The Joint Review Mission Report - UHC2030...were deployed in six Regional States of Tigray, Amahara, SNNPR, Oromia, Afar and Gambella including the Federal Ministry with a mission

The Joint Review Mission Report

EFY 2001

FMOH, July 2009


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CONTENTS

Executive Summary .......................................................................................................................................................3

1. Introduction ..........................................................................................................................................................8

1.1 Objective..........................................................................................................................................................8

1.2 Methodology...................................................................................................................................................9

1.3 Limitation ......................................................................................................................................................10

2. Service delivery ...................................................................................................................................................12

2.1 Maternal Health ................................................................................................................................................12

2.2 Noenatal and Child Health ................................................................................................................................23

2.3 Tuberculosis ......................................................................................................................................................26

3 Health Systems Strengthening............................................................................................................................30

3.1 Implementaiton of health Care delivery core process ......................................................................................30

3.2 Accelerated expansion of primary health care .................................................................................................32

3.3 Logistics and pharmaceutical supplies ..............................................................................................................37

3.4 Planning and monitoring ...................................................................................................................................41

3.5. Human resources .............................................................................................................................................44

3.6 Roll out of the HMIS system..............................................................................................................................47

3.7 Some notes on the validation of information flow ...........................................................................................50

4 Progress in harmonization and alignment................................................................................................................51

5. Overall conclusions and recommendations.............................................................................................................58

6. Annexes ...................................................................................................................................................................69


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EXECUTIVE SUMMARY

1. Between June 5th to 14th,a joint group of six teams from government and development partners

were deployed in six Regional States of Tigray, Amahara, SNNPR, Oromia, Afar and Gambella

including the Federal Ministry with a mission to make a quick review of the implementation of

EFY 2001 Woreda Based Core Plan at all levels of the system. The review sought to supplement

the annual performance report generated from HMIS by presenting data from the field—more

specifically, by obtaining primary data from the visited health facilities and discussions. The

overall objective of the JRM was to make a quick assessment of the EFY 2001 implementation.

The specific objectives were to:

assess the implementation of HSDP III priority activities,

assess the challenges/constraints faced and gaps existing in the health sector,

identify and document best practices and lessons learnt,

identify inputs that will be taken up in the preparation of HSDP IV, and

highlight the implications of various initiatives and reform measures that are underway

in the health sector.

2. The scope of this JRM was limited to look into: (i) maternal, neonatal and child health, and (ii)

tuberculosis and (iii) selected health systems. These two service delivery thematic areas were

chosen mainly because of their low progress in achieving targets set and existence of

inadequate information on the progress made and challenges faced as compared with other

related priority health areas such as malaria and HIV/AIDS.

3. The findings, challenges and recommendation of this report should be read keeping the

limitations of the review in mind. The mission was carried out in a very short period, within a

week. Considering the various thematic areas identified for the mission and given the vastness

of the scope it is entrusted with, the composition of its regional teams was not adequate to

cover these areas. In some cases, respondents chosen to provide the required empirical data

for the mission were engaged in many other competing tasks. It was thus difficult to fully

involve them. Moreover, the mission had to cover only a few woredas and health facilities

designated as ‘high’ and ‘poor’ performing by health bureaus. Understandably, the results may

not be used to make generalization about woredas not involved in the study. The findings,

challenges and recommendation given below are made at the backdrop of these limitations.


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4. Progress in maternal health service delivery (family planning, ANC, skilled delivery) was found

to be uneven across regions. Some regions performed better in one of the services more than

others. Of the six regions visited, only one is reported to be on track to achieve the 2001 EFY

targets. Progresses have been made towards achieving some of the targets set for family

planning and ANC service across the regions. There has, however, been very little progress in

increasing delivery by skilled attendants. Shortage of skilled midwives, weak referral system,

inadequate midwifery skills at health centre levels, lack of/ inadequate availability of BEOC and

EmOC equipment, and under financing of the service were identified as supply side constraints

that hindered progress. On the demand side, cultural norms and societal emotional support

bestowed to mothers, distance to functioning health centres and financial barrier were found

to be the major causes of for delivers at home. The establishment of the MDG fund and the

priority given to maternal health therein is expected to mobilize increased funding but its

effective utilization requires ensuring the participation of relevant directorates in the resource

allocation decision making process at the JCCC. HSDP IV design should consider creating

universal access to safe motherhood services by providing 24 hours a week delivery services in

health centres free of charge and provision of comprehensive Emergency Obstetric Care (CEOC)

at all hospitals and selected health centres, scaling up the competency training for HEW to

ensure access to clean delivery at the health post level.

5. With regards to neonatal and child health, most of the regions seem to be very near to the

targets set for child health (i.e. measles immunization and penta 3 coverage). This success story

is mainly attributed to the efforts exerted by the health extension workers; they were involved

in active mass mobilization. However, there are concerns that many health facilities do not

provide IMNCI services, and it may be difficult to reach all children with pneumonia and other

common childhood problems. There are currently ongoing efforts to pilot the effectiveness of

the provision of such services by HEWs by some partners. It will be prudent to review the

effectiveness of these pilot programs and develop a strategy based on the findings of such

review to, if found successful, use the HEWs by training them on how to assess, classify and

manage common childhood and newborn problems including pneumonia, complementing it

with regular follow up and supportive supervision. Newborn health has not yet received due

attention at policy and programmatic levels. HSDP IV should consider, among others,

establishing newborn unit/ corner in hospitals and health centres respectively.


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6. While progress in meeting target set for TB treatment success rate seems to be fairly

acceptable, detection rate remains very low. Identified as reasons for hindering detection rate

include: inability of the sector to exploit potential areas for improving detection rates (

including integrating TB detection in all OPDs as part of the provider initiative testing );

inadequate involvement of health extension workers to refer those with signs of the disease;

the inability of some of health facilities to provide the service due to lack of properly

functioning laboratories and skilled human resources. Bias of the training and supervision

towards improved success rate ( as compared with increasing detections) also contributed to

low performance in detection rates.

7. Health care delivery core process was one of the 8 core processes redesigned and set up as

part of an extensive institutional reform in the FMOH. The implementation of the new core

processes created structures that would address the agrarian, urban and pastoral population

health promotion and disease prevention health needs. The new process based work is

expected to bring reduction in transaction costs and duplication of efforts. However,

deployment of staff fall short of meeting the numbers and qualification requirements set in the

BPR in the various directories. Many recommended posts remained vacant, and the deployed

staff are not generalist enough to address public health concerns.

8. Significant progress was made in achieving the targets set for accelerated expansion of primary

health care. Of the total FMOH planned financed HC (XXX), % percent of them are either under

construction or completed. Of the total RHB financed HC, XX or (XX) % are either under

construction. The financing of 411 health centers (of which XX % should be financed by RHBs) is

yet to be secured. While the construction process is ongoing, there seems a slow procurement

of equipment through the FMOH and furniture through RHB financing. The health sector should

continue lobbying for greater political leadership and commitment at woreda level to allocate

sufficient budget to furnish constructed health posts by using the evidence based planning

process that are taking roots in the health sector. FMOH should strengthen its follow up on

PFSA to fast track of the procurement of equipment of HP and health centers. More efforts are

therefore needed to synchronize construction and upgrading of health facilities with equipping

and staffing, and to make them fully functional as per the national standard including ensuring

availability clean water supply and power.

9. PHARMID was transformed into service provider PFSA as per the logistics master and BPR

process. The agency reported that it was able to procure all its plans both for health

commodities using RDF and program funds. The procurement of health center equipment

through PFSA was reported slower as compared to its procurement plan but found to be much


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more cost effective than the previous arrangement. There was also some but slow progress in

strengthening warehousing, distribution, human resources and LMIS. Still, further efforts are

required to strengthen the capacity of the agency to provide demand driven health

commodities.

10. There is significant progress in strengthening the Woreda Planning process. The sector

managed to support and to develop plans for 801 Woredas. In EFY 2001, in addition to the

innovations made previously (see MTR report), there were two innovations: the inclusion of

activities in the planning process and hospital level plan development as part of the woreda

planning process incorporating relevant functions and interventions. As the planning process

evolves and matures over time, ownership of the plan is being strengthened at lower levels,

particularly from region down to woreda levels. The Woreda based planning process is being

considered as the best example for the public sector planning both at the federal and regional

levels. There is relatively better collaboration between stakeholders at woreda level. However,

because of the limited participation and involvement of health facilities, NGOs when Woreda

plans are developed at Woreda levels, as well as the limited capacity of health facilities and

Woreda health offices to negotiate with the region and the woreda, the process appears to

dominated by the top‐down targeting.

11. There was some progress in getting some of the human resource training programs initiaited.

Training of Health Officers on emergency obstetric care have been initiated in three

universities; Preparations are underway to scale up HEW training from level 3 to level 4, and

enroll 300 midwives per year. However, the HRH strategy remains to be endorsed to guide the

comprehensive HRH actions. Capacity constraint at newly established HRD Directorate was

observed and it is important to consider assigning some technical assistance to bolster its

leadership.

12. There is consensus on the strategy to strengthen the HMIS process. The family folder when

put into operation will provide the necessary information at household level. There is less

controversy on the feasibility strategies designed to strengthen facility level interventions

health management information system. However, there is a consensus both at the federal

and regional levels that HMIS rollout is delayed. The principal reason for the delay is the lack

of adequate financing at the regional level to hire the health information officers, mainly by

the larger regions. Under financing, particularly for printing of the necessary forms and

registers, and inadequate effort to bring all stakeholders to have consensus on the


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implementation and scaling up effort and to mobilize additional funding for the exercise have

also contributed to the delay. There is a need to review and re‐strategize the implementation

of the scaling up process with all stakeholders.

13. A significant progress was achieved in EFY 2001 in terms of putting the right frameworks and

agreements that will push alignment and harmonization agenda forward. The International

Health Partnership roadmap was finalized and its Compact signed at the beginning of the year.

That has created the environment for the establishment of the MDG Performance Fund. Some

of the signatories of the MDG fund started disbursing funds to the account. Most of the action

plans designed to strengthen the systems for operationalization of MDG Performance Fund

are have been initiated. The integration of MDG fund with the annual planning and decision

making process is a still work‐in‐progress and could only be known when EFY 2002 plan is

endorsed. In terms harmonization, a number of issues were highlighted for action including:

a. alignment of all community activities by all stakeholders into the country system,

working towards full alignment with the annual plan and reducing the

transaction cost for health extension workers.

b. Government and 11 development partners have signed the IHP+ compact and of

which only 7 have signed the joint financing arrangement that established the

MDG performance fund;

c. Of these that have signed the Joint financing arrangement, only 5 partners have

disbursed to the MDG performance Fund, and

d. Of the total resource pledged for the MDG PF, most of the resource is not new

money (with the exception of DFID and Spanish) and the effort to scale up aid

and meet the resource gap does not seem materializing.

e. Progress in using one plan, one budget framework and monitoring framework

seems slow.

