are motivated, competent, and compassionate (MCC)
to provide quality health service. Health facilities do not have adequate HR as per standards; motivation
packages have not been equally implemented in all regions; competency assessments have not been
fully implemented due to a lack of resources and standards; and there were gaps in the implementation
of competency-based training that include inadequate skill labs, reading corners, preceptors in hospitals;
and shortage of budget for health workforce training/education. In addition, unforeseen events such
as conflict, COVID-19, and infrastructure issues also influenced the implementation of the integration of
CPD with licensing renewal, and it was not started in B/Gumuz, Afar, and Amhara regions.
Recommendations
i. Invest in ensuring all health facilities have the number of health workers as per standards, with
low rates of absenteeism;
ii. Design and implement incentives and mandates to incentivize all stakeholders to emphasize
CPD and consider it their own agenda.
iii. Change admission requirements for public and private health PSE programs so that trainees are
enrolled based on their interests and compassion and their origin from medically under-served
communities.
iv. Approve, budget for, and implement financial and non-financial retention and performance
incentives
v. Financing: Need long-term increased, earmarked financing for HRH
vi. Accountability and Implementation Gap: Mandates are often not enforced. There have been
gaps between policy and action.
One of the initiatives on the health financing transformation agenda is to mobilize sufficient and
sustainable health finance. As part of this, at federal level, first, efforts are underway to increase resource
allocation from federal government through innovative and exempted service financing to establish a
national Resilience and Equity Health Fund (REHF) with the objective of introducing innovative financing
(mobilizing domestic resources from sin taxes) to finance emergency responses, exempted health
services, and activities that promote equity for socioeconomically disadvantaged groups. It is expected
that the approval of REHF will increase the resources allocated to the sector, address the resource
gaps in the three areas (emergency, exempted, and equity), and decrease dependency on external
sources. Currently, a REHF document has been developed and shared with the Ministry of Finance
and Ministry of Justice and their comments were fully addressed and they confirmed that they do not
have any technical comments. As part of streamlining the provision and financing of exempted health
services at the national level, a committee has been established and is currently working on refining
the list of exempted health services, costing them, and devising the financing sources and mechanisms.
The endorsement of REHF can alleviate the huge financial burden on health facilities related to the
provision of exempted services that aren’t currently getting reimbursement, especially in maternal and
Apart from the efforts to improve domestic resource mobilization, there has been notable progress
in improving the management of external resources. For instance, a risk assessment of the SDG PF
management was conducted, and the SDG PF Joint Financial Arrangement was revised. In addition, the
Channel 2 Administration Directive is about to be approved, and a public finance management manual
was developed.
In addition to the efforts to mobilize additional finance for the sector, a number of initiatives on the health
financing transformation agenda have been implemented. In this regard, priority investment areas for
public-private partnerships (PPP) were identified (e.g., diagnostic services, medical gas plants, oncology)
and registered by MOF, and feasibility studies were conducted. To facilitate the implementation of PPP,
FMOH employees were also trained on PPP and completed levels 1 and 2. In order to enhance private
investment in the sector, a private investment user guide was developed and uploaded to the Ministry
website; advocacy is conducted with the Investment Commission every year; private investment
proposals were reviewed; and follow-up of private investments were undertaken.
It is fair to recognize the attention given to health financing by the Ministry as it is one of the five
transformation agendas in the HSTP II, unlike the previous strategic plans. However, the implementation
of the health financing transformation agenda initiatives (such as DRM) did not make major progress,
particularly in relation to the high-level political advocacy and cascading it to regional level. Hence,
Recommendations
As the progress in the implementation of health financing transformation initiatives is very limited, it
recommended to develop an implementation plan and high-level political advocacy. As part of improving
the domestic resources allocated to the sector, DRM structures at the level of the directorate, like that of
Addis Ababa, Amhara, and Oromia regions, have to be scaled up to other regions. For this to happen,
the Ministry needs to support regions in terms of creating awareness about the importance of such
structures and also developing the capacity of staff at regional health Bureaus. With the scale-up of
capitation at health centers level, the design of PBF needs to consider blending it with such type of
provider payment mechanism.
The major interventions planned as part of HSTP II to transform leadership under this transformation
agenda are redesigning & restructuring the health system, institutionalizing accountability mechanisms,
strengthening clinical governance, ensuring regulatory system autonomy, strengthening stakeholder
engagement and partnership, building leadership capacity at all levels, and incorporating the Health in
All Policies approach throughout the government.
In this regard there are good achievements in the last two and half years. First, MOH undertook an
organizational restructure for the 2014 aiming at strengthening linkage and coherence between
directorates and RHBs; provide better flexibility for making quick decisions; enhance the capacity to
put health policies and initiatives into action. The Civil Service Commission approved a new structure,
which has been implemented beginning 2023. The second important achievement is the development
and approval of the alignment action plan, which make Ethiopia the first country to implement the
alignment framework (maturity model) with engagement and ownership of all stakeholders. The MOH
successfully conducted a diagnostic exercise that assesses a country’s status against the domains of
One Plan, One Budget, and One Report and then Alignment Action Plan were developed and approved
by all stakeholders creating fertile ground to move towards the implementation phase. The main driver
of the exemplary success of Alignment Framework is continues commitment of the top management
of the MOH.
Another are of investment was building the capacity of leadership through Leadership Incubation
Program (LIP) was initiated for MOH staff to enhance the MOH junior experts and team leaders who
aspire to be leaders in the health system. 175 trainees have attended the LIP program out of which
47% are women on average. LIP is focused on creating leadership continuum accordingly, the program
targets.
Well organized COVID-!9 Response: The MOH leadership was able to mobilize resources and create
platforms to engage development partners, NGOs, civil society and private sector to effectively manage
COVID-19 response without compromising the delivery of basic health services.
Post-Conflict Recovery efforts: The MOH leadership quickly engaged in the rehabilitation and resumption
of services in conflict affected areas, mobilizing resources from all stakeholders including the diaspora
community. The twinning of some hospitals with hospitals affected by the conflict a model innovation
with significant impact.
Although efforts made to foster leadership and governance, the effort remains fragmented and has
limited coverage. Despite the efforts made, there is still low coverage of merit-based assignment of
leaders at various levels. Inspite of the efforts made to strengthen alignment, , there is suboptimal
alignment and increased number of program initiatives undermining the implementation of the alignment
agenda . There is still a gap in effective planning and tracking mechanisms for leadership action plan.
Recommendations
According to the 2022 Ethiopia Conflict Impact Assessment and Recovery and Rehabilitation
Planning (CIARP), the conflict had disruptive impacts on health service delivery, with 1) damage to
health infrastructure, 2) widespread looting of medical equipment and medicines, 3) insecurity, and
4) displacement of households and health workers. It is estimated that 3,217 health posts, 709 health
centers and 76 hospitals were either partially or completely damaged in Afar, Amhara, Benishangul
Gumuz, Gambella, Tigray and Konso zone of SNNPR.17
In Amhara, over 9,888 health workers fled from their duty stations during the conflict. The health
workforce also suffered greatly due to the conflict. Table 8 presents findings from the CIARP that
indicate the impacts of the conflict, with an emphasis on infrastructure.
Table 8: Damage to Physical Infrastructure, According to Conflict-Affected Zone and Type of Health Facility
• 5 Blood banks
• 8 Zonal Health Departments
Amhara 1728 452 40 • 56 Woreda Health Offices
• 124 damaged or looted ambulances
• 1 EPSA pharmaceutical store
• Unspecified quantity of damaged or looted
drugs, equipment, medical supplies,
motorbikes, patient and health facility
Afar 59 21 2
records
• 20 ambulances damaged or destroyed
• 1 EPSA pharmaceutical store
172 (of which 16 (of which • Unspecified quantity of drugs and medical
Benishangul
155 were fully 12 were fully supplies looted
Gumuz
damaged) damaged) • 51 ambulances damaged or destroyed
Konso Zone
8 0 0
of SNNPR
34 (82.9%
565 (76% of all 113 (50% of all
Tigray of all
health posts) health centers)
hospitals)
Source: CIARP Final Health Sector Report and Costs, 2022, Pages 11-14
17
Ministry of Health. 2022. Ethiopia Conflict Impact Assessment and Recovery and Rehabilitation Planning (CIARP).
• Maternal and newborn health: Pregnant mothers lost timely access to necessary and basic
antenatal care and institutional delivery services
• Child health, immunization and nutrition: Children lost access to basic child health services,
including immunization, Vitamin A supplementation, screening and treatment for malnutrition,
and treatment of other childhood illnesses.
• HIV: People living with HIV missed their regular drug and treatment follow ups, including
interruptions in drug refills.
Conflict has also impacted social determinants of health. A published study (Gessew et al., 2021)
on the conflict’s impact in Tigray noted disruptions in basic services such as ANC, supervised delivery,
postnatal care and children vaccination, particularly during the first 90 days of the war. However,
there were other byproducts of war that relate to social determinants of health such as destruction of
livelihoods, widespread hunger and the heightened occurrences of sexual and gender-based violence
during the conflict.19,20
18
Ministry of Health. 2022. Ethiopia Conflict Impact Assessment and Recovery and Rehabilitation Planning (CIARP): Final Health Sector Report and Costs, p. 17
19
Gesesew H, Berhane K, Siraj ES, et al The impact of war on the health system of the Tigray region in Ethiopia: an assessment BMJ Global Health
2021;6:e007328.
20
The authors of the above study issued a later correction: Correction: The impact of war on the health system of the Tigray region in Ethiopia: an assessment
Table 9: Performance against HSTP II targets relevant to Selected Service Delivery Areas
Performance
Performance
(% achieved)
against MTR
Color Rating
Data Source
Target 2022
End Target
Dec. 2022
(2024/25)
Mid- term
Indicator
Baseline
through
Targets
SD 1: Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health and Nutrition (RMNCAYH-N)
Trends in maternal mortality,
2000–2020,2000 estimates
Maternal Mortality Rate - Per
401 279 267 >100% by WHO, UNICEF, UNFPA,
100,000 live birth
the World Bank Group, and
UNDESA/Population Division
Estimates developed by the
United Nations Inter-agency
Under 5 Mortality Rate – per
59 51 43 47 >100% Group for Child Mortality
1,000 LB
Estimation-2022 Report for
2021 GC
Estimates developed by the
United Nations Inter-agency
Infant mortality rate per - 1,000
47 42 35 34 >100% Group for Child Mortality
LB
Estimation-2022 Report for
2021 GC
Estimates developed by the
United Nations Inter-agency
Neonatal mortality rate - per
33 28 21 26 >100% Group for Child Mortality
1,000 LB
Estimation-2022 Report for
2021 GC
Contraceptive Prevalence Rate 41% 45% 50%
Proportion of pregnant women DHIS2 -Six Months Data
43% 60% 81% 75% >100%
with four or more ANC visits Analytic Report
Proportion of deliveries
DHIS2 -Six Months Data
attended by skilled health 50% 62% 76% 71% >100%
Analytic Report
personnel
Early Postnatal Care coverage, DHIS2 -Six Months Data
34% 53% 76% 32% 60%
within 2 days Analytic Report
DHIS2 -Six Months Data
Cesarean Section Rate 4% 6% 8% 5% 83.3%
Analytic Report
DHIS2 -Six Months Data
Still birth rate (Per 1000) 15 14.5 14 11.7 >100%
Analytic Report
Proportion of asphyxiated
DHIS2 -Six Months Data
newborns resuscitated and 11% 29% 50% 82% >100%
Analytic Report
survived
• Deployment of mobile health and nutrition teams during conflict (was previously just in pastoralist/
hard-to-reach areas; In 2023, development of Mobile Health Services guidelines for broader
application in different settings)
• Pre-positioning of essential commodities for disease prevention and control in emergency
hotspots
• Evidence-informed targeting based on disease incidence, program coverage and priority
population groups (Done for service delivery areas such HIV, nutrition, TB, emergency services)
• Streamlined service packages to help sustain service delivery during shocks (e.g., as done for
Neglected Tropical Diseases [NTDs])
• Intentional community engagement to maintain continuity of care during crises
• Public-private partnerships for laboratory services, dialysis and oxygen generation
Key drivers of achievements under HSTP II have been the leadership/buy-in within the MOH; deliberate
and meaningful community engagement, particularly during shocks (e.g., conflict, COVID-19 pandemic,
drought); nimbleness of local stakeholders and decision makers in mobilizing domestic resources and
capacities to address service delivery challenges; and infusion of financial and technical support from
development partners to advance priorities such as NTDs. As described in the next section, different
programs are at different stages of evolution. However, there are also systemic issues that are impacting
all programs, namely the following: Challenges with multi-sectoral coordination and accountability for
issues needing non-health inputs (e.g., antimicrobial resistance (AMR), nutrition); Continuum of care
shortcomings, e.g., (From screening to care/treatment (e.g., HIV cascade); maternal health cascade
(multiple ANC visits to skilled delivery to timely postpartum care) and referral gaps (within facilities,
across levels/tiers, across regions); the disruptive nature of external (i.e., non-health-sector-specific)
factors such as:multiple, overlapping shocks (public health emergencies, insecurity/conflict, drought)
disrupted service provision; macroeconomic issues such as inflation and disruptions in global markets,
supply chains.
According to the 2021–2022 ESPA, the Ethiopian Ministry of Health (MOH) master list of active health
facilities includes 27,036 facilities, of which 421 are hospitals (of which 333 are government facilities),
3,789 are health centers (most of which are government facilities), 5,252 are clinics (most of which are
private) and 17,574 are health posts (all of which are government facilities).21
Excluding health posts, the most available services in Ethiopia’s health facilities are emergency services
(93%), curative care services for sick children (92%), diagnosis or treatment of sexually transmitted
infections (STIs) excluding HIV (91%), diagnosis or treatment of malaria and noncommunicable diseases
(84% each), and family planning (FP; 83%).22 Service availability is suboptimal for RMNCH services such
as normal delivery services (54%), child growth monitoring services (51%), child vaccination services/EPI
(47%), Cesarean delivery, blood transfusion, and neonatology services (each at available in only 6% of
all facilities), and intensive care unit (ICU) services (2%).23
Among health posts, service availability is highest for FP (including modern, fertility awareness, and
sterilization methods) services (94%), followed by child vaccination services (90%); growth monitoring
services, whether facility-based or via outreach (88%); curative care services for children under age 5,
whether facility-based or via outreach (88%), antenatal care (ANC) services (80%), diagnosis or treatment
of malaria (62%) and diagnosis, treatment prescription, or follow-up for tuberculosis (TB; 27%).24
The HSTP II provided strategic initiatives in various programmatic area. This review also assessed
the relevance availability, equitable access, effectiveness and quality of each of the major programs
Annex 1 provides a qualitative description of each program’s progress vis-a-vis five domains: relevance,
service availability, equitable access, effectiveness and service quality. The following section provides
a concise overview of the performance of individual programs under HSTP II.
Family Planning and Reproductive Health: Driven by the country’s Family Planning (FP) Guidelines
(2020),25 there has been progress in the expansion and reach of FP (e.g., via outreach; through greater
postpartum FP access); health worker training, clinical mentorship and supportive supervision; and
implementation of the Public Private Mix Implementation Guidelines for RMCAHN Services (2020).
However, limited method choice; gaps in quality and responsiveness of services to the needs of key
subgroups such as adolescent and young people and dwindling FP funding by donors are reported as
major challenges.