14. One of the objectives of this JRM process was to validate the performance reports at

various levels of the health system. It has provided useful information on the progress made

in the implementation of EFY 2001 plan, challenges faced and possible actions to be taken

in the design of HSDP IV. It therefore supplements the annual performance report produced

by the FMOH. However, it falls short of checking the reliability of information due to

shortage of time. This process of jointly reviewing the performance of the sector needs to

be strengthened in the coming years from design to implementation to enable it carry out

the validation process.


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1. INTRODUCTION

1.1 OBJECTIVE

15. This is a synthesis report of the Joint Review Mission (JRM) on the implementation of EFY 2001

plan, which is the fourth year of HSDP III implementation. It is prepared in compliance with the

agreements of IHP compact and provisions of JFA that requires the Government and health

sector stakeholders to conduct a joint review of the performance of the health sector. The JRM

report supplements the annual performance report generated through the routine system. This

helps to strengthen and institutionalize the single monitoring framework by replacing separate

donor missions.

16. The Joint government‐development partner’s review mission was held from June 8th to June

15th 2009 and focused on the assessment of EFY 2001 plan implementation at all levels of the

health system. In addition to the Federal level, the review covered 6 regional visits: Tigray,

Amhara, SNNPR, Oromia, Afar, and Gambella National Regional States. While reviewing the

overall performance of the annual plans, the 2009 JRM chose to focus on MNCH and TB outputs

and processes to track health delivery performance in the health sector. This is mainly due to

two reasons: (i) the sector does not have adequate information on the progress and challenges

as much as the other priorities, i.e. malaria and HIV/AIDS; and (ii) maternal and newborn deaths

have stubbornly stayed high and tuberculoses detection rates were found to be very low

despite measures taken.

17. The overall objective of the JRM was to make a quick assessment of the EFY 2001

implementation. The specific objectives were to:

assess the implementation of HSDP III priority activities,

assess the challenges/constraints faced and gaps existing in the health sector,

identify and document best practices and lessons learnt,

identify inputs that will be taken up in the preparation of HSDP IV, and

highlight the implications of various initiatives and reform measures that are undergoing

in the health sector.


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18. Validating the completeness, consistency and reliability of information generated through the

routine system was the other objective of the JRM process. The Health sector performance

report 2001 presents the comprehensive sector achievements and constraints in the ARM

2009. Included in the JRM report are also anecdotal evidences collected from the health

facilities visited and views generated from interviews conducted with health managers at

different levels of the health system. In addition to presenting thematic findings, the JRM hopes

to offer some overall statements regarding credibility of the information generated and

discussed in the annual performance report.

1.2 METHODOLOGY

19. One federal and six regional teams were deployed to assess the performance of the sector (see

annex 5.1 for team composition). While two of the regions (Amhara and Oromia) had two

teams, the other four had a team per region. The regional team that had only one sub team

visited at least two completely different areas (one high performing area and one poor

performing area) and documented the best practices and lessons learnt. The regional team

consisting of two sub teams interviewed all the relevant health stakeholders as presented in

table 1.1.

Table1.1: Generic Visit Schedule for the Regional Teams

General HIGH PERFORMING POOR

PERFORMING

RHB X

Zones X

Woreda One One

Hospital One One

Health centers One One

Health posts One One

Community group

discussion

X


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20. To ensure that the assessment of performance are comparable across regions, a standardized

questionnaire and reporting format was developed and used during mission visits. The

standardized questionnaires used were:

Federal level

Regional level

Zonal

Woreda level

Facility (hospital, health cents, health posts ); and

HEW and the Community level.

21. The other important aspect of this JRM process was to provide some information on the

completeness and adequacy of the information generated through the HMIS system. This was

carried out whenever the teams have access to reports and information and it followed the

procedures indicated below:

At the federal level, the completed HMIS information for 2001 (nine months) was

distributed to teams to help them use it` as the basis for validating information;

Some regional team tried to obtain the regional reports and compare IT with the inputs

from the Woredas and recorded any inconsistency;

Finally, the team also collected the output of the woreda and compared it with the

submission of health facilities and recorded any inconsistency.

These activities were helpful in garnering information that would enable the research team to

reach some reasonable conclusions regarding the completeness and accuracy of information

with some degree of error.

1.3 LIMITATION

22. This report has some limitations as indicated below

o The duration of the mission’s field visit was too short to carry out intensive and in depth

assessment. The teams had to work with a very tight schedule of a week’s visit (including

travel time) that somehow compromised the quality of the data collection process. Since

most sites were not informed of the visit in advance, the teams had to rely on goodwill of

respondents to participate at short notice. Despite these predicaments, the teams

managed to complete most of their tasks.


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o The JRM process was not given adequate attention. Some partners (e.g., CDC) withdrew

the experts they committed at the last minute for various reasons. Some other partners

((e.g., USAID) failed to fully engage the experts they involved for the entire week of the

JRM mission. The Federal team, on its part, did not conduct all interviews as a team.

These things somehow affected the quality, scope and depth of this report.

o The JRM was carried out at a time when the regional health bureaus were engaged in

many competing activities. All regions were in the development of the 2002 EFY plan.

Some regions were undertaking extended outreach services. There were thus times JRM

teams found it difficult to meet and discuss with all department heads and the heads of

the health bureau on HSDP III implementation. This might have contributed to not fully

addressing the perspective of these managers.

o The report does not claim to have enough/representative sample size as it only covered

few Woredas and facilities. The review focused on only two comparative areas (one,

identified as ‘high performing’, and another, as a “poor performing “area), and could not

provide a detailed reflection of the situation across a wide range of areas between these

two extremes. Even with this shortcoming, the methodology has, on key issues,

achievements and challenges at the different levels of service provision.

o Partly because of the differences in expertise in the composition of the team and in type

and depth of information obtained from interviews and site visits, the quality of the

regional reports showed considerable variation Some regional reports did, for example,

have complete information on the regional achievements and hence had relied on

information obtained from Woredas and health facilities visited. This made it difficult to

present a regional comparative analysis of service delivery indicators in this report.

o Though one of the objectives of the exercise was to undertake a validation exercise about

the quality and completeness of the routine system, it was not adequately carried out.

This was because most teams were not able to get reports at different levels as requested

in the methodology.


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2. SERVICE DELIVERY

23. HSDP III and EFY 2001 targets in service delivery include all services that health system

provides. This JRM, however, is limited in scope as it was given the task of reviewing the

progress in achieving the targets set for EFY 2001 through tracking two main health services

delivery areas: (i) maternal, neonatal and child health and (ii)Tuberculosis. As pointed out

earlier, these services were selected because of lack of adequate progress in meeting the

targets set as well as lack of adequate information in comparison with other related priorities.

This chapter therefore brings together the findings of the regional and the federal reports in

maternal, neonatal and child health, and tuberculoses.

2.1 MATERNAL HEALTH

24. One of the goals of HSDP‐III is to reduce the maternal mortality ratio from the 673 per 100, 000

live births in 2004/05 to 6001 by 2010. These HSDP targets are translated into 2001 operational

objectives through the following targets:

Increase family planning services to 64.5 percent

Increase skilled attendance at birth from 23 to 37 percent

Increase Emergency Obstetric and Newborn Care (EmONC) coverage, basic in

100% of Health centers and Comprehensive in 85% of Hospitals

Increase ANC coverage to 80.5 %

Increase PMTCT coverage from 10.7 to 50 percent

Increase clean delivery by health extension workers from 10 to 29.3 percent

Increase health services that provide post abortion services from 120 (15%) to

600 (75%).

25. In order to meet the above targets, unplanned pregnancies must be prevented through FP;

women must have access to quality ANC, and deliveries must be attended by skilled birth

attendants. Furthermore, major obstetric complications must be treated appropriately;

1 Though HSDP took 871 as a baseline, DHS later estimated MMR to be 673.


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community must be supported to develop required behavioral change to utilize a continuum of

care along the health system and through pregnancy and childbirth.

26. Improving maternal health is the priority program for both the federal and regional levels. At

Federal level, critical challenges and bottlenecks including inadequate number, mix and

accountability of human resource were identified. While expansion of infrastructure is

noticeable in many of the sites visited, most are still under construction. Very apparent at all

levels of health system is the inadequacy of essential equipment /supplies. This is compounded

by poor quality of care and ineffective referral system. On the demand side, there is a challenge

of increasing utilization of services (delay in seeking care). The major underlying reason for all

these is the under‐financing of maternal health and inefficient partnership and program

integration.

27. In order to address these challenges, the Federal MoH is rolling out infrastructure expansion

with the aim of availing 1 HP to 5,000 population, 1 HC for 25,000 population, 1 primary

hospital for 100,000 population, 1 Zonal hospital for 1,000,000 population. This expansion is

being supported through health workforce performance improvement mechanisms. The

Human Resource for Health (HRH) strategy (still in draft form) outlined strategies for improving

access to skilled attendance at birth by targeting 1 midwife at every HC. This is envisioned to be

done through training of existing nurses an additional course on midwifery (Nurse‐midwifery)

and through developing generic midwives.

28. In EFY 2001, training programs like the accelerated training of HEWs, health officers, Masters of

Science program on Integrated Emergency Obstetrics and Surgery have been scaled up. While

acknowledging the need for accelerating training at all levels, The JRM has, however, noticed

that this scaling up of trainings should be done on phased approach to ensure quality of

training.

29. The staffing challenge is not limited to the health facilities. It is also reported by various

Ministry Directorates where the split of the previous Family health department (FHD) into three

has left staff with unclear responsibilities which may have the potential for further weakening

the capacity. With the BPR rolling out, the need for development and implementation of a well

thought out capacity development plan should not be underestimated.


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30. To address the inefficient and ineffective referral system, the development of a referral

guideline that aims at reducing unnecessary referrals and strengthening referral feedback

mechanisms has been initiated. The case of St. Paul Hospital illustrates a significant number of

obstetric complications that can be treated at HC level are being referred from the catchment

health Centers. Though the hospital has tried to solve this by organizing a monthly feedback

forum with the HCs, the problem still persists. The hospital leadership is looking forward to the

referral protocol to be issued by the FMoH as an ultimate solution in improving effectiveness of

referral and patient follow up.

31. The IHP+ compact and the resulting JFA has prioritized maternal health services as one of the

core areas to be financed from increased resources coming from the various stakeholders. This

has laid down a favorable ground for increased resource for maternal health more than before.

This opportunity should be maximally utilized through improved participation and engagement

of relevant MoH directorate on the development of comprehensive annual plans and meetings

of health sector governing structures (e.g. JCCC during the management and decision of

resource allocation for this fund.) Since the MDG Fund financing mechanism is new all directors

were aware of its existence and how resources are allocated to priority areas. Without a

commitment, participation and regular attendance of relevant directorates in these decision

making structures, the effort to give more priority to maternal health can easily be lost.

Progress in ANC and Family planning services

32. At federal level there have been a few but critical achievements in improving maternal health.

The major ones include implanon scaling up using the HEWs, safe and clean delivery training for

HEWs, establishing linkage between HEWs and community volunteers, and undertaking

national surveys such as EmONC and PMTCT. In some of the regions visited, limited progresses

have been made towards achieving some of the MNCH targets set for family planning and ANC

service. In almost all regions, the achievement recorded in the last nine months is lower than

both the targets set for 2001 and baseline for 2000. If the first nine months trend continued in

the rest of the year, the achievement in these two services would likely be more than the

baseline and somewhat lower than the target set. While this is the general trend, the picture is

quite mixed between high and low performing areas in some regions. A case in point is the

situation of antenatal care coverage and family planning uptake in the Amhara region. While


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an encouraging trend is observable on this regard, the areas visited in East Gojam zone, e there

is a serious lag in South Gondar zone in particular and in the rest of the region regional level. In

SNNPR, the overall coverage is impressive. Still, both high and low performing zones are likely

to have difficulty in achieving the very high targets set.

Table 2.1: Progress in Family Planning and ANC

Family planning ANC services Regions

Baseline Target Achievement Nine months 2001 EFY


Tigray 55.9% 64.4% 78% 68.3%* 82.8 69%

Afar 16.5%* 20%* 14% 49% 57.9% 42%

Amhara 57.1% 65%* 42.6% 51.5% 80% 43%

Oromia 38.7% 51%* 31.6% 51.7% 72*% 47.4%

SNNPR 85.2% 85% 48% 85.4%* 92.6% 21%

Gambella 14.2% 56.7% 36.6% 79.3%

*note that what is reported as baselines and targets in this report is different from the ones shown in the HSDP III

Woreda Based Annual Core Plan, EFY 2001.

33. Many factors are reported to have contributed to improvements in family planning and ANC

services. Proper utilization of the already deployed HEWs supported by the community leaders

and direct support provided by community health volunteers is, for example, one of the factors

reported to have contributed to increased community access to these services. The role of

community health volunteers particularly in community mobilization for outreach services, in

providing information on any vital event taking place in their community and in improving the

health care seeking behaviour of the community was reported to be vital in some of the regions

(e.g., SNNPR). Furthermore, high commitment of health managers at all levels, the regular

supportive supervision conducted by regional, Zonal and woreda health managers and HEW

supervisors and the direct involvement of the community in the planning and execution of all

health activities have been important factors the overall achievement. Last but not least, there

was always a continuous supply of equipment and consumables. On this regard, support of

partners is very much appreciated. Over the last one year, there was no major shortage of

supplies for FP commodities.

Progress in Skilled Attendance at Birth


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34. The overall finding of the JRM this year is that there was very little progress in increasing

deliveries attended by skilled health personnel. At national level, the reported progress in terms

of skilled attendance at birth was 50 percent off the annual target. Of the six regions visited,

only one is reported to be on track to achieve the 2001 EFY targets. Two regions are likely to

perform below their targets. Still worse, another three might even perform lower than baseline

level indicated in their plan.

Table 2.2: Progress in Deliveries Attended by Skilled Health Personnel by Regions

Regions 2000 baseline

2001 target 2001 Nine months performance

Tigray 30%* 34.6% 35%

Afar 21% 26.6% 32% (This needs verification)

Amhara 15.6 29% 11.7.% (All visited health facilities are working far below the target set for each one)

Oromia 16.9 33.5% 17.5 %

SNNPR 48.5 50% 36 (together with HEW)

Gambella 6.1% 25.9%

35. The JRM noted some evidence generated from regional reports worth mentioning. The majority

of HEWs did not receive training in clean and safe delivery. On a positive note, those few, the

HEWs trained gained community acceptance and started attending deliveries together with

trained TBAs. For instance, in the Dire Jibo health post in Oromia region, the HEWs attended 56

births in the 9 month of 2001 when compared with the 16 of EFY 2000. Overall, though, many

challenges hindered progress in increasing deliveries attended by skilled health personnel. The

following are the major ones identified by this JRM mission.

Actual delivery levels are not known

36. The regional coverage for deliveries attended by skilled health personnel was not exactly

known. In many regions (e.g., in SNNPR and Oromia) the information available included

deliveries attended by both HEWs and skilled health personnel in gross terms. This needs to be

rectified as there is a need to distinguish between clean and safe delivery and skilled birth

attendance.

Social factors influencing deliveries at home:


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37. According to the information generated from community group discussions during this JRM, the

emotional support provided by close relatives and neighbours during delivery at home is very

much appreciated. This tends to encourage mothers to deliver at home rather than giving birth

at a health facility where such social support is not available (see box 1). The traditional foods

and drinks provided immediately after delivery to family members also have similar effect.

Some cultural beliefs such as

amechissa in Oromia, for example,

contributed to delivery at home.

Unless they are made aware some

specific problems that mothers

encounter at birth, community

members are very likely to be

reluctant to go to medical facilities.

Distance discouraging facility

delivery

38. One of the main barriers preventing

mothers from attending deliveries at

health facilities is long distance. Given

the limited number of health facilities

with functional delivery services,

mothers have to travel many Kilo

meters to reach the nearest health

facility. To make matters worse, as

pointed out earlier, the onset of

labour can be sudden while the

mother is in her farm or home doing

her routine activity. The time it takes to travel with the mother in labour to reach to the health

facility is too long. Because of that, not surprisingly, many women deliver on their way there.

In some cases, that could be fatal. In one of the kebeles visited in Amhara region (Socham) two

women have reported to have died while giving birth due to delays to reach a properly

equipped health facility. Even though some he community members admit that the HEP

program has brought the service closer to where they live, its potential for delivery has not

Box 1: Community views on factors influencing home

deliveries In SNNPR

When mothers deliver at home they are surrounded by close

relatives and neighbors with prays and blessings and with a

lot of emotional support. At the same time, immediately after

birth, traditional foods and drinks are provided by the family

members to delivering mother at home. Therefore unless, a

mother is told that she has some problem during labor,

delivering mother will be reluctant to go to the facilities for

normal delivery.

The other barriers mentioned are long distance and financial

barriers. They said spontaneous labor starts suddenly. Most

of the time, that happens while the mother is in her farm

doing her routine activity Naturally, to organize a transport

for a mother in labor will take some time and then 2‐3 more

hours are needed to reach to the Health Facility. The

community also believes, if the HEWs have the skill to

conduct delivery; it will be easier for the mother to deliver in

the HPs.

Source: SNNPR regional report


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been fully exploited. Community members have further suggested that if the HEWs had the skill

to conduct delivery, it would be easier and closer for mothers to deliver in the HPs.

39. The efforts being made in accelerating the expansion of primary health care at all levels will

have a positive effect in reducing distance barriers. However, this will take some time before

the facilities under construction are made fully functional. Until the regions manage to expand

the primary health care service by expanding fully functional HCs, it will be prudent to improve

the skill of HEWs through training and practical skills on clean and safe delivery including

training on basic neonatal life support. There is a big potential that sector has created that

needs to be tapped more (see below).

Financial barrier affecting demand for facility based delivery

40. The Essential health packages defined in 2005 delineated delivery at health centre as one of the

exempted services (due to its public health benefits) to be provided free of charge. However, in

practice, , albeit not formally required to pay directly for delivery, a delivering mother is

forced to buy gloves, drugs and IV‐f fluids because of the unavailability of adequate supply of

these it items at a health facility . This hinders especially low income families to go to health

facilities for normal delivery. It is in fact worth noting that the findings of the JRM regarding

financial barrier are mixed. For example, In Wukro of Tigray region, delivery (be it normal,

treatment of PPH or caesarean section) is free whereas delivering mothers in Adwa in the

same region are charged ETB 2 for registration. In spite of that, in both places, mothers are

requested to buy materials required for delivery because of shortage of budget for supplies. On

the other hand, in one health centre found in Oromia, on average, mothers are requested to

pay ETB 20 for delivery services. In Kuergand health centre in Gambella, pregnant mothers pay

10 ETB for delivery to cover the cost of cleaning detergents. In the same region, when obstetric

complications arise, mothers have to cover the cost of fuel and other related expenses for their

referrals from the health centre to the regional hospital, which costs as high as 350 ETB.

Community members have mentioned these financial burdens as reasons preventing pregnant

mothers from going to health facilities. The acceleration of social health insurance and

prepayment schemes will help address these out of pocket burden and the existing efforts

should be given adequate attention. Furthermore in collaboration with its development

partners, the government should thus make sure that free maternal health policy is

implemented and supplies and drugs are available at the health facility levels. Mechanisms


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should be put in place that ensures such finance gaps are met if the reduction of maternal

mortality is to be achieved.

Shortage of human resources, skill and attitude of staff

41. The major challenge for accelerating skilled attendance at birth is generally the shortage of

skilled midwives in the health system. For instance, in Gambella hospital, the referral hospital in

the region, there are only two midwives, two anaesthetists and one obstetrician. The

obstetrician was employed on contractual basis and left the hospital during this mission. There

is no regular quality improvement mechanism such as maternal death review/audit in the

region. Worse, no health worker is trained on Comprehensive Emergency Obstetric Care

(EmONC) in the last one year. In Amhara region, none of the visited health centres and offices

had sufficient number and mix of staff. Absence of midwives in the health centres and their

inadequacy in hospitals has been quite conspicuous. Sedde Adada, a health centre in Amhara

region, was, for example, run by just three nurses. Interestingly, none of them stayed more

than four months. And there was only one junior nurse who was providing service during the

mission’s visit. The situation was not better even in Saint Paul hospital, a tertiary hospital, as it

is being run by midwives less than 50 percent of its requirement.

42. In facilities with reasonably adequate number of health workers (for example in Wukuro

Hospital) there was no maternal death for the last three years. Similarly, the presence of a

specialist on OB/GY in Adwa Hospital was instrumental for hospital to be on schedule to meet

its target of assisted deliveries for 2001.

43. There are only about 1,200 midwives in the national health system. If one uses the standard 1

midwives to 5000 population, Ethiopia requires about at least ten times as much. Given the

current annual intake of 300 trainees per year, the potential of training institutions to train the

required number of midwives in the short run does not seem promising. The government’s

strategy of task shifting is expected to have an impact in contributing to improved maternal

health outcomes. In this regard, the plan to train and deploy nurses with midwifery skills in all

the 823 functioning health centres in the next financial year is a measure that will create some

capacities at that level. Training of health officers on Integrated Emergency Obstetric and

Surgery to provide comprehensive EmONC including emergency Caesarean section service was

initiated in three universities (Jimma, Hawassa and Mekele Universities) in January 2009

supported by UNFPA. The accelerated training of 5,000 health officers will also contribute


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positively to this trend. However, scaling up the midwifery training may not be able to meet the

needs of the health sector at this scale.