Maternal, Neonatal and Child Health (MNCH): There have been strides in the expansion and
strengthening of integrated community case management of newborn and childhood illnesses at health
posts, expanded access of the neonatal care package, and safe delivery and improved management
of maternal and neonatal complications (e.g., via introduction of ultrasound services at health centers
(particularly in urban areas), maternity waiting rooms, community engagement in emergency transport
and expansion of OR blocks in health centers). However, there are persistent supply-side gaps, e.g.,
in essential MNCH supplies, the full complement of required equipment in OR blocks and the health
workforce. There also gaps in health service delivery related to important contributors to child morbidity
and mortality (e.g., child injury prevention).
21
Ethiopian Public Health Institute (EPHI), Ethiopia; Ethiopian Ministry of Health and ICF. 2022. Ethiopia Service Provision Assessment 2021–2022 Preliminary
Report. Addis Ababa, Ethiopia: EPHI; Ethiopian Ministry of Health, Addis Ababa; Ethiopia; and ICF, p. 3.
22
Ibid., p. 9.
23
Ibid.
24
Ethiopian Public Health Institute (EPHI), Ethiopia; Ethiopian Ministry of Health and ICF. 2022. Ethiopia Service Provision Assessment 2021–2022 Preliminary
Report. Addis Ababa, Ethiopia: EPHI; Ethiopian Ministry of Health, Addis Ababa; Ethiopia; and ICF, Table 3.2.
25
MOH (2020), National Guideline for Family Planning Services in Ethiopia.
Adolescent and Youth Health: There was an HSTP II vision to expand youth-friendly services, enhance
parental skills and promote adolescent and youth life skills and healthy behaviors27. There have been
strides in the provision of youth-friendly health services, weekly iron and folic acid supplementation,
provision of school feeding and measurement of nutritional status, although strides are on a limited
scale. However, lack of budget, inadequately trained health workers to address adolescent and youth
health needs, increased cases of sexual and gender-based violence in conflict areas and delayed
mainstreaming and integration of adolescent and youth health in other sectors (pace/scale of efforts
were impacted by COVID-19 pandemic) are reported to have hindered further progress.
Nutrition: The first 2.5 years of HSTP-II implementation entailed enhancing and scaling nutrition services
and expanding the Seqota Declaration (from 40 to 240 woredas) on multi-sectoral collaboration to end
child undernutrition. Key achievements related to the First 1,000 Days initiative (e.g., deworming and
micronutrient supplementation services, expansion of nutrition screening of children and pregnant and
lactating women). Whilst there are still funding shortfalls, the Government increased its annual budget
allocations for nutrition, complemented by financial and technical support from development partners.
However, the country has made limited progress towards World Health Assembly nutrition targets. The
National Food and Nutrition Strategy Baseline Survey, point prevalence estimates of child stunting,
wasting, underweight and overweight are 39%, 11%, 22% and 6%, respectively.28,29 Challenges relate to
the complexities of a multi-sectoral nutrition response, impacts of shocks (e.g., drought, conflict, public
health emergencies) and inadequate private sector engagement.
Hepatitis: Under HSTP-II, there were plans to initiate and expand hepatitis testing, treatment and viral
load testing service at hospitals and health centers, integrating hepatitis services with other health
services (e.g., HIV, TB, FP/SRH, MNCH). Major achievements relate to increased public awareness
and screening (particularly via integration with HIV services). However, the hepatitis program has not
been fully integrated with other health programs, and testing and treatment are available in only a few
hospitals. Financial factors (e.g., high costs of hepatitis treatment) remains an impediment to service
expansion and integration.
Tuberculosis and Leprosy: Key achievements under HSTP II have been strengthened TB case finding,
contact tracing and screening services, as well as improved contact tracing of leprosy cases. Strides have
been made in strengthening TB/drug-resistant TB diagnostic services (e.g., through a sample referral
network, more-sensitive screening tools such as chest x-ray and GeneXpert, provision of community
TB screening and treatment, passive case finding). The development of the TB national strategic plan,
adoption of new technology, advocacy at all levels, private-sector engagement and launching of the
26
MOH (2021), Ethiopia Health Sector Transformation Plan (2019/20-2024/25).
27
MOH (2021), Ethiopia Health Sector Transformation Plan (2019/20-2024/25).
28
Food science and Nutrition Research Directorate at the Ethiopian Public Health Institute (EPHI). National Food and Nutrition Strategy Baseline Survey: Key
Findings Preliminary Report, March 2023.
29
Stunting (chronic malnutrition) is defined as height-for-age below -2 standard deviations (SD), wasting (acute malnutrition) is defined as weight- for-height
below -2 SD, underweight is defined as weight-for- age below -2SD and overweight is defined as body mass index-for-age above +1SD.
Malaria: Under HSTP-II, key achievements are improved malaria surveillance, improved screening and
epidemic response, strengthened diagnostic services and vector control activities through community
interventions. Evidence-informed targeting in implementing the Ethiopia Malaria Elimination Strategic
Plan (2021–2025)30 is a cornerstone of the program. Challenges have included shocks such as droughts
and conflict, systemic gaps in key health system building blocks (e.g., supplies, health workforce, etc.)
and maintaining malaria as a priority amidst other health-sector priorities.
Prevention and Control of Neglected Tropical Diseases (NTDs): There has been an expansion of
NTD service availability, with services for arboviruses and rabies now available beyond the initial nine
priority NTDs. The NTD program has effectively advocated for multi-sector engagement and elevated
community awareness for NTD prevention and control. The major challenge is a lack of NTD integration;
the NTD program is still a vertical program with limited government financing and a reliance on donor
support.
Prevention and Control of Non-Communicable Diseases (NCDs): NCD prevention and control efforts
focused on strengthening the enabling environment (enforcement of comprehensive policies, legislation
and/or regulations [e.g., on tobacco and alcohol]; establishment of a multi-sectoral coordination
mechanism) and expansion of NCD-related interventions within primary health care (PHC) through task
shifting, task sharing and improved referral networks. Challenges relate to ensuring accountabilities
and effectiveness of the multi-sectoral coordination and limited awareness-raising programs on NCDs
and risk factors.
Mental Health: Under HSTP II, there was a vision to develop legislation, strengthen mental health care
integration at each level of the health system, raise public awareness, establish a National Institute of
Mental Health and ensure a continuous supply of essential medicines and diagnostic technologies31.
Mental health service availability has expanded but there remain shortfalls in meeting the population’s
mental health needs (see section on Transformation Agenda 1). Relative to other health services, mental
health is a lower priority, as reflected in limited budgeting and health workforce development in this
domain.
Hygiene and Environmental Health: The hygiene and environmental health program focused on
addressing environmental determinants of health to improve the quality of health services and health
outcomes. The Health Extension Program (HEP) focused on improving the availability and utilization
of basic sanitation services at household and community levels. Strides have also been made in
improving water source quality and safety through water quality monitoring and surveillance systems,
in collaboration with the water sector. However, continued progress is contingent upon the inputs of
other sectors, and there have been challenges with multi-sectoral coordination and accountability.
30
MOH(2021), Ethiopia Malaria Elimination Strategic plan (2021- 2025), Addis Ababa.
31
MOH (2021), Ethiopia Health Sector Transformation Plan (2019/20-2024/25).
Clinical Services: The expansion of specialty and subspecialty services, as per the the country’s National
Specialty and Subspecialty Roadmap,32 has been a major achievement under HSTP II. This includes
expansion of surgical and anesthesia care, ophthalmology services and basic dental services. Major
progress was also made in piloting the “system bottlenecks focused reform (SBFR)” in four hospitals,
and in the expansion of operating rooms (ORs) in health centers to enhance access to surgical services.
One area for which progress has lagged is developing and implementing the national medical tourism
strategic plan.
Pre-facility, Emergency, Trauma and Critical Care Services: Various shocks have had disruptive effects
on health service delivery, but a positive unexpected outcome of those shocks is the advancement of
critical care over the past 2.5 years. There have been strides in standardizing and strengthening basic,
advanced, ambulance and prehospital services. Some hospitals have included emergency, trauma
and critical care services as part of QI, which has contributed to overall efforts to institutionalize QI.
However, there remains a need to continue strengthening health system resilience and optimizing
referral mechanisms within facilities, across facilities and levels of care, and across regions.
Blood Transfusion Services: As highlighted by stakeholders consulted for the MTR, there has been a
strengthening of blood transfusion services, with intensified community awareness creation to promote
blood donation/collection and strengthened quality-assured testing. However, there remains a limited
number of blood donors.
Laboratory and Other Diagnostic Services: Laboratory quality management systems have improved
over the past 2.5 years. Additionally, there has been an expansion of national proficiency testing
and improved availability of national and regional lab infrastructure. Like critical care, the COVID-19
pandemic has proven to be a major impetus in directing greater stakeholder attention and investment
in improving laboratory services.
Antimicrobial Resistance (AMR) Prevention and Containment: Progress has been made in AMR
stewardship and awareness-raising on AMR and its adverse impacts. Sentinel sites are nodes of
surveillance and research to inform AMR efforts. Challenges include supply gaps (e.g., lab reagents),
finance and support from partners, multi-sectoral coordination (e.g., maintaining accountability for
contributions from stakeholders outside the health sector), data quality from sentinel sites, and AMR-
related capacity and buy-in across all regions.
32
Ministry of Health, National Specialty and Subspecialty Service Roadmap 2020–2029, Ethiopia
Equity in Health Service: The MOH has conducted a health equity analysis and developed national
equity strategic plan33 that informed the development of evidence-informed equity program design.
However, strides were not made in terms of mainstream and institutionalizing equity in the delivery and
monitoring of health services. The major challenge and gap is a lack of contextualization of health service
programs and service delivery models within different settings across the country. The forthcoming
findings from EPHI’s National Equity Assessment (not available for inclusion in the MTR analysis) will
be a critical source of evidence to inform tailored strategies that address equity dimensions and are
responsive to the needs and dynamics of known vulnerable and/or underserved subpopulations.
33
Ministry of Health (2022), National Health Equity Strategic Plan 2020/21-2024/25, Ethiopia
i. Design and implement ‘catch-up’ initiatives and innovative service delivery platforms (e.g.,
mobile service delivery, telehealth) to address existing inequities in service delivery, service
disruptions and backlogs.
ii. Integrate findings and assessments from regulatory bodies, assessments on service availability
and other data sources to enhance regional planning processes to reflect all available contextual
evidence.
iii. Establish strategies and targets/milestones to address identified gaps in health system building
blocks, with a particular focus on optimizing the continuum of care for all programs/service
delivery areas, e.g., via:
b) Functional referrals (across tiers/levels, between regions, within the same facility, between
public and private facilities)
On the other hand, the MOH had developed and implemented a 5-year health sector transformation
plan (HSTP-II) which included public health and disaster risk management (PHEM) and hence a midterm
review (MTR). PHEM is among the major thematic areas evaluated. This brief report attempts to
summarize the major findings and recommendations as shown below.
Progress of key performance indicators (KPIs): there were two KPIs included for PHEM and DRM. These
are ‘health security index’ and ‘proportion of epidemics controlled within the standard of mortality’.
Ethiopia’s health security index as measured by the annual SPAR (State Party Self-Assessment Annual
Report) has progressed from the baseline 0.63 to 0.74 in 3 years and surpassed the expected 0.70 mid-
term target (see figure 2). In terms of proportion of epidemics controlled within the standard mortality,
only measles and cholera have a predetermined standard mortality.
IHR Capacity
80 72 74
70 67
63
58
60
50.4
50
Status (%)
40
30
20
10
0
JEE 2016 SPAR 2018 SPAR 2019 SPAR 2020 SPAR 2021 SPAR 2022
While the average case fatality rate for measles was 1.1% much lower than the standard 3%, the CFR
for cholera was 1.45% which is higher than the standard 1%. Since, other diseases don’t have standard
acceptable mortality rate, it is difficult to measure this indicator.
The following are some of the achievements and enabling factors during major emergency management
such as COVID-19 and conflict: Establishment of the Multi-sectoral engagement support team at MOH,
which facilitated expanding testing, isolation, and treatment capacity by creating makeshift centers
(approximately 150) and engaging private sector; reached almost all households nationwide to test,
isolate, and treat COVID-19 through COMBAT; Twinning of hospitals in conflict affected regions with
hospitals from other regions; mobilization, training, and deployment of thousands of volunteers
and HCWs for COVID-19, conflict, and other emergencies; digitalization of the PHEM system during
COVID-19 response; expansion of Emergency Operations Centers (EOCs) at national, regional, and
sub-regional level; Vulnerability Risk Analysis and Mapping (VRAM) and Emergency Preparedness and
Response Plan (EPRP) for over 300 woredas; national and regional PHEM call centers established and
operationalized; domestic financing of COVID-19 and conflict.
Besides, the following are among the best practices and lessons learnt/identified during COVID-19,
conflict, and other emergencies: (i) local production of hand sanitizer, non-medical masks, and oxygen
during the COVID-19 pandemic by engaging HEIs and the private sector; (ii)establishment of scientific
Advisory Council & Professional Associations Consortium; (iii) introduction of life and disability insurance
for HCWs working on COVID-19; ( iv)initiation of ntra-action reviews (IARs) during prolonged/protracted
responses provides useful lessons to improve response; (v)utilization of the Dagu system for PHEM-
RCCE (Risk Communication & Community Engagement) has to be managed cautiously since information
spreads fast and communication relies on honesty; and (vi)there are recurrent and prolonged PHEs in
several regions despite response efforts.
On the other hand, there were persistent and recurrent challenges that affected the PHEM system.
The PHEM system is an inverted pyramid when viewed from federal to HF level-resources where
human capacity, systems are not available at the local level where actual emergencies occur. There
is delayed, fragmented, and multiple resource mobilization structures during emergencies affecting
multiple sectors and agencies. More importantly, there is no systematic budget for preparedness and
response at all levels of the system including lack of contingency funding at all levels that often result in
Emergencies/disasters have impacted the health system at different levels. For example, resources
were shifted to pandemic or conflict-strain in the health system; regular provision of service & utilization
was compromised in conflict affected areas & during COVID-19 (e.g., EPI program, HIV care & NCD
services); there was fatigue of health professionals, private sectors, partners, volunteers, governmental
sectors, and civic associations during the COVID-19 and conflict periods; and decline n general health
seeking behavior for other health Services other than Covid-19.
Recommendations
Below is the list of major recommendations suggested to improve the PHEM system categorized based
on the health sector building blocks.
LMG
• Revise the PHEM legal framework to ensure multisectoral (including PS) and multiagency
coordination and collaboration.
• Empower PHEM officers in enforcing public health recommendations and reduce political
interference.
• Align, revise, and capacitate the governance structure of the national and sub-national PHEM.
• Provide PHEM leadership and Incident Management System (IMS) trainings to national and sub-
national PHEM staffs and other relevant management from the health system.
RF
• Expedite the approval of REHF program to institutionalize domestic financing mechanism for
PHEM.
• Facilitate financing (PPP, loan) of the private sector based on clearly identified gaps for priority
PHE preparedness and response.
SD
• Engage Higher-education Institutions (HEIs), health agencies, and local and international private
investors to produce emergency commodities.
• Develop an emergency logistics SCM capacity at the national and sub-national level either by
modifying EPSS or establishing a separate entity for this purpose.
• Conduct regular resource mapping exercises for emergency commodities.
HIS
• Comprehensive digitalization of the PHEM system at all levels including multisectoral databases.
• Conduct and utilize IARs and AARs regularly.