44. In the mean time, the 80 percent of the deliveries that are currently conducted at home will

continue with the existing trend until services are closer to them. The potential of the HEW to

assist these mothers in clean delivery has been recognised. The seemingly apparent conflicting

view about the effectiveness of community based deliveries attended by HEWs and facility

based deliveries (attended by skilled health personnel) has been one of the causes of lack of

progress in either of these options. Ethiopia is in fact working hard to increase access through

vigorous expansion of primary health care that will significantly contribute to the availability of

basic and to some degree COEmNC service. However, there will be a time lag until these

facilities become functional and adequate midwives and other professionals are made

available. On the other hand, the HEP can accelerate access to clean delivery if the HEWs are

adequately trained.

45. HSDP IV should develop strategies that will allow a balanced development and linkage of both

community (safe and clean delivery) and facility based (skilled attendance at birth) to record

early success, particularly at affordable cost. Such a strategy should ensure that long term

investments are made to increase human resource base, including midwives, and strengthen

the system for skilled care. It is, however, important to note progress in providing skilled care

may not be fast enough for the health system to bring about meaningful impact on the

mortality required to achieve MDGs 4 and 5 in the short term. This makes exploiting the

potentials of HEWs and scaling up some of the experiences shown above very attractive and

cost effective. The training of HEW to provide clean and safe delivery should therefore be

scaled up to provide as an interim solution.

Low confidence of mothers on the quality service provided


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46. Most of the health facilities, specially health centres visited, do not provide a fully functional 24

hours a week services for mothers. The referral system is weak at all levels. Many hospitals are

providing normal delivery services that could have been carried out at the health centre level.

In Saint Paul Hospital, for

example, it is reported that more

than 75 percent of mothers were

wrongly referred from health

centres. The prevalence of

inappropriate referrals is massive.

Most of these happen because

health workers at the health

centre level were not adequately

trained on midwifery skills and in

effect lack the confidence to

assist mothers. Information

gained from the Medical Service

Directorate reveals that the

referral Guideline has been

developed to correct the ‘broken’

referral systems and that is an

encouraging sign (see Box 2).

47. Furthermore, the health facility

delivery environment and the

attitude of the health workers are not attractive to mother to come and deliver. In some of the

regions, the JRM has received recommendations on improving the delivery at facility levels.

Among other things, members of the community recommended that the delivery room should

be clean, that it should have enough places for labouring mother and for the immediate

postnatal period and that health workers should be supportive, competent and skilled to

handle some of the social problems encountered by delivering mothers.

BOX 2: Efforts to strengthen the Referral system in Addis Ababa

Addis Ababa RHB brings national and regional referral hospitals and

health centers staff in Addis to improve communication and develop

strategies on strengthening the referral system. This is carried out

through a monthly meeting. According to interviews conducted with

the federal hospitals, this did contribute to better communication

with catchment health centers. The sub‐cities that were

coordinating these meetings have recently stopped this.

The federal hospitals suggested that this mechanism could be

strengthened through for example assigning specialists to catchment

health centers once a month for chronic diseases through better

coordination and scheduling between the hospitals and health

centers. This will bring the service closer to the beneficiaries and at

the same time reduce the burdens in the hospitals. Provision of

mandatory feedbacks to the lower levels may be necessary to

ensure the functioning of the referral system.

Source: Federal JRM Report

48. In many facilities, there is insufficient skill to handle obstetric complications. Even that is of

most of the health professionals, it is much more apparent among the midwives, particularly


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among those who graduated from private colleges. This requires strengthening the pre‐service

training, and the need for establishing objectively structured evaluation system before

deploying midwives into health facilities. Organising regular supportive supervision and

coaching through integrated refresher training for those who are on‐the‐job is likely to remedy

some of the skill gaps. Motivation of Health workers is also a concern and needs to be

addressed through some form of performance based incentives.

Lack of equipment and maintenance

49. The lack of/ inadequate availability of equipment in most of the hospitals and health centres

has also reduced the ability of the system to provide quality delivery services. There is slow

procurement and distribution of HC equipment to facilities whose construction has been

completed. In Gambella, for instance, the regional referral hospital is poorly equipped with very

old MVA kit and no blood transfusion service. Some health centres in Gambella and SNNPR

were found to lack even the most basic equipment such as BP apparatus. For these reasons,

mothers who needed the services are referred to Mettu hospital which is 180 Km away.

50. The JRM mission noted that maintenance capacity the most of the regions visited is inadequate.

Including BP apparatus and autoclaves, all types of equipment and instrument, were broken

and lying in health institution without getting fixed for a long time. Standard system for

handling malfunctioning tools does not seem to exist in most of the regions. In Gambella, there

is only one person who is supposed to be working on the maintenance of medical

instruments/equipment. Interestingly, he is neither a professional nor was he trained on

maintenance. With the expansion of primary health service (about 3200 health centres and

their equipment by the end of EFY 2002), the JRM recommends that the sector develops a

clear strategy and strengthening program component in HSDP IV to ensure the existence of

maintenance capacity at all levels.

51. These maternal health challenges described in the preceding paragraphs are not

insurmountable. The sector should look into creating the necessary commitment to increase

resources and put the right strategies, structures and interventions in the design of HSDP IV. As

part of the overall drive of universal coverage that the government is committed to, HSDP IV

should consider to create universal access to safe motherhood services through: (i) providing 24

hours a week delivery services in health centres nation‐wide (this requires defining input

requirement and mobilising resources especially for under‐serviced regions and areas within


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regions); (ii) provision of comprehensive Emergency Obstetric Care at all hospitals and selected

health centres by establishing functional maternities, nurseries, maternity theatres and

laboratory services; (iii) continued effort to ensure availability of family planning commodity in

health facilities (commodity security and distribution); (iv) developing and implementing a

functional Referral Strategy; (v) continued demand creation for health services through HEP;

(vi) introducing free deliveries in all health facilities (health centres and hospitals), by possibly

financing health facilities for their forgone revenue because of the introduction of such a policy

at hospital and health centre levels) through other sources of funding.

2.2 NOENATAL AND CHILD HEALTH

52. The national targets for child health in EFY 2001 were to: (i) Increase coverage of penta 3 to

85% and (ii) increase measles immunization coverage to 86.4 %. If the implementation trends

witnessed in the first nine months (see Table 2.3) continue with the same pace for the

remaining three months, most of the regions will either be on target or find themselves very

near to meeting the targets set Most regions attribute this success to the efforts of health

extension workers and community volunteers that were active in mass mobilization.

Table 2.3: progress in immunization

Penta 3 Measles Regions



Tigray 80.4% 100% 78.9% 95.4%

Afar 61.7% 79.2% 68% 50.4% 68.6% 54%

Amhara 82.9% 97% 69.5% 72.5% 88.8% 76.4%

Oromia 84.6% 95.1% 31.7% 73.6% 83.8% 76.9%

SNNPR 96.7% 98% 66% 91.3% 96% 52%

Gambella 45.8% 83% 42.3% 84.3%

IMNCI services:

53. There is progress in providing IMNCI services. In Amhara for instance, all “type A” health

centres are providing IMNCI services. In SNNPR, at the regional level, it was reported that all

the existing 161 health centres are implementing IMNCI services as they have under‐five clinics


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with at least one IMNCI trained person. The JRM team however observed that these services

are not provided by all the facilities at as reported at regional level. There are facilities that are

not providing the services. A case in point is the situation in Doworo Zone. In this Zone, there

are 18 Health Centres and out of which only four are fully functional. The remaining 14 HCs

have not been providing the services at all simply because they don’t have the trained health

professionals to do the job.

54. Given the limited number of health facilities and health workers the sector has, not surprisingly

this JRM noted that it is difficult for the sector to reach all children with pneumonia and other

common childhood problems. To scale up these services, it is thus prudent to think of using the

human potential existing at the community level particularly that of the health extension

workers (HEWs). However, the potential benefit as well as cost (including but not limited to

burden to the health extension worker, the need for the additional training, and other costs

required) need to be explored and the design of HSDP IV should be informed by the results of

the current pilot exercises.

Newborn Care

55. In spite of having a very high National Neonatal Mortality rate, 39/1000LB (EDHS‐2005), in

general, there is lack of focus and capacity for Newborn health at the federal and regional

levels. The JRM report was not able to obtain data on the number of children provided with

any of the new borne care and treatment services. Reducing neonatal death, however, requires

following up the progress made in addressing the three major killers of newborn babies:

neonatal infection, birth asphyxia and pre‐maturity and low birth weight.

56. It was found that most of the Regional and Zonal hospitals visited in this JRM mission do not

have any kind of neonatal unit (i.e. a special Unit) to admit separately sick newborns. Existence

of such a unit would allow aseptic techniques are fully applied to prevent hospital acquired

infection‐‐a major problem in managing common newborn problems. Delivery and maternity

rooms of most of the hospitals and health centres lack a separate newborn corner inside the

labour room with thermo‐neutral environment to provide routine immediate newborn care

including neonatal resuscitation immediately after birth that will prevent deaths due to

asphyxia. The case of the referral hospital in Amhara and at Saint Paul National Referral

hospital ,where these services are available, is more of an exception than the norm


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57. Advancing advocacy for newborn health to bring the necessary attention and focus at policy

level and to ultimately enable all health facilities to offer basic health service for this group is

very much required and imperative. Based on the observations made during the JRM, the

following have been recommended as a way forward to improving the newborn health at the

national level:

Introduce and set a separate target for newborn health in the Fourth Health Sector Strategic Plan;

Establish newborn unit in all regional and zonal referral hospitals and make sure that right health workers with appropriate training and skills are assigned and have the necessary supplies to provide essential newborn care;

Establish newborn health corner in all delivery rooms and maternity wards of all health facilities in order to provide essential care including neonatal resuscitation.

Scale up skilled based training of HEWs in clean and safe delivery including training on Essential Newborn Care.

Increase the coverage of home based postnatal care Using the available community based health cadres to primarily identity early newborn problems for prompt treatment and to ultimately improve the outcome of the overall neonatal case management

Harmonize community maternal, neonatal and child health activities by different partners to synergize the ongoing efforts, and reducing duplication of activities.

Nutrition

58. The national Nutrition Program that translates the strategies of National Nutrition Strategy into

program actions for five years (2009‐2013) has (in consultation with partners) been developed ,

approved and launched. The iodization of salt was also launched. While the National Nutrition

Coordination Body (NNC), the highest policy making organ, had its inaugural meeting in

December 2008, the other coordinating organs are yet to be established. This all shows that

nutrition agenda has now moved higher in the ladder of priorities within the government.