• Conduct nationwide and localized RCAs for recurrent and prolonged PHEs.
• Advocate and facilitate joint multisectoral risk profiling for health hazards at all levels and
prepare joint EPRPs.
3.3. Improve Access to Pharmaceuticals and Medical Devices and their and
their rational and proper use
This strategic direction in HSTP II focuses on strengthening the pharmaceutical supply chain, pharmacy
services, and medical device management systems to ensure uninterrupted availability and accessibility
of safe, effective, and affordable medicines and medical devices that are needed to address the health
problems of the community and ensure that they are used rationally. This strategic direction addresses
reduction of pharmaceutical wastage and strengthening of systematic and environmentally friendly
disposal of expired and damaged pharmaceuticals and non-functional medical devices. The direction
also includes development and implementation of strategies that strengthen local manufacturing of
medicines, medical devices, and standardization of procedures for procurement and management of
medical devices.
Performance
Performance
Target 2022
(2024/25)
9 months,
Mid- term
EFY 2015
EFY 2014
Indicator
Rating in
Baseline
Remark
Colors
Target
Availability of essential 76%
medicines by level of health 84% (Dec.,
care 2022)
30% St.
27.9%ARHB
Supplier fill rate 100% 98.6%
form EPSS
Paul’s
Hosp.
*National joint supportive supervision report on pharmaceuticals supply chain management, January, 2023 by MOH and EPSS
**Annual performance report, MOH, 2014
MOH, as part of its recent restructuring, has restructured PMED from directorate to lead executive
office (PMDLEO), that enabled the lead executive office to have sector oversight and coordination
role in ensuring the availability of essential medicines and medical devices and promoting rational use
working hand in hand with internal and external stakeholders (EPSS, EFDA, EPHI,AHRI and others).
Establishment of the Pharmacy and ME advisory board at MOH with subsector based TWGs is expected
to fill some of the gaps. A coordination platform with establishing supply chain steering committee,
involving key supply chain stakeholders such as EPSS, EFDA, and MOH (PMDLEO, health programs
and Finance and Procurement LEO) is a now in place, which gives special emphasis on strengthening
the overall health program commodities supply at all levels. health program supply chain management
coordination and governance protocol was also developed in April, 2023. there are ongoing efforts in
revising policies and guidelines with in the Ministry and the agencies like revision of Medicine Policy;
development of the national pharmaceutical and medical devices roadmap. EPSS’s draft proclamation
is at its final stage for ratification.
Strengthening domestic pharmaceutical producers is one of the major initiatives in HSTP II. There are
five cGMP compliant pharmaceutical manufacturers in the country. In the MOH annual performance
report 2014 EFY, local producers have supplied pharmaceuticals worth of 197.2 million Birr to EPSS. This
is only 29% of the expected amount. Currently, local manufacturing account only about 8% of the EPSS
annual procurement.
Auditable pharmaceutical Transactions and Services (APTS), that introduces transparent and accountable
pharmaceutical transactions and services, has reached to 361(e-APTS-38) in 2014 EFY health facilities
from 117 in 2013 EFY. Different digital health-commodity management systems were developed and
implemented at service delivery units and EPSS sites. Dagu, a software designed to manage supply
chain functions at service delivery points, is implemented in 1106 health facilities. National supply
chain end to end dashboard prototype is developed and implemented (2015 EFY, 9 months report).
EPSS has completed the preliminary preparation to implement the enterprise resource planning(ERP)
system by the end of this year which is expected to improve its financial, risk management and supply
chain operations efficiency. An Antimicrobial resistance prevention and containment strategic plan,
including human, animal and environmental health, is developed and sector specific work plan was
also developed by Ministry of Agriculture, Ministry of health and the Ethiopian environmental protection
Agency.
There is Inadequate allocation and distribution of budget for pharmacy and Medica Equipment SCM
and services at MOH and lower-level structures, despite the fact that the pharmaceuticals and medical
devices hold the major financial share in the HSTP costing. This is more visible in the area of lack
of adequate operational budget allocated for logistics, training and supply management, waste
management and the pharmaceutical services. According to the survey by SmartChain, quantifications
carried out by health facilities were not based on quality data and not in line with the budget allocated
EPSS is overburdened and had diffused focus on medical devices and Laboratory reagents supply –
EPSS has grown from 10-billion-birr business in 2010 EFY to 45 billion birr in 2014 EFY which makes it
difficult for the agency to provide equal and appropriate focus for pharmaceuticals, medical devices
and laboratory supplies and satisfy the ever-increasing demand. Although medical equipment and
laboratory supplies management requires healthcare technology management which involves setting
technical specification, installation, commissioning, operation and safety, maintenance and repair,
contract management, utilization, decommissioning, and disposal, there is fragmented procurement,
very limited maintenance capacity, and weak contract management (e.g., Placement- lab reagent
received before the machine arrived and commissioned at the HF).
Issues of data visibility and ownership in the SCM – quality and accurate data at facility level is the
basis for proper selection, quantification and forecast of the HF’s demand (reconciling its need with the
available budget) - this can efficiently be realized only through digitalization or automation of the flow of
health commodities with in the health facility and making it accessible to the leadership and the higher-
level structure in the supply chain thereby ensuring visibility and hence accountability. There is weak
Emergency SCM system - Limited budget, coordination and lack of storage infrastructure.
RDF medicines accounts for 1272 (92.6%) items in the PPL as compared to the 101 (7.4%) program items.
In addition, in 2014 EFY, EPSS has procured pharmaceuticals and medical supplies worth of 44.9 billion
Birr. From the total procurement, the revolving drug fund accounted for 5.3 Billion Birr, health Programs
accounted for 5.1 Billion Birr and aid accounted for 34.5 Billion Birr. Although, the RDF accounts for
equivalent amount in value terms to program drugs, RDF was not given the necessary managerial
attention and resources which ultimately compromises the primary health care service delivery which is
the mainstay of the HSTP (universal health coverage ) and the national health policy. The limited focus
on the supply of non-PPL (list of pharmaceutical and medical devices outside the EPSS procurement
list) products is still a concern to be addressed. The delay or absence of reimbursement for exempted
services and the infrequent reimbursement (every 3 months) from CBHI had further aggravated the
supply deficiency in the HFs.
There are many system related challenges raised as part of this review. These include the concern that
focus on community pharmacies (conflict of interest- percentage based compensation) led to a drift
attention from the regular hospital pharmacy resulting in compromising the HFs pharmacy supply and
service; weak pharmacy and program integration at all levels of the health care system compromising
the public health programs performance at service delivery points; the malfunctioning of Drug and
therapeutics committee(DTC), drug information services (DIS) and clinical pharmacy service in the HFs
as compared to up to the standard set in the Ethiopian Hospital service guideline (EHSTG); there is
inadequate Pharmaceutical Waste disposal system and practice throughout the health care system
(MOH/EPSS procured Incinerators, few installed but not yet functional). There is also inadequate
implementation of antimicrobial stewardship (AMS) and weakened intersectoral collaboration and
coordination platform for AMR containment. It is also not cascaded down the health care system. Issues
related to public procurement agency procurement directive is also hampering the health commodities
procurement throughout the health care structure.
There is a need to make Supply Chain Management one of the top priorities in the upcoming health
Sector Development and Investment Plan (HSDIP), 2016- 2018EFY, with a clear strategic shift to:
• Restructure and capacitate the regional and down to woreda level pharmacy units in terms of
skill and number – The pharmacy unit’s structure appears wide at the federal level but very lean
at the RHBs and lower levels structures. The organization of the pharmaceutical and ME unit
across regional states and lower-level structures should be restructured and aligned with the
new structure at the federal level.
• Ensure end to end visibility of supply data – with political commitment and ownership of
supply data by enabling Health facilities to have automated SCMS for inventory management,
quantification, ordering and report generation that creates intra-facility visibility and enable end
to end visibility in the SCM.
• Centralize the national laboratory service to have appropriate lab equipment’s and supplies
demand and supply management - restructure, equip and expand the central lab at EPHI with
chains/Hubs/ of labs throughout the country – at mapped and accessible sites with adequate
array of sample collection points.
• The MOH needs to start developing an option on how to supply commodities which are outside
of EPSS’s Product Procurement List (PPL). Explore, identify and implement different options of
public-private partnership in pharmaceutical and medical devices supply chain management
and services.
• Digitalize and scale up APTS to e-APTS to improve the service delivery and reduce the
professional’s workload. Address the issue of indemnification for the pharmacy practitioners.
Scaleup e-APTS implementation and make it the standard pharmacy practice throughout the
public health system.
• Prioritize and invest on promoting local manufacturing - Restructure and revitalize the
Bioequivalence center at the school of health sciences, school of pharmacy, AAU. The
government need to support the local manufacturers to do bioequivalence tests by cost sharing
mechanisms. MOH together with MOFED need to create a pooled fund (soliciting fund from
agencies - global financing organizations- GFF, WB,GAVI, IMF and other bilateral agencies) in
hard currency for the local Manufacturers as it does for EPSS. Incentivize cGMP compliant local
manufacturers differently than the non- compliant ones.
• Integrate Pharmacy with public health programs, align and work in harmony.
• Develop HR capacity and infrastructure to revitalize the DTC, DIS and clinical pharmacy
service in the HFs according to the Ethiopian Health Service Transformation Guideline and the
pharmaceutical and medical equipment M&E framework.
• Reactivate the antimicrobial resistance (AMR) containment coordination platform at national level
and roll it out to the regions and lower-level structures. Expand and strengthen antimicrobial
stewardship(AMS) into the HFs.
• Engage Public procurement agency (PPA) to make the procurement directive conducive towards
Medicines and MEs supply at all levels in the health system.
• Develop capacity, ensure to avail functional facility and establish separate management for
pharmaceuticals and MEs waste management and decommissioning service
Performance
Color Rating
Target 2022
Baseline
Mid-term
Indicator
The ratification of proclamation 1112/2019 has enabled EFDA to focus on health products only and to be
responsible to ensure the safety and quality of food, efficacy, safety and quality of medicine, and safety
and performance of medical device, cosmetics, tobacco and tobacco products control. Following this
EFDA is undergoing organizational restructuring at federal and regional level. Aligned with HSTP II,
EFDA developed the second Food and Health products regulatory sector transformation plan (FHRSTP-
II) which covers the period between 2013-2017 EFY (July 2020 -June 2025 and envisions to build a
leading and excelled food and health products regulatory system.
The regulatory information system (e-RIS) is in place enabling online GMP inspection application,
registration (i-register), inspection and port clearance (i-clearance), i-import, online adverse effect(AE)
reporting, I-verify, track and trace system to establish an effective, transparent, and accountable system
that ensures adherence by all state and non-state actors to national health regulatory standards and
legal frameworks. These digital systems are currently managed and supported by a partner. EFDA, has
also developed a web-based food safety alert and notification system for rapid exchange of food safety
incidents information among stakeholders, which enabled the public and organizations to report food
safety incidents. Post marketing(PMS) was planned based on reagent availability and for port inspection
there is a consignment list developed. The regulatory authority has very limited mini-labs at branch level to
be used at the entry and exit ports. EFDA also developed different guidelines, directives and regulations
like guideline for emergency use authorization of medicines for public emergency situations; medicines
waste management & disposal directive, Medicine MA directive; medicine donation control directive and
Pharmacovigilance directive to mention some. Improved adverse drug event(ADE) reporting with safety
investigation task force and pharmacovigilance(PV) advisory committee has also been established at
the regional and federal level, respectively. COVID 19 creates an opportunity for PV activities to receive
better attention by the leaders and politicians as PV becomes mandatory to get COVID-19 vaccines into
the Country. A serious adverse drug reaction investigation and causality assessment was conducted on
about 13 cases of COVID-19 vaccination. Moreover, reports on vaccination safety and adverse events
were collected from different parts of the country and submitted to WHO’s database. This leads to
the integration of PV into the public health programs(PHPs) and the formation of safety and regulatory
committee led by EFDA which is cascaded down to the regions.; Currently, the ADE detection rate has
increased to 35,000. Three traditional medicines are under clinical trial. The Ethiopian Food and Drug
Authority prepare the regulatory standards and specifications for medicines and implement them upon
its approval from appropriate organization. However, no official herbal remedy has yet been officially
confirmed to ensure the overall quality of herbal medicines. In some regions EFDA work in collaboration
and conduct plan alignment with the regional regulatory body.
The existence of different structures at federal and regional levels requires mutual understanding and
agreement between them to enforce regulations. However, due to gaps in this area, there is inadequate
enforcement of EFDA’s regulations in the regions and the lower-level structures (issue of autonomy). The
MTR team has observed role confusion between EFDA and regional regulatory body as the regional
regulatory body is structured as FMHACA.
Although it was one of the initiatives currently, there is no established regulatory system for safety and
quality of blood, blood products , human tissues and organs so far, though there is registration of such
products;
Shortage of QC reagents and Mini labs due to procurement bureaucracy has affected its PMS,
consignment tests and quality control tests for market authorization. Although, there is a huge
improvement in ADR reporting associated with COVID 19 vaccines, there remains a lot in ADE reporting
activities from other classes of medicines, pharmacovigilance communications also remain to be
the biggest gap at RHB & HF level. According to the respondents, one of the reasons for delays in
registration was attributed to inadequate understanding of registration guidelines by customers.
Currently, there are five cGMP compliant local manufacturing companies out of the twelve manufacturers
in the country supplying their products to the local market, implying lenient regulatory enforcement
by EFDA (42%). For successful pharmaceutical exports, the regulatory authority needs to be seen
by the global community as applying strict regulatory controls. EFDA might thus have to enforce the
remaining manufacturing companies to become cGMP compliant ASAP or close or suspend non-GMP
manufacturers. The Regional Bioequivalence Center at the college of health sciences in Addis Ababa
University is still not capacitated and functional to provide the anticipated services for the manufacturers.
EFDA uses a number of electronic/digital applications for its activities, but the regulatory body is totally
dependent on partners for its IT system development, data management and support. The 2018 Ethiopian
Food and Nutrition Policy (FNP), identified food safety and nutrition as a governmental responsibility at
the federal level. Despite an enabling policy framework, federal food safety regulation, enforcement,
and compliance is spread across three Ministries (Ministries of Health, Agriculture, and Trade) and lack
clarity and integrated approach.
The second most important aspect of regulation planned in HSTP II is related to health professionals
and services. The main targets were to strengthen the regulation of professional ethics and code of
conduct of health professionals and traditional medicine practitioners; enforcing adherence of health
and health-related facilities, both public and private to the Ethiopian health facility minimum standard;
undertake competency assessment of all graduates before joining the health workforce; introduce and
scale up clinical audits to ensure quality of practice in health facilities and engage private health care
facility associations in health regulatory system .
The responsible body for regulation of health professionals, health and health related institutions is the
Health and Health Related Institution and Professional Regulatory Lead Executive Office (HHRIPR-LEO)
in the MOH. Before the launching of the new structure at MOH (January 2023), regulation of health
professionals and institutions (health and health related) was organized under two separate Departments
in the Ministry: The Health Professional Competency Assessment and Licensure Directorate and the
Health and Health Related Regulatory Directorate respectively. This is a key achievement from the
restructuring process which harmonized different regulatory activities, upgraded it to Lead Executive
Officer level, organized it under 4 Directorates and was better staffed. Various regulatory documents
are in place to provide legal framework for implementation. Accordingly, relevant proclamations,
regulations, directives, and guidelines are available at the federal level as well as regional levels.
Registration and licensing of health professionals and traditional practitioners is conducted at the
regional levels. The main strategy used is linking Continuous Professional Development (CPD) with
licensing of health professionals in the last three years. License renewal is done every three years in
most cases. However, in Oromia license renewal is done every five years. In order to renew license,
health professionals need to accumulate 30 credit hours in CPD. There is good experience of close
collaboration with professional societies. Societies are actively engaged in supporting different aspects
of regulation i.e., designing strategies, guidelines, manuals, exam blueprint development, reviewing
performance of graduates on COC etc…Furthermore, a Health Professional Council establishing
proclamation was drafted by the MOH through support of a committee which comprised of wide
participation from professional societies. The proclamation has passed through crucial steps of
An assessment was made on health professional licensing practice in 365 hiring bodies (56% private ,
44% public and 73% HFs) and reviewed 4991 files of health professionals (1581 from private and 3410 from
public health organizations) (Alemneh et al, 2022). The assessment documented that there is no system
for detecting fake licenses and controlling revoked licenses does not exist; about 33% of professionals
work without license and 12% work with expired license; most human resource managers (88.2%) said
that they had not received any training about health professionals’ licensing; private institutions had
better licensing practice than public counterparts and about 20% of hiring bodies had experience in
hiring health professionals without a license.
Regulation of health and health-related facilities, both public and private (enforcing adherence to the
Ethiopian health facility minimum standard). There are various progresses in terms of revising the current
health facility standards and develop new standards for health and health related institutions.
The Ministry also has target of increasing proportion of HFs adhering to the Ethiopian health facility
minimum standard from 43% to 48% in the current fiscal year. As of April 2023, the proportion has
reached 62%, well beyond the target (2015 EFY 9-month report). However, a challenge reported is
that most government HFs do not renew their license on time (MOH 2015; 9-month report). There are
good experiences from the field in this regard. HFs in Amhara cannot get supply of medicines and
medical equipment unless licensed. Similarly in Dire Dawa, facilities cannot operate unless licensed.
Another major undertaking has been the development of a Master Facility Registry (MFR) to enhance
informed decision making. The Registry is regularly updated and is a comprehensive list of all health
facilities (private, government and NGOs) in the country. The MOH has been supporting regions in
terms development of data collection tools, training for the data collectors and transferring of budget.
Reconciliation of MFR with DHIS2 and eCHIS is in process.
MOH and regional regulatory bodies have developed guidelines and tools to help inspect such
institutions. There is good experience from Addis Ababa FMHACA who have developed various
guidelines and tools for regulating a range of health-related institutions. These documents have
also been adapted by EFDA for federal level engagement. MOH has also developed a standardized
inspection tool for four-star hotels using the international standard, reviewing literature, and scientific
knowledge. Another key initiative is the designing of a Health Professionals Competency Assessment
and Licensure program whereby first-degree graduates have to undergo a competency assessment
exam and get registered and licensed before joining the workforce. Accordingly, competency
assessment exams were developed initially for nine medical professions ((Medicine, Nursing, Health
Officer, Nurse Midwife, Anesthesia, Medical Laboratory Technology, Pharmacy, Dental Medicine
and Medical Radiology Technology). Later on, the competency exam system has expanded to four
additional professions (Emergency and Critical Care Nursing, Psychiatric Nursing, Pediatrics and Child
Health Nursing and Environmental Health Care Professions) increasing the list to 13. Consequently,
between July 2019 and May 2022, 84, 848 professionals that graduated from public and private training
institutions underwent competency assessment exam. Of these, only about 46% have passed the exam
(APR, 2014). Assessment by MOH in selected HEIs (49 HEIs – 20 public and 29 private) has identified
the main reason for the poor performance of graduates on licensure exams is the difference in the
method of assessment used by higher education institutions (HEI) and that employed during licensing
exams (MOH, 2021). The licensure exam uses a Blueprinting or table of specification approach, which
allows developing an exam that encompasses content and learning objectives of a study program and
Introduce and scale up clinical audits to ensure quality of practice in health facilities.
Clinical audits are key undertakings that would go a long way in improving quality of care. However,
such audits have rarely been conducted by the Regulatory due to lack of professionals with diverse
specialties and budget limitation to hire such expertise when required.
Engage private health care facility associations in health regulatory system. MOH regulatory unit has
engaged the private health facility associations in the development of HF inspection tool. Structure of
the regulatory bodies lack harmony between regions and in most cases there is no delineation between
service provision and regulation functions. As it was mentioned above, the health professionals and
institutions regulatory body is under the MOH at the federal level. Progress was made in formulating
a proclamation to establish Health Professional Council that would assume regulation of health
professionals based on global best practices. The plan is to have representatives from the government,
societies, the public and other key stakeholders, and it provides an opportunity to have multi-disciplinary
expertise. The draft proclamation was reviewed within the MOH and was shared with the Attorney
General who provided comments. The Attorney General’s comments have been incorporated and re-
sent, however, the process stalled.
The Regulatory Units at federal as well as regional levels face capacity issues. There is budget limitation
affecting the extent to which regulation activities are carried out as expected. For example, clinical
audits which are key interventions to improve quality are rarely conducted at federal or regional level
due to budget shortage to hire technical experts. At the federal level, the LEO also faces adequate
staff skill mix i.e., they do not have physicians, pharmacists etc. as they cannot afford to hire and keep
such experts. In addition, they do not have partners that support its interventions regularly. Currently,
they only have one technical assistant (TA) and his contract with previous partners ended in September
2022 and he has not been paid since, but he is still working (as compared to 90% of existing staff hired
as TA under Health Infrastructure LEO). During the restructuring, most of the staff chose to compete
and move to other Directorates where there are better partner supports and hence better incentive
mechanisms. The situation is worse in most of the regions.
At the regional level, Addis Ababa, Gambella and Somali Regions have independent Regulatory
Bodies; in Gambella and Somali the Regulatory is accountable to the RHB (semi-autonomous). In Somali
Region, there is regulatory structure down to the woreda level. In the other regions, the regulatory is
organized just as one Directorate under the RHB. Exceptions are SNNP and Southwest Regions that
have established the regulatory as an Authority under the RHB and they get budget directly from
Bureau of Finance. Most of the regions are in the process of revisiting their structure and they are at
the final stage in Dire Dawa to reformulate it towards independent body. Of the regional structures, the
one in Addis Ababa is the strongest and the most independent. The Food Medicine and Health Care
Administration and Control Authority in Addis Ababa City Administration is accountable to the Mayor’s
Office, gets its budget from Bureau of Finance, its well budgeted and staffed.
Licensure
4pharmacy
2HO MPH
1 MPH
Tigray food medicine and 1Health service
Tigray Within RHB 5 Environmental MPH
health care Directorate management
5 HO MPH
1HIT
1labratory
TOTAL 19
Food and medicine 1 midwife 3MPH
product and health and 1environmental 5 BSC nurse
Afar Within RHB
health related regulation 2drugist 1Msc
directorate TOTAL 13
Food and medicine 1MPH Enva licensing
product and health and 1MPH(Ho) 1Mpr(nurse)
Amhara Within RHB
health related regulation 2MPH(Nurse) 1HO
directorate 2MPH(pharmacy) TOTAL 8
Food and medicine 1mph(HO) 2MPH(Pharma)
product and health and 4MPH(Enva) 1 MPH(midwives)
Oromiya Within RHB
health related regulation 1MPH 1 Environmental health
directorate MSC and TOTAL 10
Food medicine health care
Independent
Somali administration and control TOTAL
Authority
authority
Food and medicine 5environmental 1 MPH
Benishangul product and health and 2 HO 1phrmacy
Within RHB
Gumz health related regulation 1BSC nurse 1 BSc
directorate TOTAL 11
Food and medicine
3 environmental 2 pharmacy
product and health and
SNNPR Within RHB 3 health officer 2 laboratories
health related regulation
1professional nurse TOTAL 11
directorate
Food and medicine product
3 MPH
Sidama and health and health Within RHB
TOTAL
related regulation authority
Food and medicine product 2 nurse 1radiology
South West and health and health Within RHB 1 health education and 1 pharmacy
related regulation authority promotion TOTAL 5
Food medicine health care Independent 2 clinical nurse 2 non health
Gambella administration and control Authority 1 druggist professional
authority 1 pharmacy TOTAL 6
Food and medicine
1 nurse
product and health and 2 environmental health
Harrari Within RHB 3 pharmacy
health related regulation 1 food technology
TOTAL 7
directorate
General Health professionals and health and health related institutions regulatory bodies lack
independency and legal framework to operate on a legal ground .The Regulatory is organized as a Lead
Executive Office under the MOH. Similarly, regional regulatory structures are quite diverse and most
lack indolence (they are Directorates under the RHB) and are not well budgeted and staffed. The best
case is Addis Ababa which is independent, well budgeted and adequately staffed. The plan to establish
HP Council went a long way but stalled, which limits the opportunity to have an independent regulatory
body for health professionals with involvement of key stakeholders and expertise. The regulator lacks
an adequate number of staff and the required professional mix such as physicians; pharmacists etc. are
in dire shortage. It also faces shortage of budget and support from partners across the board (federal
as well as in regions). Because of structural and capacity constraints, the regulatory function has not
been as strong as expected. Key functions such as clinical audit does not take place, staffs are not able
to conduct surprise inspections (evenings, weekends etc.) in health and health related institutions (no
overtime payment). Regulatory bodies have not been able to attract and retain experienced staff.
There is a problem in inter-sectorial collaboration especially with Ministry of Trade, Tourism, Environmental
and Forestry, Customs, and Police to enforce regulatory measures. There is a lack of framework for
cross-sectorial collaboration within regions as well. Regulatory measures could potentially involve
conflict with institutions that might not receive favorable feedbacks during inspection. Some of the
feedback could go as far as closing institutions temporarily until the issues are addressed. There have
been cases within regions whereby regulatory personnel have been physically harmed. Risk mitigation
and protection measures remain to be developed and instituted.
There are many licensed CPD centers (200 plus) and about 40 accreditors. Neither the accreditors nor
the Regulatory Body at the MOH has adequate capacity to regularly inspect CPD centers to ensure
quality of course content, trainers, training venue and infrastructure etc. Cases of fraud and malpractice
around CPD practice have been reported. Some CPD centers are considering it as a business, and it
has been reported that certificates are being sold to professionals without attending training. There
is a potential conflict of interest that could emanate from the practice of licensing the same institution
as a CPD center and accreditor e.g., universities, professional societies. Graduates performed poorly
on COC exams, with only 46% passing from 2011 to 2014. It was discovered that the majority of HEIs
i. Support the endorsement of HP Council Proclamation. MOH should also support regions in
the ongoing process of structure review to develop a more standardize regional regulatory
structures.
ii. Strengthen ongoing efforts to strengthen CPD such as building verification mechanisms and
establishing unique identifier ID, linking trainer center to regulatory information system and
making hiring bodies accountable to record CPD related data of their staff as part of HR filing
system.
iii. There is need to strengthen quality of pre-service training of medical professionals in
collaboration with the MOE to focus on skill and competency-based approach and integrating
medical ethics knowledge more effectively. Furthermore, MOH should work with HEIs to create
better awareness among students and faculty about COC, reformulate exam modalities, and
also arrange post licensure exam support to those that fail.
iv. MOH should push for uniform HP licensing renewal period. (Currently it is done every 3 years in
SNNP but every 5 years in Oromia).
v. There is a need to develop legal framework upon which the regulatories operate.
vi. Consider moving to make regulatory body an independent body.
The mid-term evaluation of HSTP II revealed that progresses has been made in improving human
resource development and management. In the HSTP II period, improved capacity-building activities
were observed. One of the main achievements was in continuous professional development (CPD).
Several regions started to require CPD for license renewal and the FMOH accredited 205 institutional
CPD providers and 37 CPD accreditors. In addition, at the national level professional standards were
developed and approved for 31 professions.
Improved efforts on motivation and retention of the health workforce were made, such as the
introduction and implementation of the special risk allowance payment guideline for COVID-19 workers,
life insurance coverage for the health workforce in case of fatality, and conducting national recognition
week for acknowledgment of all stakeholders involved in the response against COVID-19. In addition,
the Federal Ministry of Health permanently employed many of the health professionals who had been
temporarily deployed in the fight against the COVID-19 pandemic. An assessment conducted by Jhpiego
During the HSTP II period, the total health workforce employed in public health facilities showed an
increasing trend; with 219,386 health workers employed in 2012 EFY, 301,710 in 2013 EFY, and 330,025
in 2014 EFY (excluding the Tigray region data). Based on 2014 EFY data, the total health workforce was
about 342,899, including university hospitals and private health facilities. Of these workers, 221,046
(64%) were health professionals and the remaining 121,853 (36%) were administrative/ supportive staff.
The national health workers density for core health professionals (Doctors, Health Officers, Nurses, and
Midwives) has improved; increasing from 1.0 in 2012 EFY to 1.16 in 2013 EFY and 1.23 in 2014 EFY.
Improved results were also observed in strengthening health facility-based education and in-service
training of existing health workers. These achievement included: integrating academic activities into
service provision, integrating research into teaching hospitals; redesigning health workforce intake
approaches through joint Ministry of Education and Ministry of Health planning and integration
mechanisms; enhancing demand-driven health workforce forecasting, planning, and development; and
empowering women in the health sector.
Challenges
Though the gains made in improving human resource development and management is undeniable,
there is still gap in achieving the transformation agenda, strategic direction and initiatives, and targets
related to human resources for health set in the HSTP II. The capacity-building process requires
continuous effort because standards of care evolve over time and health workers frequently change
jobs and need continued motivation. In order to meet quality goals, the FMOH and regions need to
complete provider competency assessments on a regular basis, and improve health facility-based
education. A number of improvements need to be made to pre-service education, as the mass training
of health professionals has compromised the quality of education. Inadequate health workforce
motivation, retention, and performance management mechanisms are still a concern due to a lack of
budget and uniform motivation and incentive packages.
Low health worker density and inequitable distribution of health workers are also critical areas to be
addressed. The national health worker density varies greatly from region to region and from rural to
urban areas.
Other items on the unfinished agenda include: establishing a health professionals’ council and
engagement of health care workers, developing and implementing strategies to enhance health
workforce safety, and women’s empowerment, especially in leadership.
Finally, COVID-19 and the conflicts negatively affected human resource development and management.
COVID-19 affected the availability and distribution of HRH with health workers dying, leaving the
sector, and being pulled away from their regular stations to staff COVID units. In addition, the conflict
in some regions especially in the northern part of the country resulted in death, disability, looting, rape,
psychological trauma, displacement, and overburden on human resources for health.
Based on the midterm, review the following recommendations are made to assist Ethiopia in meeting
its HRH goals:
• Institutionalize a system providing incentives for HRH, especially for rural and remote areas.
• Emphasize the allocation of HRH budget and other resources to conflict-affected areas
• Strengthen and integrate information systems to ensure up-to-date HRH data and data sharing
across the HRH sector
Below is the summary table with the various labour market elements of the health workforce life cycle
and the recommended activity. The priority actions are highlighted in green.
The mid-term review of the second Ethiopian Health Sector Transformation Plan (HSTP) highlights the
implementation of initiatives to enhance informed decision-making and innovation in the health sector.
This section examines the key findings of the mid-term review, showcasing the achievements and
drivers of success in promoting evidence-based information decision-making and fostering innovation.