59. Through EOS/TSF, seven million children and 1.5 million pregnant and lactating women are

screened for malnutrition every six months and are referred to Targeted Supplementary Food

and Therapeutic Feeding Program. It was, however, reported that there was significant delay

between referrals and actual provision of the TSF. An effort has been initiated to move from

campaign mode of delivering Vitamin A, de‐worming and nutrition screening through EOS to

locally organized Community Health Days (CHD) delivered by the HEWs supported by VCHW.


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Currently, 1,200 therapeutic feeding units (TFU) and Outpatient Treatment Program (OTP) sites

are providing service. 315 Woredas have either inpatient TFP or OTP programs. The national

capacity for management of SAM has increased from nearly nil in 2003 to over 90,000 severely

malnourished patients every month to date. Another area where progress was made is the

implementation of the Community Based Nutrition. Some 560 Woredas are expected

implement preventive community based nutrition activities with support of partners.

60. Nutrition program is being implemented in weak health care delivery systems both in terms of

access and quality of care. For the intended outcomes of the nutrition strategy and program are

to be implemental, there are challenges that all stakeholders should invest on. These include: (i)

re‐retraining the HEW and VCHWs/model households with necessary practical skills in all

aspects of promotion, care and referral related to nutrition; (ii) training supervisors adequately

and supporting them to move around and provide mentoring and coaching to the HEWs; (iii)

strengthening the health centres to provide timely and appropriate treatment to those referred

to them, (iv) building the capacity of the Woreda health Offices to manage and supervise the

programs; (v) provision of fund to support the implementation of the service delivery

components of the NNP; and (vi) supporting and financing the training and deployment of

critical mass of human resources, particularly nutrition practitioners and/or nutrition focal

persons at different levels as per the HR study.

61. The implementation of the nutrition strategy has just begun and some of the indicators are

integrated into the annual planning and monitoring process. As a result, availability of

information on nutrition is expected to improve in the next ARM. However, there is currently a

gap in the availability of nutrition information. In Amhara region, for example, there is no data

on OTP at any levels of the health system. Some hospitals have functioning therapeutic feeding

units. A hospital visited in Amhara region provided therapeutic feeding for 30 children in the

last six months and also had five deaths during this time. In Gambella the TFU was closed during

this JRM because support was discontinued from the donor. (It is worth noting that the support

was discontinued because of the hospital’s failure to provide timely activity report).

2.3 TUBERCULOSIS

62. The national target for tuberculosis for EFY 2001 was to increase detection rate from 33 to 67.8

percent and cure success rate to at least 85 percent. This target was to be achieved through

making drugs available for about 145000 patients, re‐agents, for 820,000 tests; improved


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communication and community mobilization, expanding the PPM‐DOTS providing institutions

from 116 to 300 health facilities.

63. According to information generated from the Medical Service General Directorate, the overall

national TB detection rate remains very low. As observed in the table below, with the exception

of Afar and Gambella, the detection rate from other visited regions remains very low compared

to the targets they set.

Table 2.4: regional detection and success rates during the JRM visits

Regions Detection Rate Success Rate

Tigray 25.4% 84%

Amhara 28% 80%

Oromia 38% 85%

SNNPR 42% 89%

Gambella 50.18% 88%

Afar 53% 93%

64. In general, targets set for success rate does seem to be achieved. For example, the regional

coverage for TB treatment success rate stood as high as

93 % in Afar and 89% in SNNPR. The success observed

improving this rate is mainly to sector’s

focus/commitment to improving TB clinics (improving

the clinical services through training and supervision)

treatment.

65. The major challenge remains increasing TB detection

rate, where the sector is unable to make significant

progress. In SNNPR, where focused research program

put a lot of inputs to increase detection rate,(as is the

case in Dale Woreda) the rate has improved barely to

the required standard, 70 percent only. This experience

in fact questions the validity of the WHO recommended

standard denominator of (168 per 100,000) in the

Ethiopian reality. The TB prevalence survey initiative by

BOX 3: Integration of TB and HIV services a good

practice the case of Fiche Zonal hospital

HIV and TB programs are well linked at hospital level

(Fitche Zonal referral hospital) activities. Those that

are found HIV positive were screened for TB and all

TB patients were tested for HIV in line with the

guideline provided. TB/HIV activities at Fiche

Hospital OPD reveal that a total of 485 patients

were registered and almost all of them were

screened for HIV. Out of the 485, 34 patients were

found to be positive for HIV. TB patients found

positive were referred to chronic care.

Source: Oromia regional JRM report


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the Medical Service General Directorate could provide more contextualised and reasonable

estimator by the end of EFY 2002. This does not, however, fully explain the lack of progress in

increasing detection rates. To this JRM, it is reported that the sector has not fully exploited

potential areas for improving detection rates. Integrating TB detection in all OPDs as part of the

provider initiative testing could have improved the detection rate. The experience of Fiche

zonal hospital in integrating TB and HIV/AIDS need to be expanded to other services and this

best practice be widely implemented in other hospitals (see box 3). In addition, not all health

facilities are providing this the service. Amhara for instance provides the service in: all hospitals,

198 HCs, 321 upgraded HCs and 383 health posts, and 35 private health facilities. It also has the

plan to roll out the service to all facilities in the coming fiscal year. At the same time, the

potential of the community health extension workers as regards to referring those with signs of

the disease to the health facilities have not been utilized. The training and supervision focused

more towards improving improved success rate, and not on detection rates. The General

Directorate is planning to redouble its efforts and prioritize detection rates. It hopes to develop

better strategies for increasing detection rates by learning from best practices of other services

like HIV/AIDS. The lack of capacity and focus at regional level for coordinating programmatic

interventions that will continue to be another challenge Because of capacity constraint, it is

reported that the resources obtained from Global Fund has not been fully absorbed. There are

also other operational constraints that have limited progress in increasing the TB detection

rates. Some of these constraints are discussed below.

Lack of functional laboratories:

66. There is a general lack of functional laboratories in many of the visited health facilities visited.

In some facilities, there were more laboratory technicians than microscopes. In some other

areas, microscopes are broken. In situations where the necessary equipment and human

resources are available, reagents happen to missing and affects detection. Shortage of reagents

has been a constraint in many health facilities visited. The Sedie Adada health centre in

Amhara, for example, does not have reagents to do AFB and is only doing follow up of patients

diagnosed and referred from other centres.

Lack of human resources and skills:

67. Many of the health professionals have been trained on how to make diagnosis of TB both in

adults and children; and a standard guideline is in use for this purpose. In spite of that, lack of

skill on how to do microscopic examination using the AFB staining is apparent in some of the


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laboratory technicians. That calls for the need to strengthen the pre‐service training to improve

quality of laboratory technicians as well as providing in service training for all laboratory

technicians particularly to those who are working at the Health Centre levels.

68. Some of the regional teams learnt from their discussion with the community members that

communities are quite aware of the signs and symptoms of TB. Some are even cognizant of and

what to do in case of TB. Though it is difficult to characterize every community in the same

way and arrive at conclusions that and that they are all aware of what tuberculosis is all about,

it is possible to tell that there is a potential for the HEPs for creating awareness about this

disease at all levels. Creating demand for the service should also be further exploited. There

may be a need to empower Health Extension workers to play active role in bringing the service

closer to the community. It is necessary to train them on detecting signs of TB suspects in the

community.


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3 HEALTH SYSTEMS STRENGTHENING

3.1 IMPLEMENTAITON OF HEALTH CARE DELIVERY CORE PROCESS

69. One of the major preoccupations of the Government of Ethiopia in all sectors, including the

FMOH, this year was the completion and pilot testing of the Business Process Re‐engineering

(BPR). Health care delivery core process was designed and is being pilot tested for the last five

months as part of the overall BPR process. It is reported that these processes were designed to

lend themselves for regional, woreda health offices, and health facilities adaptation. The

healthcare delivery core process is organized under four directorates: Urban, Agrarian, and

Pastoralist Health promotion and disease prevention directorates and Medical Services

directorates. The eight core processes identified have developed Standard Operating

Procedures (SOPs). These SOPs are serving as operation manual for all the case teams in the

FMOH. Case teams, including officers, have signed team charter with the directors regarding

vision, mission, values and responsibilities.

70. Compared to the previously implemented vertical programs, the new process based work is

expected to bring significant reduction in transaction costs and duplication of efforts. The

various vertical programs have developed technical guidelines to be implemented at different

levels of the health systems. For example, while infection prevention guideline was developed

by health service provision department other teams in parallel were also developing their own

guidelines: Tuberculosis infection control guideline; proper waste management etc. The new

approach provides the opportunity to bring all these together in one integrated guideline. In

this regard, the best example worth citing is the development of the standard community level

intervention guideline. The guideline aims at installing a paradigm shift by major stakeholders

of health sector with regard to harmonization of planning, training support supervision and

other relevant activities at the community level. There will not be different strategies and way

of working at the community level by any stakeholders.

71. It is reported that a better enabling environment has been created through the implementation

of the core process as it helps officers to get focused on specific regions. In addition, unlike the


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vertical programs where jobs are highly dependent on highly skilled officers, the current

structure requires generalists.

72. The structures are filled with the existing human resource available at the FMOH, with some

additions. Consequently, deployment of staff in the various directorates fall short of meeting

the numbers and qualification requirements set in the BPR. Though the system requires

generalists to perform all the support functions at the federal level, many of the existing

deployed staff are sanitarians, economists, and sociologists that need to be re‐trained to

become full‐fledged generalist. In consideration of this gap, efforts are being made to recruit 19

Technical Assistants that are expected to be on board in two months time. The FMOH should

strengthen its effort in ensuring continuous training and coaching to improve the knowledge

and skills of the officers.

73. There are some responsibility demarcation issues between health promotion and prevention

and control directorates on one hand and the medical services directorate on the other. Clarity

is, for example, lacking on who is charge of maternal death review/audit and cervical cancer

screening. As a whole, though, unless additional human resources are employed the full scale

implementation may increase workload of existing staff.

74. There are also other important achievements in putting the right policy and regulatory

framework for service delivery and financing. In this regard, 10 hospitals in Addis Ababa have

already started to implement a new hospital standards complemented by the hospital

management whose blueprint was developed two years ago. This is expected to provide

responsive and efficient service for clients. These hospitals reported that an emergency service

unit has been reorganized. In tandem with that, some efforts are underway at the federal level.

Hospital administration regulation has been drafted and submitted to the council of Ministers

for review. A proclamation on health service delivery and management was drafted. On the

basis of comments/suggestions comments from the Council of Ministers, RHBs and other

stakeholders (employers and employees Federations), the draft social health insurance law and

strategy,, has been revised and re‐submitted for the Council for action.