Another area of success is the improved practice of data use for supplies forecasting. Evidence
generated by all hubs of the Ethiopian Pharmaceuticals Supply Agency (EPSA) informs the procurement
of supplies, ensuring an evidence-based approach to supply chain management. This improvement
in supplies forecasting has resulted in a reduction in supply wastage, aligning with recommended
ranges and improving the efficiency of the supply chain. Additionally, the mid-term review highlights
the initiation of a performance management system for evidence-based planning and performance
management at the EPSA and the Ethiopian Food and Drug Authority (EFDA). This system enables the
monitoring of performance indicators, facilitates evidence-based planning, and supports performance
management processes.
In conclusion, the mid-term review showcases significant achievements in enhancing informed decision-
making and promoting innovation. The increased leadership commitment, collaboration with academic
and research institutions, establishment of data management centers, data quality initiatives, improved
data reporting rates, availability of data analytics reports, evidence-based supplies forecasting, and
performance management systems are all drivers for success in promoting evidence-based information
decision-making and fostering innovation in the Ethiopian health sector.
Several challenges and gaps have been identified in the implementation of this strategic direction.
The first key challenge identified is the suboptimal level of data quality. The findings indicates that
the timeline of reports is only 65%, indicating delays in reporting. Additionally, there is a significant
gap between survey results and routine reports, highlighting inconsistencies in data collection and
reporting processes. A notable gap is the irregularity of routine data quality assessments (RDQA) at the
national and regional levels, which are essential for ensuring data accuracy and reliability. The second
challenge heighted is the low culture of information use for evidence-based planning and decision-
making. Despite efforts to promote data-driven decision-making, there remains a gap in translating
data into actionable insights and using evidence for planning and decision-making processes. The
functionality of Performance Monitoring Teams (PMTs) is another area of concern. The review reveals
that PMTs often lack rigor beyond conducting meetings, suggesting a gap in their effectiveness in
monitoring and evaluating the performance of health programs. Low Health Management Information
System (HMIS) reporting rates by private health facilities are identified as another challenge as only
35% of private health facilities have adequate reporting rates. This poses a barrier to comprehensive
health information management and affects the accuracy and completeness of health data. The review
Recommendations
i. Develop a national data analytics platform that generates and shares actionable insights on
selected impact indicators, quality dimensions, and equity aspects;
ii. Elevate the national data access and sharing guideline to the regulation level.
iii. Aligning the planning timelines with regional planning and budget decisions to ensure seamless
coordination and resource allocation;
iv. Strengthen Integrating Quality Improvement (QI) and Performance Monitoring Teams (PMTs)
at the health facility level and promote department-level performance reviews; Expanding
mentorship and coaching of PMT members to build their capacity to analyze, interpret, and use
data
v. Ensure the regularity of data verification processes and implementing feedback mechanisms;
vi. Invest on advancing the use of emerging data analytics technologies, such as data science,
machine learning, and artificial intelligence;
vii. Develop an open data access portal and providing online access to health data for researchers
and citizens is another significant recommendation.
viii. Generating and disseminating evidence by triangulating data from routine and population-
based sources
ix. Consider redesigning Health Information Technology (HIT) training and developing a new
curriculum for data stewards that includes healthcare applications of emerging technologies.
x. Incentivizing improved organizational and individual-level performance by continuously
monitoring, reviewing, and analyzing performance data.
xi. Develop a multi-year calendar of different national surveys, mobile resources, and timely
conduct surveys and disseminate results
xii. Establish research advisory council, develop priority thematic areas for health research, mobilize
funding for priority research areas, and prepare policy briefs and organize policy dialogues
As indicated in the above table, general government expenditure on health as a share of total general
government expenditure is short of the target set. In fact, it has decreased in 2014 EFY to 8.71% from its
level of 10.51% in 2013 EFY. On the other hand, progress in the coverage of community-based health
insurance (CBHI) was much higher than the target set, which highly contributes to the achievement of
universal health coverage, particularly at the primary health care level. Unlike the progress on CBHI,
social health insurance (SHI) has not commenced and the target set has not been achieved. Progress
on total health expenditure per capita, OOP as a share of total health expenditure, and the incidence
of catastrophic health spending was not possible to measure as there was no data in mid-2015 EFY as
the National Health Account was not conducted after 2012 EFY or 2019/2020.
The initiatives stated both in the transformation agenda and strategic directions are relevant, with the
exception of reforming the cost recovery mechanism. With the current level of high government subsidy
in the provision of health services at different levels of care, the low ability-to-pay of communities, and
low health insurance coverage, moving from such a high level of subsidy to cost recovery doesn’t seem
feasible and timely. Rather, the move should be to strengthen the cost sharing mechanism through
proper methods of user fee revision informed by the cost of health services and the ability to pay of
the population. Further, although their relevance is unquestionable, there is repetition and overlap in
initiatives between the transformation agenda and strategic direction. For example, performance-based
financing and health insurance are included in both the transformation agenda and strategic direction
initiatives. Further, there is a lack of clarity on the “reforming the role of FMOH in health financing to
improve…” initiative stated in the strategic direction.
Achievement
Resource mobilization from different sources for the COVID response was encouraging. It was possible
to mobilize close to US$411.6 million in the 2013 EFY from government, local, and development
partners. Further, development partners were flexible enough to shift resources for COVID-19 and other
emergency responses. In addition, development partners (SDG PF contributors, Bilateral partners, UN
organizations, the Global Fund, GAVI and Foundations) have also disbursed US$ 316.2 million in 2014
EFY, though it has decreased from its level of US$ 388.2 million in 2013 EFY. Revenue retention and
utilization (RRU) has continued to serve as the lifeline of health facilities in the absence or inadequate
There are efforts to improve efficiency as well. In this regard, a diagnostic assessment was conducted,
and an action plan on alignment and harmonization (one plan, one budget, and one report) was
developed and approved to improve the efficiency of resource utilization from development and
implementing partners. A financial management manual has been developed and implemented, and
the financial reporting system has also been revised to ensure accountability in addition to the existing
practice of reporting statements of expenditure (SOE). Channel 2 administration directive was also
developed in consultation with regional health bureaus and approved by FMOH management and
has been submitted to the Ministry of Finance for approval. The directive puts conditionality before
the transfer of funds to the regions to improve utilization and liquidity. Further, the World Bank has
supported the recruitment and financing of about 80 personnel to be deployed at lower levels to
improve utilization and liquidation. Progress has also been made in including health financing indicators
in the DHIS 2. Eight health financing-related indicators are included in the DHIS2, which can improve
decision-making at various levels. But regular and complete reporting of the health financing indicators
in DHIS 2 needs improvement.
One of the tremendous advances in the health sector is the expansion of the community-based health
insurance (CBHI) program which is providing access to millions of households and significantly reducing
financial hardship. Despite various challenges in the last couple of years, such as the COVID-19 pandemic
and conflicts, the CBHI program has made a lot of progress. The main drivers of success are high
political commitment, community awareness, and ownership at all levels of the system. This is reflected,
among others by the endorsement of the CBHI proclamation. This is a big achievement in the CBHI
program’s implementation as it gives legal foundation for roles, mandates, and accountability in CBHI
implementation, including implementing compulsory membership, increasing coverage to the poor,
higher-level pool formation, increasing the share of general subsidy, and establishment of reinsuring
mechanisms for insolvent schemes.
The total CBHI woreda coverage (excluding Tigray) has reached 980 woredas in 2022/2023, which is
84.7% of all woredas in the country, and it is a big jump from the 70% baseline in 2020. As a result, close
to 12.2 million households (56 million individuals) are enrolled in the program as of 2022/2023, which
makes the enrollment rate 81% that surpasses the target set for 2025 (80% enrollment rate). Close
to 2.2 million households (18%) of the CBHI members are indigent (their contributions are covered by
the government). The CBHI program has consistently demonstrated high renewal rates in the last ten
years; for instance, the national renewal rate in 2022/2023 was 93% and 100% in some regions. This
has contributed to improving health service utilization and increasing the internal revenue of health
There is modest progress in strengthening the strategic financing function of CBHI. For instance, a
strategic purchasing scoping review was recently conducted, the CBHI benefit package revision is in
the final stage, and the capitation payment mechanism is piloted and now in the scale-up phase. There
are also encouraging efforts to document the beneficiaries of the CBHI program disaggregated by
gender and level of income (contribution households and non-contribution poor households).
The share of general government expenditure on health as a share of general total government
expenditure is not progressing well. It is still below 9% and quite low compared to the target set. Looking
at the share of the health budget in the total government budget at different levels of administration
sheds light on the extent to which the challenge exists. In this regard, the share of total health budget
to total government budget at the federal level is small (max. 6.6% in 2013 EFY) compared to regions
allocation of 10-15% of their total budget, with the exception of Addis Ababa (7%). In addition to the
small share of the health budget in total government expenditure at the federal level, even this small
share has decreased over the last three years (6.6%, 5.9%, and 3.4% in 2013, 2014, and 2015 EFY,
respectively). A further look at the share of the health budget in the government budget from domestic
sources at the federal level shows that it was very small and ranges between 1.8% and 2.6%, i.e., 2.1%,
2.6%, and 1.84% in 2013, 2014, and 2015 EFY, respectively. The budget constraint is manifested in the
visited health facilities by the absence or limited allocation of the operational budget.
The implementation of the Essential Health Service Package (EHSP) is constrained by the absence of a
clear investment and implementation plan. As a result, the required service provision norms, costs, and
financing mechanisms were not clearly identified, and the feasibility was not assessed. For example,
there are generous lists of exempted health services in the ESHP, which constitute 549 interventions
(53.8% of interventions listed in the EHSP).
Despite the commendable progress, there are major gaps and challenges in the design and
implementation of the CBHI program. There is slow progress in narrowing inequality to access the CBHI
scheme as progress in increasing CBHI coverage in developing regional states is slow; though the
number of indigents is increasing year by year ( 1.6 million [in 2020/2021], 1.7 million [in 2021/2022], and
2.2 million [in 2022/2023]), the progress in the coverage rate is low compared to the target set (100%)
for 2022/2023) and selection criteria are not standardized within and across regions. The current flat
CBHI contribution rates (which don’t account for the difference in ability-to-pay) are regressive, can
potentially be a barrier to enrolment for people with low income, and reduce the revenue generation
capacity of the CBHI schemes.
Overall the sector has weak purchasing function, the limitation of which is reflected in different ways.
There is poor contract management (accountability) between CBHI schemes and health facilities mainly
due to the lack of alternative service providers in rural settings, and lack of provider and purchaser split,
which has contributed to poor accountability. Though the capitation pilot is encouraging, the overall
progress in implementing alternative provider payment mechanisms (to the currently practiced fee-
for service) is slow, particularly in hospital setting. In addition, the provider payment mechanisms in
place including the capitation are not well linked to Quality Improving mechanisms. There is inadequate
clinical audit practice, especially the quality of clinical audit is poor. The level of training and experience
of experts assigned to do the clinical audit for the CBHI program is not well aligned with the level of
services they can supervise, especially for services provided in general hospitals and above.
Although there were recent preparation efforts to start the SHI program for civil servants and pensioners;
it was decided to postpone it, mainly due to fiscal space-related challenges the country face due the
current context.
• Improve advocacy at all levels, especially at the federal levels, for increased buy in at higher
level political leaders for better allocation of resources to the sector as part of Program Based
Budgeting and endorse the revised exempted service financing mechanism and introduce
innovative financing-Resilience and equity fund; The Ministry, in collaboration with development
partners, need also to exert an extra effort to mobilize the required funds from domestic and
external sources as per the national reconstruction and recovery plan launched by the Ministry
of Finance.
• The FMOH should spearhead the development of methods of user fee revision and support
regions capacity to use the methods for revisions of user fees and active and meaningful
participation of health facilities in the process is important
Efforts were made to standardize and institutionalize grievance handling and monitoring mechanisms
at all levels. There are structures and initiatives for grievance handling at different levels of the health
sector. In most institutions there are grievance committees accountable to the institution Head. Internal
and external grievances are handled through these mechanisms. The partnership and coordination
mechanisms among public sectors, private for profit, CSOs and NGOs exist and functioning. KIIs reported
that the partnership and coordination that happened during COVID-19 response was a success.
The Health Service Delivery, Administration and Regulation Proclamation, a comprehensive legal
framework developed with the participation of various directorates and with the overall guidance of
Legal Services Directorate. Proclamation to establish health professional Council was another landmark
legal framework that was formulated within the MOH and externally reviewed by the Ministry of Justice
and the Attorney General. However, both proclamations have stalled without being endorsed by
Parliament. Various Guidelines have also been drafted by the MOH and specific Departments within
the MOH. At the regional level as well, some existing proclamations have been revised.
Some experiences were made to introduce financial and non-financial incentive mechanisms are to
motivate the health professionals working at different levels of the health system in some regions. In
HCs in Addis Ababa, they recently instituted incentive package for the leadership that includes housing
and transport allowance of 6000 birr/month and duty opportunity of up to 240 hours/month.
Impact of public health emergency, conflict, and war. According to the assessment conducted in 2022,
in the six regions affected by war and conflict, a maximum of 80% of the regional population is affected
in Tigray and 20% of population affected in Konso Zone, SNNP (CIARP Study, 2022). The biggest impact
of the conflict and war in different parts of the country in terms of Leadership and Governance Strategic
Direction are health infrastructure damages. Apart from the infrastructure damage, regional findings
show that leadership has crumbled in severely affected areas. ZHD/WorHO records and equipment
were damaged or looted, and key staff and leadership were displaced. In such circumstances there
is need to restore health leadership and consolidate staffing. In Tigray, salary or duty payment to
staff or management has not yet started. In addition, regular operations such as regulation is not yet
resumed. Mental health problems and post traumatic issues are prevalent among affected population
including health leadership. The priority of the leadership is on post conflict restoration of infrastructure
and service, reinstituting leadership and governance mechanisms, structures, and systems. Financial
implications of providing policy support and institutional strengthening have been estimated at 11
million USD (CIARP, 2022). In terms of COVID pandemic, it has impacted many of the ongoing initiatives
and implementations as it was mandatory to stop non-emergency related travels, supervisory visits,
inspection, trainings, community, and technical committee meetings etc. In addition, there was shift
The leadership building efforts remain Fragmentation. Duplication could happen or hard to follow-up
units/regions that fall through the crack in its implementation especially in DRSs. There is frequent
turnover of staff in legal area as the main concern are incentives (limited field opportunity), limited
opportunity for training and capacity building. Because directors do not follow the appropriate
procedures in developing legal instruments (public consultations, stakeholder engagement, technical
discussions, and other necessary steps) in drafting legal documents, there is continuous change of
ideas which causes delay in the process. This is further compromised by the delays in endorsing the
legal frameworks by the senior management of MOH; and sometimes, lack of firmness in decision-
making.
i. Integrating the course contents across Leadership, Management, and Governance (LMG), Clinical
Leadership Improvement Plan (CLIP), and Leadership Incubation Plan (LIP) and developing
one training package which includes such thematic areas as conflict management, resource
management, team building, risk assessment and mitigation,
iii. Coordinate with stakeholders to mobilize resources to provide training for the leadership,
v. The introduction of coaching to LIP attendees after they complete the training to ensure
effectiveness of the training.
vi. Strengthening of the legal Office with additional staff and budget and capacity building,
vii. Empowering the legal unit by giving them the required autonomy with the enforcement of
accountability and responsibility,
Performance
Mid- term Target Color
Indicator Baseline till December
Target 2022 (2024/25) Grading
2022
Proportion of health facilities
(health centers and hospitals)
59% 73% 90%
with basic amenities (water,
electricity, latrine,)
28% (HP)
Improved water supply 76% 86% 100% 58% (HC)
78% (PH)
14% (HP)
Electricity 61% 78% 86% 62 % (HC)
85% (PH)
The main strategic direction under the Health infrastructure are construction, rehabilitation, and
expansion of health facilities, developing standards, availing utilities, and setting up ICT infrastructure. In
this regard, the main achievements include preparation of the design of health facilities that suits health
service demand considering environmental, climate and geographic factors. The HI LEO developed a
flexible design with special consideration to Afar, Somali, Benishangul-Gumz and Gambella Regions,
which incorporated floor to ceiling elevation increase from 2.80 meter to 3.50 meter; open walls or
big windows so that it is well lit and ventilated and an AC system. Furthermore, construction guidelines
are developed. The standards for the primary health care units (health posts, health centers, primary
hospitals) were developed. Following this standardization work, the priority of health infrastructure
initiatives, currently; there are three types of HC on the ground. First, there is type A HC which is almost
like a primary hospital and has physician residence. Second is type B HC which has 5 blocks, also
called GTZ type. Third is the nucleus HC which are former clinics upgraded to HC level that has OPD
and administration and service block. Now priority task is to upgrade nucleus HCs to type B. As of May
2023, there are a total of 18,428 functional health posts in the country.
In addition, construction of 56 second generation HPs have been completed and are ready to start
service and 49 are undergoing construction (see table …). Upgrading of second-generation HPs to
comprehensive HP standard is just getting started with 5 ongoing projects in Oromia (1), Somali (2), Afar
(1) and Sidama (1) Regions. There were 3675 functional HCs in the country. In addition, construction has
been completed for 242 new HC and the construction of 48 are ongoing. There are 614 HCs that are
upgraded out of which the 308 projects are completed and 306 are under construction. There are also
48 HCs under maintenance and 37 of which maintenance has been completed. Furthermore, there is
expansion of OR rooms in 413 HCs, of which the work is completed in 366 and 47 are still ongoing. There
were 395 hospitals, of which 26 were comprehensive specialized hospitals, 2 were referral hospitals,
101 were general hospitals, and 266 were primary hospitals (Table). Three new general hospitals are
being built in Addis Ababa’s sub cities of Kolfe, Nifas Silk, and Bole sub cities.
General Hospital
Primary Hospital
Comprehensive
Construction
Construction
Completed1
Specialized
Completed
Functional
Functional
Ongoing
Ongoing
Hospital
Region
The contribution of SDG fund has been crucial in the construction , as about 3,600 projects have been
constructed using SDG funds, including the construction of About 5,000 staff houses in remote HCs.
There are also other federal specialty projects that are currently under construction. These include
government financed (i) Trauma center in ALERT Hospital with 500 bed, ICU about 60 beds (50%
completion); AHRI laboratory center of excellence and research with about 40 labs and 120 offices up
to 200 vehicle parking spaces, meeting hall. (99% completion); (iii) Diagnostic center in St Peter Hospital
(lab, imaging, pathology). There are also other construction works ongoing on hospitals, EFDA quality
assurance center, 13 regional laboratories etc.
There were Covid-19 related construction projects including the construction of 13 COVID-19 Projects
(Point of Entry, Isolation center and Quarantine center) is completed and 11 COVID-19 Treatment centers,
funded by World Bank, bid document evaluation was completed to proceed to the next milestone. There
were also other projects that were completed over the past three years include: Of the 180-ergonomics
work that was planned in 6 federal hospitals and Institutions accountable to MOH, 175 projects have
been completed and the remaining 5 projects are at 85% completion; renovation of Black lion Hospital
9 Wards and Central kitchen and St. Paul Hospital Wards and Emergency, and St. Peter Hospital MDR
wards funded by World Bank. MOH has supported an estimated 46 million birr for construction and
renovation of health facilities for Amhara region, Somali region (three HC construction and one HP
upgrading to comprehensive HP-CHP), Afar (one HP upgrading to CHP), Dire Dawa City Administration
(one HP upgrading to CHP), Sidama region (HC renovation), Oromia region (HP upgrading to CHP and
MOH HI LEO has 42 staff out of which 90% are technical assistants hired by the WB, of these 19 are
supporting RHBs as focal persons. The structure of HI in regions is quite mixed. Oromia and Amhara
have structure almost equivalent to the HI LEO in MOH organized as a Core Process (Oromia) and
under Vice Bureau Head (Amhara). Somali region have HI Section; it has 8 staff and much better than
the situation in other emerging regions but organized as a sub core process under Plan and Program.
On the other hand, AA City Administration, SNNPR, Sidama and SW Ethiopia Regions do not have HI
unit and they get support from regional Construction Bureaus. In regions that do not have Focal Points,
the MOH assigns TA to follow up on projects constructed through matching fund modality and other
projects financed through the MOH.
Absence of HI structure in some RHBs. Health construction projects financed through regional budgets
are executed by Construction Bureaus. Construction Bureaus have no specific department that follows
up health projects. In addition, they lack experts with a specialty in managing health infrastructure which
asks for unique expertise by way of familiarity with HF standards, knowing the service flow, types of
equipment, etc. Hence, they face challenges in terms of meeting standards, considering the workflow,
progress delay is commonly reported as Construction Bureau provides support to all line Bureaus. In
addition, there is weak information flow to MOH as there is no reporting line between construction
Bureau and the MOH. To address this challenge the solution adopted by MOH is assigning TA to follow
up on projects constructed through matching fund modality and other MOH financed projects. There
is also a sharp decline in SDG fund that has affected the construction sector as it was crucial source
of finance. Because of fund limitation, the plan to construct 300 HCs did not materialize. In 2015 there
were no new projects undertaken.
i. Undertake Health infrastructure need and capacity assessment to establish structure in regions.
ii. Align the priorities of construction efforts to proposed essential service investment plan (for
construction and equipment) to ensure that priority services are financed given the limited fiscal
space. Strengthen collaboration, coordination, and joint planning platforms with programmatic
departments right from the design development through the construction process to ensure
that this proposed plan is implemented. Revisit the roadmap for the expansion of basic and
comprehensive health posts in line with the investment plan.
iii. Invest in building the capacities of The HI LEO requires through experience sharing visits and
exposure to international architectural designs of health facilities, and diagnostic centers.
One of the key drivers of success identified in the mid-term review is the deployment of the digital
health project registration and app inventory system. This system has facilitated the registration of
approximately 80 digital health systems, ensuring proper documentation and source code submission.
The selection and testing of these systems have paved the way for the implementation of sustainable
digital health solutions in Ethiopia.
Increasing maturity level of the District Health Information System 2 (DHIS2) has been observed in
the last two and half years driven by full ownership by the government and implemented down to
the facility level. Its widespread implementation signifies the commitment to strengthening the digital
health infrastructure and ensuring the availability of accurate and timely health data at all levels of the
health system. The electronic Community Health Information System (eCHIS) is functioning in health
posts where it is well-supported, including the provision of necessary devices. Positive results have
been observed from the implementation of Electronic Medical Records (EMR) systems in healthcare
facilities as 22 facilities have started the implementation process, with five health facilities operating
in a paperless environment. A collaborative system development environment has been established,
focusing on Bahmni EMR and DHIS2 to fosters innovation and enhance the quality of digital health
solutions.
The capacity of the Ministry of Health’s data center has been strengthened through the installation
of a backup power generator, increased bandwidth, acquisition of high-end servers, installation of
cooling machines, and the functionality of the Disaster Recovery Center (DRC) at St. Peter to support
the growing digital health infrastructure and ensure the availability, reliability, and security of health
data and digital health systems. Full digitization of regulatory core functions (such as licensing, product
registration, and quality assurance) has been achieved, enhancing the traceability of data and improving
cost-effectiveness. The implementation of a single windows system with strong interoperability across
sectors is another significant achievement. This system enables seamless data exchange and integration
between different health and non-health sectors, facilitating coordinated and holistic service delivery.
Interoperability promotes data sharing, collaboration, and efficient decision-making processes.
Challenges
Several challenges and gaps in the implementation of digital health systems have been identified.
One of the key challenges is the rollout of multiple systems at scale with questionable functionality
and usability. For example, the electronic Community Health Information System (eCHIS) has faced
challenges in terms of its functionality and usability. While some progress has been made with the entry
of health workforce records at the national and regional levels, the transition of the Integrated Health
Information System (iHRIS) from the development stage to implementation stage is struggling. This
review findings show the absence of a clear roadmap for the implementation of the national eHealth
architecture, that outlines the key milestones, timelines, and strategies for the implementation of the
eHealth architecture. The development of foundational shared services has stagnated, with only 50%
of the planned shared services being implemented with unknown timelines and resource commitments.
The systems are challenged with inadequate health IT human resource capacity in terms of the skill
mix, numbers, and skill sets of health IT professionals needed to support the implementation and
sustainability of digital health systems. There is also weak device management and tracking system,
Recommendations
i. Establish an effective and functional partnerships with Ethio Telecom and other government
agencies, such as the Artificial Intelligence Institute, and local universities to leverage their
hosting infrastructure and services, reducing the costs associated with data hosting and
management and to promote the adoption and use of emerging healthcare technologies,
revolutionize healthcare delivery, improve diagnostics, and enhance patient care.
ii. Strengthening digital health investment prioritization processes and its effective governance
that will lead and guide its prioritization and implementation process. This should be supported
by close and effective joint work with Regional Health Bureaus (RHBs) to harmonize digital
health structures across regions and levels (human resources; standardized digital health
structures and processes). Programs need to also be actively engaged in digital health systems
design and implementation (including (eCHIS) and Electronic Medical Records (EMR)) to ensure
system design and functionality alignment with program requirements and goals. Revisit the
digital systems implementation approach and strategy to include interventions beyond the initial
deployment, adequate support, training, and supervision to ensure that digital health systems
are effectively utilized and meet the needs of end-users. Continuous improvement efforts
should focus on enhancing user experience and optimizing system functionality. Enhancing
interoperability of systems, including interoperability across systems of different stakeholders, to
facilitate seamless information flow, improve coordination, and enhance the overall functionality
of the digital health ecosystem. It is also critical to strengthen the implementation of foundational
shared services, such as the master facility list, the national health data dictionary, the national
product catalogue, the master patient and provides index, and gradually move into shared
health records.
iii. Prioritizing investments in telemedicine, teleradiology, and other remote health service delivery
mechanisms to enhance access to healthcare services, especially in remote and underserved
areas. This can be facilitated by a clear strategy that attracts private investment in digital health
technologies, innovations, development, and implementation, especially with the context of
liberalization of Ethio-telecom for additional resources, expertise. This should also include
collaborating with emerging local and private digital hubs and innovation centers.
v. Enhance the monitoring of the functionality of digital health systems and infrastructure and
utilizing the data for digital health program monitoring to provide insights into performance,
identify areas for improvement, and inform evidence-based decision-making. This can be
better facilitated through building internal capacity of government for system implementation,
maintenance, and support ensures sustainability and reduces dependency on external partners.
vi. Expanding IT infrastructure at government health facilities, including the provision of computers,
LAN, and connectivity. Reliable and secure infrastructure supports efficient data management,
communication, and the integration of digital health solutions into routine healthcare processes.
vii. Invest on unified, integration and interoperability digital supply chain system with good maturity
level that removes silos and multiple applications and ensures data security, accountability, and
avoid theft of supplies at all levels.
Achievements
Traditional medicine is structured at desk level in the Ministry of health under pharmaceuticals and
medical devices lead executive office. MOH has also reached an agreement to develop the Ethiopian
Herbal Pharmacopeia in collaboration with Ethiopian Pharmacists and pharmaceutical scientists
Association in the Diaspora (EPPAD) and memorandum of understanding (MOU) signed. Registration
and Licensing of traditional healers started. Regions like Amhara, have established traditional healers’
association. Three traditional medicinal products are under clinical trial. Efforts underway in developing
guidelines, roadmap and policy: Traditional medicines directive, traditional medicines clinical trial
guideline, traditional medicine 10 years roadmap and draft traditional medicine policy was developed
that needs to be revisited and ratified by the responsible body.
Currently the efforts made are more fragmented as there are too many stakeholders acting separately
such as Health, Education, Agriculture, Environment, Industry, Culture & heritage, and others to exploit
the rich source and untapped knowledge of traditional medicine in the country. KIIs in this review
identified that there is lack of an inclusive and integrated policy framework and legislation for traditional
medicines and practices. Due to this lack of legislation and enforcement, there is limited protection and
preservation of indigenous knowledge resulting in lack of trust among the traditional healers and the
researcher’s impeding collaboration for validation of traditional remedies. There is also limited interest
and support for traditional medicines specifically for R&D, training of professionals, practitioners and
the community.
The HSTP II initiative to create incentive package for large scale production of scientifically validated
traditional medicines in industries looks unattainable in the coming three years.
Recommendations
i. Revisit and ratify the draft National Traditional Medicine policy or integrate well in the new
medicines and medical devices policy and develop the associated legal framework to establish
an independent herbal regulatory system, that promotes and enforces legal protection for
intellectual property rights and registration of indigenous knowledge rights in traditional medical
practice.
ii. Build the capacity of traditional medicine in terms of human resources (numbers and skills),
infrastructure, and a system to enhance the development of traditional healers’ data base,
conservation and documentation of medicinal plants, traditional medicine knowledge, and
practices in the country.
iii. Strengthen the regulatory activity on traditional medicinal products and the practice. Create
awareness on importance of health regulation among the community regarding traditional
medicine practice.
iv. Enhance collaboration and create alignment among the multi-sectoral stakeholders in traditional
medicine.
v. Establish center of excellence for traditional medicine and promote systems for information,
training, and education on traditional medicine.
Though Health In All Policy is not yet implemented , there is multisector engagement ongoing with One
WASH, Nutrition and COVID-19 prevention and control, NCD, occupational safety in industry zones,
one-stop services for victims of GBV, social and legal services for clients in some Hospitals. , effect
multisector clusters are established within regions for emergencies. The clusters conduct joint planning,
monitoring and evaluation of multi-sectorial initiatives such initiatives have contributed to availing water
and power supply to HFs. KII at federal level and regional findings show that meaningful progress has
not been made in terms of that multisector engagement to foster woreda transformation plans. While
there is a draft Health in All Policy (HIAP) document but not yet endorsed.
Health In All Policties and multisector coordination require effort and commitment from all sectors,
but not all sectors contribute equally and there is a gap in follow up by line Ministries. Multi sectorial
engagement lack regularity and structure. There is no guideline for implementation of health in all
policy in Ethiopia. And as a result, there is budget limitation, limited awareness and knowledge about
the health in all policies and limited gender mainstreaming for multisector activities.
i. Get approval and endorsement at the higher political decision-making level and implement the
Health-in All Policy
ii. Undertake advocacy for sustained political commitment and Familiarization of Health-in -All
Policy at all levels to improve allocation of resources for multi sectorial engagement.
iii. Institutionalize coordination platform in MOH with clear guideline and political commitment.
iv. Establishments of Accountability framework – all stakeholder from federal down to community
level
The corporate sector has actively participated, collaborated, and contributed significantly to the
COVID-19 emergency response. The private sector has mobilized resources (both financial and in-kind)
for the emergency response activity; played a critical role in treating patients and delivering COVID-19
laboratory testing services. Third, manufacturing industries were critical not only in the production of
PPE and other hygiene and sanitation supplies but also in importing and distributing critical supplies.