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3.2 ACCELERATED EXPANSION OF PRIMARY HEALTH CARE

75. The overall target for 2001 EFY was to fully construct all the required health posts throughout

the country (achieving 100 % coverage) and constructing 1,391 health centers. In this regard,

from the analysis of the information that the JRM teams collected from the regions, progress

has been made towards achieving these targets but unlikely to be met.

Table 3.1: Progress in Construction of Health Posts

Region Available in 2000

2001 Target

Constructed in nine months

Comment

Tigray

Afar 208 53 33 209 are providing service

Amhara 2664 1189 Data was not available at the regional level

Oromia 2070 2417 1026

SNNPR 2904 649 260 Of all these, only 1200 are reported to be fully equipped and furnished

Progress in construction of Health centers

76. The total number of required HC construction/upgrade was 2,561.Of this, the construction

of/upgrade of 1,392 HCs (54%) was to be financed through the contribution of external funding

expected to be mobilized by FMOH; and that of the 1,169 HCs (46%) to be financed through the

regional allocation as matching health centers. According to the information generated from

the PMU, the construction of 477 HCs (19%) was completed, 1795 (70%) health centers are

under construction. 1,910 health centers (75%), including those under construction, are under

contract. Of all health centers, the financing of the 411 health centers, expected to be covered

through the regional governments, has not been secured yet. The details are presented in Table

3.2.


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Table 3.2: summary of Health centre financing and progress in construction

National Summary

Existing HCs 644 Baseline 2006 (reference Annual Core Plan 2000 - Ethiopian Calendar)

Target Construction:

- By the FMoH 1,392 (500 + 891 HCs)

- By the Regions 1,169 (matching HCs)

Include 2 extra from Tigray(prv:1166)

Total construction 2,561

Total HCs target 3,205

Progress Construction:

Total Number of sites

Regional Fund Allocation Till end 2001

No. of Sites Assessed

No. of Sites Under

Contract

Construction Started

No. of Sites Completed

- By the FMoH 1,392 Na 1,339 1,200 1,121 297

- By the Regions 1,169 758 755 710 674 180

Total progress 2,094 1,910 1,795 477

NA‐ not applicable

77. There is considerable regional variation regarding financing and progress of HC construction.

Though FMOH was expected to finance the construction/upgrade of 55 % of the health centers,

the regional allocation shows that it has pledged to cover only about 43 %. FMOH’s share from

the total regional HC requirement varies among regions but the emerging regions seem to

access more in term of percentage. Of all the total FMOH financed HC, 86 % is either completed

or under constructions. Of the remaining 14 % (197 health centers) whose construction is yet to

be initiated, 82 percent is located in Amhara, Oromia and SNNPR.

Table 3.3: Progress of HC Construction Financed through FMOH

Required HC

Number of HC completed by the end of 2001

Target by FMOH 2001

FMOH constructed

FMOH Share to required HC

% of Completion of FMOH allocation

Remaining HC

Regional Dist of Remaining HC (%)

Tigray 198 65 86 84 43% 98% 2 1%

Afar 96 21 43 43 45% 100% 0 0%

Amhara 820 321 341 285 42% 84% 56 28%

Oromia 1151 403 517 448 45% 87% 69 35%

Somali 190 20 96 65 51% 68% 31 16% Benishangul Gumuz 40 22 15 14 38% 93% 1 1%


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Number of

Required HC

HC % of Regional completed FMOH Share by the end of 2001

Target by FMOH 2001

FMOH constructed

to required HC

Completion Dist of of FMOH Remaining Remaining allocation HC HC (%)

SNNPR 646 234 264 227 41% 86% 37 19%

Gambella 35 11 15 15 43% 100% 0 0%

Harari 9 7 5 5 56% 100% 0 0%

Diredawa 16 14 9 8 56% 89% 1 1%

Addis Ababa 39 0 0 0 0% 0 0%

Total 3240 1118 1391 1194 43% 86% 197 100%

78. Of the total regional financing requirements, 65 % of the health centers’ budget has been

allocated, while the financing of the remaining 411 HCs (35%) is to be sought in 2002 EFY. 90 %

of those that have budgeted for are now either under construction or completed. Of the total

projected regional financed HC, 59 % of health centers are under construction (see Table 3.4).

Tigray, Gambella, Harari and Dire Dawa were able to allocate for all health centers that should

be financed through regional budget. On the other hand, of those 411 health centers whose

funding has not been secured yet, 37% is in Oromia, 22% in Amhara,14% in Somali, 13 % in

SNNPR, 9% in Afar, 2% in Benishangul Gumuz and 1 percent in Gambella regions.

Table 3.4: Progress in Construction of Regional Financed (matching) Health Centers

Region HC Requirement

RHB financed HC

budgeted HC

% of budgeted from RHB Financed Constructed

% of constructed from the budgeted

% of constructed from the total RHB financed

Tigray 198 74 74 100% 42 57% 57%

Afar 96 39 0 0% 0 0%

Amhara 820 288 197 68% 170 86% 59%

Oromia 1151 442 288 65% 288 100% 65%

Somali 190 80 21 26% 7 33% 9%Benishangul Gumuz 40 10 2 20% 2 100% 20%

SNNPR 646 222 167 75% 167 100% 75%

Gambella 35 12 7 58% 7 100% 58%

Harari 9 1 1 100% 0 0% 0%

Dire Dawa 16 1 1 100% 1 100% 100%

Addis Ababa 39 0 0 0

Total 3240 1169 758 65% 684 90% 59%


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79. As can be seen from Table 3:5, there is considerable difference between what is reported from

the Project Management Unit and the information generated at the regional level through this

mission.

Table 3.5: Progress in Construction of Health Centers

Region Available in 2000

2001 target

Constructed in nine months

Few comments

Tigray 43 263 18 Of these 13 have started functioning without being fully equipped

Afar 14 48 Not reported in the JRM

Amhara 211 500/711 170 Another 102 are under construction and more contracts were signed to start construction for another 36. Sites for 2 have been identified while the construction of 190 has not been initiated

Oromia 198 805 113

SNNPR 161 431 54

Gambella 8 27 The targets collected from the RHBs and those set in the III‐Woreda based Annual core plan (EFY 2001) varies in most regions.

80. The construction of health centers has been delayed for many reasons. The construction done

through GTZ has faced shortage of skilled personnel, shortage of qualified contractors, lack of

willingness of contractors to take up sites whose costs are estimated based on cost saving

strategies, and lack of commitment of contractors to complete construction as per agreed

schedule. Similarly, PMU managed health centers have also faced different challenges. The slow

progress of accessing funds for 144 HCs from PEPFAR, inability to get contractors for 53 HCs

situated in remote areas, the escalation of construction prices, and difficulties in getting

construction materials to remote sites are the major reported challenges. Shortage of allocated

budget is the main challenge in the construction of regional financed HCs.


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81. The PMU is reported to have proactively tackled some of these issues. The actions taken

include: provision of follow up support to GTZ and revising the unit prices to reflect market

trends, engaging contractors trained by Ministry of Works, and importing iron bar and cement.

The regional JRM reports made a note of all these challenges. . In some regions, the mission

came to realize that constructions of HCs funded by the Regional Health Bureaus were

progressing well while there were delays and concerns on those funded by the FMoH mainly

related with low performance of GTZ.

82. Within this general performance of accelerated expansion of primary health care, variations

exist on the pace and quality within regions. In Oromia, for instance, compared to its previous

year’s performance, the progress on construction of health posts and health centers was

reported to be encouraging in North Showa Zone Out of the 129 health posts planned to be

constructed in 2001, 76 HPs were completed. An intensive campaign and social mobilization

was used to facilitate the construction of the health posts. On the other hand, in Horo Guduru,

another zone in the same region, 98 health posts were constructed in 2000 but no construction

was completed in 2001. A similar pattern of variation is observable in Amhara. While all the

required health posts were in place in East Gojam, South Gondar has to go a long way in

meeting its target. In health post construction, the commitment of the woreda administration

in allocating the required funds determines the pace of their construction. For instance,

administrative bodies did not prioritize the HC/HP construction at the beginning of HSDP III in

Horo Guduru and when they gave it priority this year, they were not able to attract contractors.

83. While construction and upgrading of health facilities are important in improving access to

primary health service, making them fully functional is also equally important to reach the

MDGs. While the information collected on the status of equipment and furniture is scanty,

there are cases where heath facilities have started functioning without being fully equipped

(e.g. Oromia and Tigray). In this regard, the Federal MoH, Regional Health Bureaus, Zonal and

Woreda health offices share responsibilities of furnishing and equipping the health facilities.

Though almost all health posts constructed in many regions have started to provide service

through the deployment of HEWs, they are not functioning to their full capacity. Most of these

facilities are not yet furnished due to shortage of woreda health budget. Furthermore, the

majority of the HPs are not yet equipped with HP Kits.


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84. The health sector should continue lobbying for greater political leadership and commitment at

woreda level to allocate sufficient

budget to furnish constructed health

posts by using the evidence based

planning process that are taking roots

in the health sector. FMOH should

strengthen its follow up on PFSA to fast

track of the procurement of equipment

of HP and health centers. The role and

responsibility of the zonal health office

in following up construction of HC has

to be clearly defined and their

supervision capacity should be

strengthened to ensure maintenance of

quality and accelerate the speed of the

constructions. There is a need to

synchronize health facilities

construction with equipping and

staffing as per the national standard.

Concerted efforts are required between

the government and development

partners to speed up procurement and

distribution of such essential medical

equipments.

3.3 LOGISTICS AND

PHARMACEUTICAL SUPPLIES

Box 4: Formulary and ABC analysis in Alert Hospital: a good example:

T As per the strategic intervention proposed by the hospital management

blueprint, the Hospital has developed its own medicine formulary. The

formulary provides information on aims and on the needs of the hospital

in relation to pharmacy, laboratory and other services. This is helping to

influence prescribing and dispensing behavior, to align donation to the

hospital requirement and to streamline its own procurement process.

In addition, the hospital undertook and ABC analysis for the EFY 1999,

2000 and 2001 (half year) that follows the Pareto principles of ‘separating

the vital few from the trivial many’. This analysis helped the hospital to

link its medicine with its budget utilization. This ABC analysis is a joint

effort between the pharmacy and finance sections of the hospital. If

properly used for management decision making at the hospital, this

would have an efficiency gain impact. The hospital is also planning to

complement the ABC analysis with VEN (vital, essential and necessary)

analysis.

Category Percentage of budget

Percentage of drug

Some notes

A 70‐80 10‐20 High percentage of funds spent on high volume or high cost items, greatest potential for savings and to identify expensive but over utilized medicines

B 15‐20 10‐20 Moderate cost, moderate number of items

C 5‐10 60‐80 Small amount of funds spent, majority of the inventory

85. The major plan for this financial were

the reorganization of the PFSA through the establishment of its board, developing the working

arrangements between the Agency and regions, strengthening the capacity of the agency

through deploying the necessary human resources, mapping of the necessary warehouses to be

built, and strengthening its transport capacity. Furthermore, development of the essential drug

and medical supplies list and quantification and forecasting tools, conducting study on LMIS

(logistics management information system) were also planned.


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86. The major achievement in this regard was the institutional transformation of the profit making

PHARMID into service providing PFSA. The establishment and strengthening of PFSA as well as

the implementation of the logistics master plan seems on track because of two factors. The

business process re‐engineering fast tracked the implementation of the master plan. In addition

to the focused and committed leadership of the agency, the proactive support by the CS0MS,

PEPFAR financed project, have both technically and financially contributed to filling some of the

major gaps that would have affected the services provided by the agency this year. The

following are the major achievements recorded.

Procurement of health commodities

87. The Agency planned to procure health commodities worth of 550 million ETB of essential health

commodities using the revolving drug fund. And it was able to fully implement its plans. 630 20

ft container of pharmaceuticals arrived in the country through Revolving Drug Fund. In addition,

the Agency procured 300 million ETB worth of program commodities. The procurement of 300

health centre equipment has been carried out through international competitive bidding and

consignment of goods is expected in the next two to three months. With the same

specification and origin of supply, PFSA procurement is reported to be more cost effective than

the previous arrangement with UNICEF. The procurement and distribution of health center and

health post kits was found to be delayed as compared to the procurement plan. The health post

kits delivered in Adama (300 20 ft containers) are being repackaged into kits. These kits are

going to be directly delivered to health posts. The mission would like to suggest that PFSA

considers evaluating its experience of local packaging vis‐à‐vis procurement of pre‐packaged

items and take actions as per the findings of their review.

88. There are lessons leant in this process. It is reported that procurement of health commodities

used to take 369 days. The business process re‐engineering set a standard target of procuring

such items within 120 days. Encouragingly, PFSA reported to have procured Anti‐TB and

HIV/AIDS testing kits within 90 days under normal government procedures. This demonstrates

that efficiency in procurement can be gained assuming that sufficient care has been taken on

transparency and accountability.

89. Another major contributing factor for improved supply of the health commodities is the

capitalization of PFSA. PFSA inherited an institution with 23 million ETB negative cash balance.

With the support of GAVI, GFTAM and PBS, it was able to mobilize $21.5 million for RDF. This


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contributed to its ability to procure the aforementioned amount of essential health

commodities. The existing capital is expected to be raised by another $10 million with the

support of PBS phase II. Though improving over the year, the low RDF capital (given the WHO

recommended $2/capita requirement=$150 million for Ethiopia) will remain one of the major

challenges for the agency to provide adequate and demand responsive health commodities in

the country.

Procurement forecasting and projection

90. In theory, PFSA would like to institute demand driven supply system where health facilities and

programs do quantify and obtain as per their requirements. In the current EFY, the

procurement of essential health commodities has been made through central projection and

this will continue for procurement of EFY 2002 as the capacity of the health facilities to properly

quantify their needs is yet to be developed.

91. In order to address this issue, it is reported that the guidelines for quantification has been

drafted. Training for drug therapeutic committee was initiated and will be scaled up. The plan is

to link, as much as possible, PFSA’s EFY 2003 procurement of health commodities with this

bottom up projections. The agency is aware that the demand may outrun its capacity to

procure (its RDF capital).

92. PFSA also procures program commodities through program funding (not RDF funding). These

include vaccine, family planning commodities, etc. The demand for these commodities is

projected by programs at the headquarter levels. The frequent stock‐out of these commodities

is partially caused by this supply‐driven system procurement system. The delay in the

implementation of the LMIS continues to contribute to delayed procurement and distribution

of health commodities. Two information specialists have been recruited to spearhead the

implementation of LMIS. When such system is not in place, shortages of medicines and medical

supplies occur. The JRM would like to recommend (i) strengthen the capacity of the programs

to forecast commodity requirements and (ii) to institute demand driven supply system for

program commodity procurement by learning from the essential health commodity supply; and

(iii) fast‐track the implementation of the LMIS (see below)

93. In addition to the procurement and distribution of commodities, it is recognized that PFSA

should also have a role to play in promoting and strengthening the capacity of the health


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facilities in the area of rational drug use. Originally, the PFSA proclamation does not provide

such provisions. The proclamation has thus been revised and will soon be submitted to

government to allow PFSA play such important functions.

Warehousing

94. In EFY 2001, PFSA has managed to put up a cold room that has increased the national capacity

by fivefold. It has identified 18 sites for constructing warehouses in different regions. These

sites are at last secured, designs are completed, and resource has been mobilized to start the

construction. It was reported that $5.3 million from PEPFAR, $4.7 from GAVI and $1.6 million

from GFTAM is available to start the construction of these warehouses. There is a significant

delay in implementing the construction of these ware houses, with significant implications on

the rental costs. There is a need to fast track the construction of these warehouses and

liquidating funds that are earmarked for this purpose. In the mean time, to ease PFSA’s

functions, SCMS has rented warehouses in different area with a monthly cost of ETB 160,000

Mobilizing adequate resources to construct the warehouses is, however, the challenge that

remains.

Distribution

95. PFSA delivers health commodities to health facilities. The Agency has 92 tracks used for

distributing these commodities and is on process of acquiring 28 more, of which 8 of them have

reached Djibouti. PFSA is well aware that this capacity is not adequate for on time delivery to all

health facilities. It therefore uses commercial tracks. To ensure that distribution is carried out

efficiently, it has deployed the necessary human resources both through PFSA and SCMS.

Capacity strengthening

96. PFSA is in the process of strengthening its organizational capacity. To that end, the following

are some of the activities include recruiting procurement officers and medical engineers to

strengthen the equipment procurement capacity; recruitment of druggists to ensure that each

store has two druggists; employment of three seconded technical assistants (2 from SCMS and

one from UNFPA) to support the process and commissioning a study to establish LMIS that aims

at linking health facilities to regional hubs and then to PFSA HQs has been completed. PFSA is

also in the process of obtaining support for Software selection. It has managed to negotiate and

influence PPA during the revision of the procurement law to ensure that the law addresses the

specific nature of health commodity procurement.


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3.4 PLANNING AND MONITORING

Planning

97. There has indeed been progress in deepening the planning process and in improving its quality

over the last three years. In this year, all the 801 woreda were trained on the development of

the WBP (woreda based plan). New standardized tools for baseline assessment and evidence

generation was developed and used. Furthermore, the JRM, both at the federal and regional

levels, has documented the following positive

developments seen this year (see also box 5):

The ownership of the plan is increasingly

strengthened at lower levels, particularly

from regional levels down to woreda

levels. It is reported that the Woreda

based planning process is being

considered as best example for the public

sector both at the federal and regional

levels.

There is relatively better collaboration

between the finance and health offices at

the woreda level in planning and

budgeting.

98. On the other hand, in spite of these gains, there

are issues that the JRM has identified that needs

to be considered to inform strategies on

deepening ownership, participation of

stakeholders and improving the feasibility of

targets further.

99. First, one of the pre‐requisites required for

fostering ownership of plan development is the

involvement of stakeholders at all levels. While there are encouraging progress in getting more

participation at regional and woreda levels, the participation of the health facilities, NGOs, at

the Woreda level in the development of Woreda targets is very limited. The involvement of

Box 5: New Dimensions of EFY 2002 Annual Plan

The planning process is evolving and maturing over time.

The annuals plans developed in the past did not

incorporate the functions and interventions at the hospital

levels. Furthermore, they focused more on setting the

targets for service delivery and articulating the resource

gaps without sufficiently linking these to action. EFY 2002

corrected these weaknesses through:

Development of hospital plans as part of the

woreda planning process.

Ensuring the inclusion of activity plans in the

annual plan at all levels to help set mechanisms

for follow up on actions are made rather than

only numbers (targets and baselines)

This may also help assist the development partners that

require activity based planning for their funding to align

and reduce the transaction cost of developing vertical

plans. In this regard, it is necessary to agree on the details

of the operational planning format for the coming EFY plan

to do away with the need for operational plan for

agencies.


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program and process owners at regional level and development partners in providing the

required resource envelop seems inadequate. For instance, in the two Woredas visited in

Tigray, only the woreda finance office participated in the development of the EFY 2002 plan and

all health facilities were not involved. All health facilities visited by the JRM did not have their

own plans for 2001. This will certainly affect the realization of the targets set as it might not be

based on the actual facility realities. At the end of the day, it is the facilities that will deliver the

targets. To a great extent, their success or failure is thus determined their involvement in the

planning process. And it is the responsibility of the Woredas to ensure health facilities are

involved in the planning process. This could be further improved if the planning process also

requires and demands that the woreda planning process to be based and linked with facility

own plans.

100. Second, while the woreda based national planning is expected to synchronize top‐down

and bottom‐up planning of the sector, because of the limited involvement of the health

facilities as well as the limited capacity of the Woreda health offices to negotiate and develop

evidence based plan, sometimes the top‐down targeting from regions to woredas and from

woredas to facilities appears to dominate. While this is generally the case across the board,

Enebse Sar Midit Woreda in Amhara for instance reported that it was provided with the

projected targets from the region without any consultation. The JRM was informed that the

annual targets in most cases were provided from the higher level and accepted by the lower

level assuming that all the necessary inputs will be in place along with the expected

performance improvement through the BPR. Consequently, n most cases, the annual targets

were too ambitious and not unsurprisingly, many of them were not met. This was further

exacerbated by the low capacity at woreda and HEW level to relate the targets with the existing

situation at grassroots level. In addition, woreda baseline information was not fully collected to

serve as a basis for 2001 annual planning as required by the process. In connection with this,

the process of capacity building is an area that needs to be looked into. It is reported that few

mentors assigned do play a gap filling role in developing the plan (developing it themselves)

rather than assisting woredas develop their capacities through learning by doing.

101. Another concern reported to the JRM team is that the process of planning is too long

with high transaction. Staffs are taken away from their routine activities for more than a month.

As the capacity of planning is getting improved, naturally, the time it takes to produce an

annual plan may reduce. It is also necessary to communicate planning development schedule


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early enough to all levels in advance and to caution all planning units to own and stick to this

schedule. To ensure the curtailing of other parallel planning processes, this process should also

be supported through more alignment and harmonization of other plans(see below)

102. In EFY 2001, there was a delay in

finalizing and officially communicating the

annual targets to the lower levels nationally.

The agreement on the national core plan was

signed by regions and zones and woreda

during the 2nd quarter (after 4month) of

2001. Keeping this long delay in mind, the

Oromia region took its own measure and

communicated a revised plan to the zones

and Woredas to facilitate timely

implementation of the plan. This created

discrepancy of targets for similar activities of

EFY 2001 at national, regional, zonal and woreda level as compared to the published national

core plan. Such a discrepancy calls for a need for Planning, Policy and Finance directorate to

share the final plans to all the regions even before they are signed off in the Annual Review

Meeting.