Although plans were made to construct about 14 centers with various specialties and serving as centers
of excellence to attract medical tourism, the effort did not progress as expected.
The first draft of the Health Sector Private Sector Engagement Strategy is prepared with the participation
of key stakeholders. The Strategy covers themes such as areas for them to engage in and incentive
mechanisms. There is good public private collaboration in many regions such as active GO- NGO
forums.
Lack of prior experience and limited awareness on transactional PPP made it difficult to convince
decision makers and get potential bidders from the private sector. Decision making is a time consuming
process. MOF’s Board of Directors meets quarterly, and sometimes biannually and as a result many
studies are awaiting approval. Forex policy is strictly enforced and that limits the leveraging the potential
of the private sector. The country’s existing insecurity has a negative impact on the degree of interest
from foreign investors. There is still inadequate private sector participation in commodity management
system (warehouse management, distribution and last mile delivery while EPSS inefficiencies affect the
availability of supplies.
Component 1: Reproductive, Maternal, Neonatal, Child, Adolescent, and Youth Health and Nutrition
• Still relevant;
• Innovative designs to mitigate
• More people reached but
new and unmet needs, with
unmet need in pastoralist • Effective coverage • Generally rated high
Program 1.1: some degree of success
areas and emerging lower than contact in interviews and
• Scope for greater focus on • Expanded but unmet needs
Family Planning regions coverage due to supply reviews but room for
fertility services for those who remain; scope for further
and Reproductive • Need for efforts to interruptions in many improvement in terms
desire to get pregnant, not just demand creation
Health align with/be sensitive rural areas and some of responsiveness and
child spacing or fertility limitation
to lifestyle and cultural population centers supply issues
services.
values
• High level of support for this
program at all levels
• Effectiveness varies
by facility readiness,
• Expanded • Inequity has decreased, referral pathways , • Quality improvements
• Great investment in with access expansion health seeking behavior since HSTP I (e.g.,
expansion of access in previous emerging • Declines in national obstetric ultrasound,
to operative deliveries, regions and pastoralist MMR and USMR but operative delivery
Program 1.2:
• Highly relevant, ranked high community case areas high levels of drop out access, improved
Maternal, Neonatal
priority at all levels of the sector management of childhood • Gap remains in hard-to- from ANC to skilled referral) and capacity
and Child Health illnesses reach areas, urban poor birth attendance of staff
• Major expansion of neonatal and slums • High rates of stillbirth • Data gaps impede
services at community and • widening unmet need in and NMR (need to re- the ability to monitor
facility but inadequate post- conflict areas examine effectiveness service quality
of interventions
delivered)
1.1. Background
The health sector of Ethiopia has developed and implemented sector wide strategic plans in the last
three decades. The health sector of Ethiopia has developed and implemented long-term health-sector
strategic plans for the last three decades. Four rounds of Health Sector Development Plans (HSDP I
to HSDP IV) have been developed and implemented from 1997/98 to 2014/15. After the four rounds of
HSDP, Ethiopia has developed and implemented the first health sector transformation plan (HSTP) that
spanned from 2015/16 to 2019/20. During the HSDP I- HSDP IV and HSTP-I strategic periods, the sector
has been conducting evaluations of the strategic plans and has been using the findings for designing
and implementing strategies and interventions for better performance of the health sector.
The latest sector wide strategic plan, the second health sector transformation plan (HSTP-II), is a five
years plan that spans for the period 2020/21 to 2024/25 (2012 EFY-2017 EFY). HSTP-II is developed
as the first part of the 10-year health sector plan and it is developed with an extensive consultation
with relevant stakeholders; and the strategies and targets are aligned with national and international
development agendas and priorities.
The overarching objective of HSTP-II is to improve the health status of the population by realizing
four objectives, including; 1) Accelerate progress towards universal health coverage; 2) Protect people
from health emergencies; 3) Woreda transformation and 4) Improve health system responsiveness. The
plan has identified ambitious but achievable targets that are aligned with national and international
commitments. In order to achieve the objectives and targets, 14 strategic directions are identified to
be implemented during the strategic period. The plan has defined five priority areas or transformation
agendas. The five transformation agendas of HSTP-II are: 1) Quality and equity; 2) Information Revolution;
3) Motivated, Competent and Compassionate (MCC) health workforce; 4) Health Financing and 5)
Leadership.
The monitoring and evaluation plan of HSTP-II outlines the importance of conducting regular monitoring
and periodic evaluation of the implementation process by generating and using quality data for evidence
informed decision-making. In addition, optimizing monitoring and review systems is one of the major
implementation arrangements of the strategic plan. In the M&E plan, mid-term evaluation at the mid-year
of the strategic period and end line review at the end of HSTP-II period are planned to be conducted.
Monitoring and mid-term evaluation is critical component to ensure that implementation is proceeding as
planned and to take appropriate action. Findings from regular monitoring and evaluations is essential to
identify implementation challenges early so that appropriate interventions can be implemented towards
achieving the objectives and targets of HSTP-II. Findings and recommendations from the MTR can be
used to re-direct program implementation towards achievement of HSTP-II targets and objectives.
The mid-term review will be conducted in all regions of Ethiopia to review the implementation status
of HSTP-II from July 2020 to January 2023. The evaluation will be conducted in all regionsof Ethiopia.
The mid-term review is expected to provide pertinent information on the progress and relevance of
implementation of strategic directions, major initiatives, transformation agendas and initiatives, and
progress towards the objectives and core targets of HSTP-II. It will assess the impact of conflicts and
2. Objectives
General Objective: The general objective of the MTR is to assess the level of performance and progress
towards the objectives and targets of HSTP-II, and to draw lessons from successes and challenges of
the implementation process.
The Specific Objectives: The specific Objectives of the MTR are to:
The final-result expected from the MTR is a comprehensive evaluation report, the “Main MTR report”.
Before submission of the final report, interim progress updates and reports are expected at different
periods of the review
• Inception report: A report that includes all the preparatory phases of the evaluation, including
design of methods and data collection tools
• Regional reports: A report that includes quick analysis and key findings of each region for all the
seven sub-teams/thematic areas
• Draft MTR report: Final Main report (Qualitative report, Quantitative report, Synthesized Report)
• The level of progress of HSTP-II directions and initiatives, using core HSTP-II indicators
• Progress of transformation agendas of HSTP-II
• Effect of conflicts and emergencies on the performance of the health system
The evaluation will utilize a mixed method for data collection and analysis. It will apply qualitative and
quantitative data collection methods. The qualitative data will be collected through desk review and
by conducting key informant interviews using a semi-structured interview guides. It will mainly be
used to assess the process of HSTP-II implementation, identify best experiences, success stories and
challenges during implementation. The quantitative data collection will mainly employ collection of data
from secondary data sources such as HMIS data, administrative program reports, surveillance data,
financial data, human resource data, LMIS, regulatory information system (RIS) data, surveys (SPA+,
EDHS…) and other available data sources.
Three types of final reports will be prepared: a qualitative report, quantitative and synthesized report.
The overall process will include the following steps:
• Inception phase: During this step, the methodology will be designed; data collection tools and
guides will be developed, sample regions, Woredas and facilities identified and logistics for
data collection will be organized
• Data Collection Phase: Data collection team travels to data collection sites, data collection will
be done, quick analysis of regional data will be conducted, regional briefing and de-briefing by
the data collection team members will be performed
• Data analysis Phase: Analysis of qualitative and quantitative data will be done, triangulation of
data from the different sources, interpretation of data etc..
• Reporting: Prepare draft reports, present for MOH team, presentation to JCCC, send it for
comments and feedback, incorporate feedback from different sources, prepare final report
• Dissemination: The final report will be disseminated to a wide range of stakeholders using
different media of communication. A national and sub-national level dissemination workshop
will be organized, the report will be published and posted on MOH website for wider circulation
A mixed design will be employed, both quantitative and qualitative methodologies. It includes use
of data from different secondary sources, desk reviews, Key informant interviews (KIIs) at all levels of
Ethiopia’s health system, KII to selected stakeholders. A semi-structured key informant interview guide
will be employed for the qualitative part of the assessment.
The study will be conducted in all regions of Ethiopia and data will be collected from all levels of
the health system (all Regional Health Bureaus, Selected ZHDs, WoHOs, facilities and health posts/
communities). In addition, qualitative data will be collected from national and sub-national stakeholders.
The assessment will be conducted from February 2023 to June 2023.
Qualitative: The sample for the qualitative component of the study will be based on purposive sampling
method. Qualitative data will be collected from all levels of the health system (RHBs to health posts) and
from selected relevant stakeholders of the health system. In order to identify strengths and weaknesses
from the different levels of the health system, institutions that have a good performance and low
performance (Based on HMIS reports of selected indicators) will be selected and assessed. At each
level, the heads or deputy heads, directors/heads of selected program units such as MCH, DPC will be
interviewed as key informants.
Qualitative data collection: Semi-structured interview guides, interview key informants using semi-
structured data collection tool
• HSTP-II document
• M&E Plan of HSTP-II
• Periodic reports to HPR, MPD, PMO
• Annual performance reports
• M&E digests
• Different program strategies and strategic plans
• Program evaluation reports, surveys, researches
• Others
Experienced experts drawn from MOH, RHBs and development partners, will collect the qualitative
data. It will be tape-recorded and will be transcribed. Data analysis will included triangulation of data
from the different sources collected.
• Three types of reports are expected from the MTR team. One quantitative report, one qualitative
report and one Synthesis report
• The progress will be presented to MOH senior management and JCCC
• The findings will be disseminated in national and sub-national workshops - Presentation at the
25th ARM
• Will be published and disseminated via printouts and websites
The MTR will be conducted by both external and internal teams. The review requires a high level of
technical expertise who are dedicated, experienced and competent. Experienced international and
national technical experts who are familiar with the Ethiopian health system and Ethiopia’s context are
required to conduct the MTR. Therefore, once this TOR is endorsed, recruitment of consultants who will
work as MTR team is essential.
Table: MTR sub-teams and potential team members for each team
The steering committee will be responsible for the oversight of the MTR process and mobilization of
resources. It will facilitate the mobilization of resources for the MTR from donors and development
partners.
Members: Members will be staff at the leadership position from the following departments/units of MOH
and donors/HPN partners. Members will be from Minister’s office, State minister’s Office (Program wing,
system strengthening and CB), Strategic Affairs executive office, and donors/HPN Groups (USAID, CDC,
BMGF, World Bank, WHO, UNICEF.)
The core team is a technical committee which will be responsible for a technical and administrative
coordination of the evaluation process. It will coordinate logistics for the overall process, provide
technical guidance and coordination of all the sub teams, in collaboration with the external review team
members/consultants. The core team will reports the progress of the process to the steering committee,
MOH management and JCCC platforms. Members of the core team will be technical experts from
the different departments and agencies of MOH and from development partners. It includes technical
members from minister’s Office, State Minister’s Office (Program wing, system strengthening and CB),
Strategic affairs executive office, Maternal and child health lead executive office, Disease prevention
and control lead executive office, Community engagement and primary health care lead executive
office, Nutrition, HRD, Finance, and from all the agencies. Technical members from HPN and DPS
include: WHO, UNICEF, JSI, ICAP, Path, etc.)
As described above, there will be seven sub-teams which will be responsible for data collection,
data management and analysis and report writing for the sub-team they are assigned. Each team will
manage, analyze and report regional and national reports for the specific sub-team.
Members: Selected technical experts from all MOH directorates/departments, Agencies, development
partners (HPN group), CSOs, professional associations and private association
Chair and co-chair of each team: International consultants will lead each sub-team and a technical
expert from the lead directorate related to the sub-team technical area will be a co- chair of each sub-
team.
Alemneh, ET, Tesfaye, BT et al. 2022. Health professionals’ licensing: the practice and its predictors
among health professional hiring bodies in Ethiopia. Human Resources for Health 20:62. Accessed
online at https://doi.org/10.1186/s12960-022-00757-6
EPHI, MOH and ICF. 2022. Ethiopia Service Provision Assessment 2021–2022 Preliminary Report.
Addis Ababa, Ethiopia: Ethiopian Public Health Institute; Ministry of Health, Addis Ababa; Ethiopia; and
Maryland: ICF.
Ethiopian Health Insurance Health Services (2013) . Annual performance report for the 2013 EFY
Ethiopian Health Insurance Service(2014). Annual performance report for the 2014EFY;
Ethiopian Public Health Institute (EPHI) [Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health
Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF.
Ethiopian Public Health Institute (EPHI), Ethiopia; Ethiopian Ministry of Health and ICF. 2022. Ethiopia
Service Provision Assessment 2021–2022 Preliminary Report. Addis Ababa, Ethiopia: EPHI; Ethiopian
Ministry of Health, Addis Ababa; Ethiopia; and ICF.
Gesesew H, Berhane K, Siraj ES, et al. 2021. The impact of war on the health system of the Tigray
region in Ethiopia: an assessment. BMJ Global Health 2021;6:e007328.
Girmaye D Dinsa, Ermias Dessie, Sarah Hurlburt, Yosef Gebreyohannes, Catherine Arsenault, Bereket
Yakob, Tsinuel Girma, Peter Berman & Margaret E. Kruk (2022) Equitable Distribution of Poor Quality
of Care? Equity in Quality of Reproductive Health Services in Ethiopia, Health Systems & Reform, 8:1,
e2062808, DOI: 10.1080/23288604.2022.2062808
Jimma University, 2022. Maturity of eCHIS Implementation in Ethiopia: Findings from maturity
assessment using Stages of Continuous Improvement (SOCI) Maturity Model.
Ministry of Health. 2020. National Guideline for Family Planning Services in Ethiopia.
Ministry of Health. 2020. National Specialty and Subspecialty Service Roadmap 2020–2029, Ethiopia
Ministry of Health. 2021. Ethiopia Malaria Elimination Strategic Plan (2021- 2025), Addis Ababa.
Ministry of Health. 2022. Ethiopia Conflict Impact Assessment and Recovery and Rehabilitation
Planning (CIARP).
Ministry of Health. 2023. National Food and Nutrition Strategy Baseline Survey Key Findings
Ministry of Health. 2023. People’s Voice Survey: Ethiopia Country Brief 2022.
Ministry of Health. Health and Health Related Indicators 2014 EFY (2021/2022).
Ministry of Health. Health and Health Related Indicators 2014 EFY (2021/2022).
MOH, 2021. Pathways to Improve Health Information Systems in Ethiopia: Analysis Report on the
Stages of Continuous Improvement — Defining the Current Status, Goal, and Improvement Roadmap
of the HIS
MOH, 2022. Effectiveness of the Integrated Data Quality, Data Use and DHIS2 training: Rapid
assessment Report.
MOH. 2021. Assessment of Higher Education Institutions Practice on Licensure Examination. Addis
Ababa: Ministry of Health, Health Professionals Competency and Assessment Licensure Directorate.
MOH. 2022. Annual Performance Report 2014 EFY (2021/22). Addis Ababa: Ministry of Health,
October.
MOH. 2022. Ethiopia Conflict Impact Assessment and Recovery and Rehabilitation Planning (CIARP)
Final Health Sector Report and Costs. Addis Ababa: Ministry of Health, June.
Regional Health Bureau of Sidama Region (2013). Annual performance report (PPT) for 2013 EFY.
Regional Health Bureau of Sidama Region (2014). Annual performance report (PPT) for 2014 EFY.
Regional Health Bureau of SNNPR (2013). Annual Performance Report for 2013 EFY.
Regional Health Bureau of SNNPR (2014.Annual performance report for 2014 EFY.
Tiruneh MA, Ayele BT (2018) Practice of code of ethics and associated factors among medical doctors
in Addis Ababa, Ethiopia. PLoS ONE 13(8): e0201020. https://doi.org/10.1371/ journal.pone.0201020
USAID and Data for Impact. End Line Evaluation of the Private Health Sector Project in Ethiopia:
Executive Summary. March 2021
Wamisho, BL , Tiruneh, MA et al . 2019. Surgical And Medical Error Claims In Ethiopia: Trends
Observed From 125 Decisions Made By The Federal Ethics Committee For Health Professionals
Ethics Review. Medicolegal and Bioethics 2019:9 23–31
WHO. 2023. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World
Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023. Licence: CC
BY-NC-SA 3.0 IGO, Annex 4, p. 63.
till December
Rate Againist
Performance
MTR Targets
Data Source
Target 2022
Peformance
(2024/25)
Mid- term
Rating in
Indicator
Indicator
Baseline
Colours
Type of
Target
2022
General
Life Expectancy at Birth World Health Statistics
1 Impact 65.5 68 68.7 >100%
(years) Data-2019
World Health Statistics
2 UHC Index Outcome 0.43 0.5 0.58 0.38 0.76 Data-2019(Comparable
estimates)
6 month parliament
Proportion of clients
report(Average of
satisfied during their
3 Outcome 46% 60% 80% 75% >100% (Good gov.+CSC+HR
last health care visit
customer service
(Client satisfaction rate)
satisfaction) ---proxy)
Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health and Nutrition (RMNCAYH-N)
Trends in maternal
mortality, 2000–
2020,2000 estimates
Maternal Mortality Rate
4 Impact 401 279 267 >100% by WHO, UNICEF,
- Per 100,000 live birth
UNFPA, the World Bank
Group, and UNDESA/
Population Division
Estimates developed
by the United Nations
Under 5 Mortality Rate Inter-agency Group
5 Impact 59 51 43 47 >100%
– per 1,000 LB for Child Mortality
Estimation-2022 Report
for 2021 GC
Estimates developed
by the United Nations
Infant mortality rate per Inter-agency Group
6 Impact 47 42 35 34 >100%
- 1,000 LB for Child Mortality
Estimation-2022 Report
for 2021 GC
Estimates developed
by the United Nations
Neonatal mortality rate Inter-agency Group
7 Impact 33 28 21 26 >100%
- per 1,000 LB for Child Mortality
Estimation-2022 Report
for 2021 GC
Contraceptive
8 Outcome 41% 45% 50%
Prevalence Rate
Proportion of pregnant
DHIS2 -Six Months
9 women with four or Outcome 43% 60% 81% 75% >100%
Data Analytic Report
more ANC visits
Proportion of deliveries
DHIS2 -Six Months
10 attended by skilled Outcome 50% 62% 76% 71% >100%
Data Analytic Report
health personnel
Early Postnatal Care
DHIS2 -Six Months
11 coverage, within 2 Outcome 34% 53% 76% 32% 60%
Data Analytic Report
days
DHIS2 -Six Months
12 Cesarean Section Rate Outcome 4% 6% 8% 5% 83.3%
Data Analytic Report
DHIS2 -Six Months
13 Still birth rate (Per 1000) Impact 15 14.5 14 11.7 >100%
Data Analytic Report
Rate Againist
Performance
MTR Targets
Data Source
Target 2022
Peformance
(2024/25)
Mid- term
Rating in
Indicator
Indicator
Baseline
Colours
Type of
Target
2022
Proportion of
asphyxiated newborns DHIS2 -Six Months
14 Outcome 11% 29% 50% 82% >100%
resuscitated and Data Analytic Report
survived
Proportion of newborns
with neonatal sepsis/
DHIS2 -Six Months
15 Very Sever Disease Outcome 30% 37% 45% 42% >100%
Data Analytic Report
(VSD) who received
treatment
Proportion of under
five children with DHIS2 -Six Months
16 Outcome 48% 57% 69% 75% >100%
Pneumonia who Data Analytic Report
received antibiotics
Proportion of under
five children with
DHIS2 -Six Months
17 diarrhea who were Outcome 44% 54% 67% 18% 33%
Data Analytic Report
treated with ORS and
Zinc
Pentavalent 3 DHIS2 -Six Months
18 Outcome 61% 72% 85% 103% >100%
Immunization coverage Data Analytic Report
Measles (MCV2)
19 Outcome 50% 64% 80% 83.3% >100% DHIS2
immunization coverage
Fully immunized DHIS2 -Six Months
20 Outcome 44% 58% 75% 92% >100%
children coverage Data Analytic Report
Mother to Child
21 Transmission Rate of Impact 13.40% <5%
HIV
Teenage pregnancy
22 Impact 12.50% 10.00% 7% 14% 12% DHIS2
rate (%)
Stunting prevalence in National Food and
23 children aged less than Impact 37% 32% 25% 39% 5% Nutrition Strategy
5 years (%) Baseline Survey-2023
Wasting prevalence in National Food and
24 children aged less than Impact 7% 6% 5% 11% 57% Nutrition Strategy
5 years (%) Baseline Survey-2024
Disease Prevention and Control
ANNUAL
Proportion of people
PERFORMANCE
25 living with HIV who Outcome 79% 86% 95% 84.8% 98.6%
REPORT 2014 EFY
know their HIV status
(2021/22)
PLHIVs who know their
ANNUAL
status and receives
PERFORMANCE
26 ART (ART coverage Outcome 90% 92% 95% 96% >100%
REPORT 2014 EFY
from those who know
(2021/22)
their status)
Percentage of people ANNUAL
receiving antiretroviral PERFORMANCE
27 Outcome 91% 93% 95% 96% >100%
therapy with viral REPORT 2014 EFY
suppression (2021/22)
ANNUAL
TB case detection rate PERFORMANCE
28 Outcome 71% 76% 81% 87% >100%
for all forms of TB REPORT 2014 EFY
(2021/22)
ANNUAL
TB treatment success PERFORMANCE
29 Outcome 95% 95% 96% 96% >100%
rate REPORT 2014 EFY
(2021/22)
Rate Againist
Performance
MTR Targets
Data Source
Target 2022
Peformance
(2024/25)
Mid- term
Rating in
Indicator
Indicator
Baseline
Colours
Type of
Target
2022
ANNUAL
Number of DR TB PERFORMANCE
30 Outcome 642 967 1365 796
cases detected REPORT 2014 EFY
82% (2021/22)
ANNUAL
Grade II disability PERFORMANCE
31 Outcome 13% 9% 5% 9.9%
among new cases REPORT 2014 EFY
(2021/22)
ANNUAL
Malaria mortality
PERFORMANCE
32 rate (Per 100,000 Impact 0.3 0.30 0.2 0.33
REPORT 2014 EFY
population at risk)
(2021/22)
DHIS2 -Six Months
Data Analytic
Malaria incidence rate
Report/ANNUAL
33 (per 1000 Population Impact 28 18 8 35.9(29.4) 28.2%
PERFORMANCE
at risk)
REPORT 2014 EFY
(2021/22)/
Premature mortality
from Major Non-
34 Impact 18% 16% 14%
Communicable
Diseases
Proportion of Women HEALTH AND
age 30 - 49 years HEALTH RELATED
35 Outcome 5% 21% 40% 1.4% 6.7%
screened for cervical INDICATORS 2014 EFY
cancers (2021/2022GC
Mortality rate from all
36 types of injuries (per Impact 79 73 67
100,000 population
ANNUAL
Cataract Surgical
PERFORMANCE
37 Rate (Per 1,000,000 Outcome 720 1071 1500 555
REPORT 2014 EFY
population)
52% (2021/22)
Proportion of ANNUAL
hypertensive adults PERFORMANCE
38 Outcome 40% 50% 60% 59% >100%
diagnosed for HPN and REPORT 2014 EFY
know their status (2021/22)
Proportion of
hypertensive adults 6 month parliament
39 Outcome 26% 41% 60% 80% >100%
whose blood pressure report
is controlled
Proportion of DM
6 month parliament
40 patients whose blood Outcome 24% 40% 60% 79% >100%
report
sugar is controlled
Service Provision
Coverage of services
Assessment 2021–
for severe mental 5% 16% 30% 26% >100%
2022 Preliminary
health disorders -
Report
41 Outcome
Depression 1% 9% 20%
Substance Use
Disorders
Proportion of Trachoma
endemic woredas
with Trachomatous
42 Impact 26% 49% 77%
Inflammation Follicular
(T.F) to < 5% among 1 to
9 years old children
Rate Againist
Performance
MTR Targets
Data Source
Target 2022
Peformance
(2024/25)
Mid- term
Rating in
Indicator
Indicator
Baseline
Colours
Type of
Target
2022
Hygiene and Environmental health
Proportion of HEALTH AND
households having HEALTH RELATED
43 Outcome 20% 38% 60% 51% >100%
basic sanitation INDICATORS 2014 EFY
facilities (2021/2022GC
HEALTH AND
Proportion of kebeles HEALTH RELATED
44 Outcome 40% 55% 80% 35% 64%
declared ODF INDICATORS 2014 EFY
(2021/2022GC
Proportion of
households having
6 month parliament
45 hand washing facilities Output 8% 31% 58% 36.5% >100%
report
at the premises with
soap and water
HEP and Primary Health Care
Proportion of Model 6 month parliament
46 Outcome 18% 32% 50% 23.5% 73.4%
households report
Proportion of health
centers and primary
47 hospitals providing Input 1.30% 9.00% 19%
major emergency and
essential surgical care
Proportion of high
performing Primary 6 month parliament
48 Outcome 5% 19% 35% 26% >100%
Health Care Units report
(PHCUs)
Proportion of health
posts providing 6 month parliament
49 Input 0% 5% 12% 22 Health Posts 1.2%
comprehensive health report
services
Medical Services
Outpatient attendance DHIS2 -Six Months
50 Outcome 1.02 1.35 1.75 1.47 >100%
per capita Data Analytic Report
DHIS2 -Six Months
51 Bed Occupancy Rate Output 42% 57% 75% 56% 98%
Data Analytic Report
Proportion of
6 month parliament
52 patients with positive Outcome 33% 42% 54% 79% >100%
report
experience of care
Institutional mortality DHIS2 -Six Months
53 Impact 2.20% 1.90% 1.50% 2.74% 24.5%
rate Data
ANNUAL
Percentage of
PERFORMANCE
54 component Production Output 23.30% 42.00% 65% 18% 43%
REPORT 2014 EFY
from total collection
(2021/22)
Ambulance Response DHIS2 -Six Months
55 Output NA 90% 90% 83% 92%
rate Data Analytic Report
Public Health Emergency Management (PHEM)
56 Health Security Index Outcome 0.63 0.7 0.78
Proportion of
epidemics controlled 6 month parliament
57 Outcome 80% 90% 100% 85% 94%
within the standard of report
mortality
Rate Againist
Performance
MTR Targets
Data Source
Target 2022
Peformance
(2024/25)
Mid- term
Rating in
Indicator
Indicator
Baseline
Colours
Type of
Target
2022
Health System Input Indicators
ANNUAL
Availability of essential
PERFORMANCE
58 medicines by level of Input 79.2% 84.0% 90.0% 76.0% 90%
REPORT 2014 EFY
health care
(2021/22)
ANNUAL
Prevalence of unsafe
PERFORMANCE
59 and illegal food Outcome 40.0% 36.0% 30.0% 37.2% -7%
REPORT 2014 EFY
products in the market
(2021/22)
Percentage of ANNUAL
substandard and PERFORMANCE
60 Outcome 8.6% 7.0% 6.0% 1.3% >100%
falsified medicine in REPORT 2014 EFY
the market (2021/22)
Out of Pocket ANNUAL
Expenditure as a PERFORMANCE
61 Outcome 31.0% 28.0% 25.0% 30.5% -2%
share of total health REPORT 2014 EFY
expenditure (THE) (2021/22)
General government
expenditure on ANNUAL
health (GGHE) as PERFORMANCE
62 Outcome 8.1% 9.0% 10.0% 13.8% >100%
a share of total REPORT 2014 EFY
general government (2021/22)
expenditure (GGE)
Total health
63 expenditure per-capita Input 33 37 42.2 36.3 98% NHA (2019/20)
(USD)
Proportion of eligible
ANNUAL
households enrolled
PERFORMANCE
64 in Community Based Outcome 49% 63% 80% 66% >100%
REPORT 2014 EFY
Health Insurance
(2021/22)
(CBHI)
Proportion of eligible
civil servants covered 6 month parliament
65 Input 0 45% 100% 0 0%
by Social Health report
Insurance (SHI)
Incidence of
66 catastrophic health Impact 2.10% 2.00% 1.80%
spending
Proportion of Primary
Health Care Facilities 6 month parliament
67 Input 61% 74% 90% 61% 82%
implemented report
Community Score Card
6 month parliament
68 Information use index Outcome 52.50% 67.10% 85.00% 60% 89%
report
Rate Againist
Performance
MTR Targets
Data Source
Target 2022
Peformance
(2024/25)
Mid- term
Rating in
Indicator
Indicator
Baseline
Colours
Type of
Target
2022
In terms of facility,
the result of
data verification
of 88%, 79%,
93%, 88%, 49%,
and 71% of the
Proportion of health Health Facilities
facilities that met a data were within the
69 verification factor within Input 82% 46% 95% acceptable range RDQA,2022
10% range for selected for SBA, Penta3,
indicators Option B+ (Newly),
New TB cases/all
forms, under five
pneumonia cases,
and Malaria side/
RDT positive cases
respectively
Proportion of births
DHIS2 -Six Months
70 notified (from total Input 35% 55% 80% 69% >100%
Data
births)
proportion of deaths
DHIS2 -Six Months
71 notified (from total Input 3.40% 18.00% 35.00% 4% 22%
Data
deaths)
ANNUAL
Health workers density PERFORMANCE
72 Input 1 1.6 2.3 1.23 76.9%
per 1,000 population REPORT 2014 EFY
(2021/22)
Health care workers’
73 Outcome 6.20% 5.40% 4.50%
attrition rate
Proportion of health
facilities (health centers
and hospitals) with 59% 73% 90%
basic amenities (water,
electricity, latrine,...)
Service Provision
Assessment 2021–
Improved water supply 76% 86% 100% 53% 62%
2022 Preliminary
Report
Service Provision
74 Input
Assessment 2021–
Electricity 61% 78% 86% 54% 69%
2022 Preliminary
Report
Service Provision
Assessment 2021–
Improved latrine 16% 31% 50% 73% >100%
2022 Preliminary
Report
Basic health care
waste management
services
Number of new/
improved technology
75 (Diagnostics, input 1 3 6
Therapeutics, Tools, or
Vaccines) transferred
Proportion of health
facilities implementing 6 month parliament
76 Input 0.53 0.65 0.8 0.62 0.95
compulsory Ethiopian report
health facility standard
1. Addis Ababa
2. Afar
3. Amhara
4. Benishangul Gumuz
5. Dire Dawa
6. Gambella
7. Harari
8. Oromia
9. Sidama
10. Southern Nations Nationalities and Peoples (SNNP)
11. South West Ethiopia
12. Somali
13. Tigray