Monitoring and support supervision

Box 6: Best practice in supportive supervision: East

Gojam

In East Gojam, the zone and woreda visited have

very good supervision and monitoring systems.

The woreda monitor health centers on a monthly

basis, and the zone monitors Woredas on a

quarterly basis. Both the woreda and zone

provide written and oral feedbacks. This may have

contributed to its selection as one of best

performing zones.

52. Within the Amhara region, there is a significant difference on providing supportive supervision.

While east Gojam is doing very well in this regard (see box 6), in contrast, in South Gondar the

support and monitoring system is very weak. The woreda does not conduct any monitoring

because it has only 2 technical staff in place. Though the zone planned to do monitoring on

quarterly basis, during the last 9 months period it only managed to conduct one monitoring

visit. In witness to that, Sedie Adada, a health center visited in the woreda in question,

reported that it has never been supervised. Nor has the zone ever received a formal monitoring

visit by the region. That in fact contradicts with the interviewees at the Region stated. Their

plan is to conduct supervision visits biannually and hold review meetings (biannual, for zones

and Woredas; quarterly, for hospitals and training facilities).


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103. In Gambella, the RHB, all the Woredas and some health facilities have participated in

the 2000 and 2001 woreda planning activities. However, because of shortage of budget, the

RHB was not able to fully monitor the progress of the planned activities. Similarly, the woreda

health offices have rarely supervised and monitored the health centers and health posts in their

catchment areas.

3.5. HUMAN RESOURCES

104. The HSDP III has aimed at training and providing relevant and qualified health workers

with appropriate staff mix. Keeping that in mind this review has focused on assessing the

existence of adequate number and right mix of skilled human resources at Regional, zonal,

woreda and health facility levels and the strategic interventions to address the challenges of

HRH at federal levels.

105. Development of HRH Strategy: The HRH strategy that was developed some time ago was

submitted for the top management of the FMOH for their review and approval. The strategy

was developed with the support of Tulane University. Although the strategy has not been

endorsed for implementation, some of its core activities that have been initiated, including the

following.

106. Accelerated training of health officers: the FMOH has planned to train 5000 health

officers. According to the HRD department, all the 5000 HO are on training and so far about

2289 HO have graduated (see box 7).

Initiation of training on Emergency Obstetric Care

107. Training of Health officers on emergency obstetric care was initiated in Makelle, Jima

and Hawasa Universities. Gondar and Horomaya universities are also assessing their capacities

to initiate this training. So far, 53 HOs have been enrolled for two years masters’ program. This

was one of the recommendations of the MTR which has now been started to be addressed.

Scaling up of HEW training from level 3 to level 4


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108. The weakness on the training of HEW particularly in relation to maternal health has

been an issue for some time, including the MTR. An initiative is on going to address this gap

through a distance learning (with Open University) and regular training to upgrade health

workers training into diploma levels. Consultation was initiated and advocacy is on going to get

the training started.

Scaling up of midwifery training

109. Consultation has been initiated to scale

up midwifery training and enroll 300 students

per year. Concept paper was prepared and

consultation on how to get the necessary

preparatory works is underway.

Training of HMIS officers

Box 7: The findings of the review of Accelerated Health

Officers training

The Accelerated Health Officers Training is

progressing on schedule. Of the total 5,000

required, 1,274 post basic and 1,244 generic HOs

have graduated todate and there are 2,925

students on training . Overcordwding of students

in schools is one of the challenges reported. The

evaluation of the training program has started.

Non university hospitals are found to be better

training places.

Most of the graduates returned to their regions

and and have been assigned in health centres,

Woreda health offices and hospitals, thiersalary

has doubled as compared before their entry to

the training. Their performaace is apprciated by

the health bureasus.

Source:Processing of 13th AHTOP management

body meeting,27th June 2009

110. The health management information

has been supported with human resource that

has not been trained for this purpose. This gap

has been identified and a plan is in motion to

start training of two years for this cadre of HR.

Human Resource Information System

111. The software for human resource

information systems has been developed. All

the relevant information at the federal level

has been collected and entered. Preparation is

underway to scale this initiative to four hospital

and institutions that are accountable to the

FMOH. The profile of all the health workers is

being collected. This will help establish the

human resource data base. The HRIS Regional

scaling up is planned for EFY 2002.

Retention strategies


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112. Aggressive communication campaign was initiated this financial year to develop a

shared vision on the need to serve for some period before requesting release between the

medical faculty graduates and FMOH. According to the HRD department, the deployment of the

2000 graduates of Addis Ababa, Jima and Gondar Universities was relatively smooth because of

the better attitude created among the new graduates. Some have even preferred to be

deployed in emerging regions. Furthermore, some token incentives (laptops) were provided to

GPs going to emerging regions. The consultation between the top management of FMOH,

medical school teachers and the graduated was reported to have positive effect on retention.

Capacity constraint at the Directorate

113. The directorate is newly established and has now taken leadership on the development

and implementation of plans and strategies related to the human resource for health. It used to

be preoccupied with routine human resource management issues rather than focusing on

strategic issues. The development of such strategic capacity takes time and investment. There is

a clear need at present to support the directorate with three technical assistants: human

resource development, human resource management and human resource information system.

These technical assistances will serve as anchor for the three critical areas of human resource

for health.

Human resource issues at the regional levels

Deployment:

114. In this fiscal year, a total of 112 General practitioners and 2,486 other health

professionals have been deployed in the different regions. In comparison with that of previous

year within North Showa zone, the staffing level has increased at all levels in the EFY 2001. This

is particularly witnessed in the front‐line and mid‐level health workers like HEWs, nurses, lab‐

technicians and environmental health workers. The mission noted that the planned assignment

of HEP supervisors within zonal and Woreda offices took place. The mission also learnt that the

number of staff to be assigned in health facilities and health offices in accordance with the BPR

is much higher the one deployed presently. For example, the woreda health office visited has

only 16 per cent of its BPR staffing requirements.

115. Availability of budget is limiting the RHBs to employ more health workers: In Gambella,

adequate numbers of health professional do apply for various posts. However, the RHB does


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not have adequate budget to employ and address its human resource gap. Junior nurses and

midwives that are unable to progress in their careers because of shortage of budget are

reported to have been forced to leave the region. Skill upgrading training is often carried out

outside the region and it requires paying a tuition fee of ETB 8,000 per trainee which the RHB

was not able to fund. On the other hand, lack of interest to be deployed in the region was

found to be the limiting factor when it comes to employing General practitioners.

3.6 ROLL OUT OF THE HMIS SYSTEM

116. The roll out of HMIS is one of the top priorities of the health sector. The following are

the major targets set for the sector for EFY

2001:

Training of 200 master mentors

Printing of all the necessary tools and

forms

Establishing electronic files in 300

Woredas of all regions

Implementing electronic medical

files in 20 hospitals, 100 health

centers

Implementing HMIS regulation

Initiate the training of health

information officers at diploma level

Deployment of the necessary human

resources of HMIS by regions

117. Progress in meeting the targets set

has been found to be mixed. According to

the information generated at the federal

level, the training of master mentors were

carried out, the necessary tools and forms

were printed. In terms of scaling up, it is

reported that implementation of the new

HMIS was rolled out to all federal and regional hospitals. Activities designed to scale the new

Box 8: Misunderstanding and miscommunication with

tertiary hospitals: a need for correction

The two tertiary hospitals visited (Saint Paul and ALERT) do have

reservation on the relevance and completeness of the HMIS

forms that have been rolled out in their hospital for the last three

months. They seem to understand that all the clinical information

required for own decision making should be included in these

forms, but find it lacking. The quality of the HMIS forms

distributed for use is reported to be generally poor. AELRT spent

more than ETB 15,000 per quarter to buy a glue to make the

form stick to each other. They feel that there was no adequate

consultation with tertiary hospitals during design and enough

openness to listen to their complaints during implementation

and either correct or properly explain. There has never been a

review of implementation of this scale up with the management

of these hospitals.

That calls for he need to properly communicate the difference

between health sector management information and clinical

information is very critical. It is also necessary to sit with the

tertiary hospitals and review their concerns and agree on the way

forward. This will ensure ownership by the health workers at the

hospital level to support the implementation of the HMIS scaling‐


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HMIS to Woreda Health Offices and health centers were initiated. It is reported that extensive

sensitization and orientation for consensus building, micro‐planning (implementation plan) for

all regions except SNNPR were carried out. Furthermore, hiring of master mentors for training,

consistent supervision and mentorship, and training conducted and completed in 5, ongoing in

3 Regions. Overall, though, there is a delay in the scaling up process. The main reason for such a

delay was inability of the regions to recruit focal persons for health information at facility and

management levels (woreda and regional levels). It is noted though that the delay has also

contributed to the more ownership of the systems as it is made part of the BPR process.

Table 3.7: status of training for HMIS scaling up as of Feb 2009

Implementation Region Number

Trained Hospital H. Center

Harari 470 ALL ALL

Dire Dawa 362 ALL ALL

Gambella 270 ALL ALL

Benishangul ‐ Gumuz 895 ALL ALL

Afar 252 ALL ALL

FMOH Hospitals 1,169 ALL

Somali 342 Partial Ongoing

Tigray (Ongoing) 970 Ongoing Ongoing

Addis Ababa RHB Ongoing Ongoing Ongoing

Oromia Ongoing Ongoing Ongoing

Amhara Ongoing Ongoing Ongoing

SNNP Ongoing Ongoing Ongoing

118. The review mission in its field visits documented that:

In Amhara, though the target was to train 16 all hospitals on HMIS, including Debre

Makros only 3 hospitals and 6 health centers benefited from the proposed training.

However, information officers are employed or assigned in all 16 hospitals. In East

Gojam, the hospital, health center and health post visited are all an HMIS pilots and as a

result all have been trained and are implementing HMIS. In South Gondar, HMIS has not


Page 49 of 73

been rolled out; at zonal level, four individuals have been trained but none of the

facilities there has started implementing HMIS.

In Gambella, the visited health centers are using the new HMIS system. The region is

reported to have implemented a full scale up. The JRM team was not, however, able to

get the nine months performance report because of the many challenges the region has

faced including: the departure of the three mentors seconded by Tulane University

from the region; the unfamiliarity of existing staff (at the regional planning and

programming department) with the new HMIS, and shortage of reporting formats at

the health facilities visited.

In Afar, the new HMIS was piloted in two health centers and one hospital. Even though

Training was given to all health center and hospital staff to initiate the new HMIS in all

facilities, implementation is still lagging behind. At the same time, the training for health

post staff was canceled because of lack of preparation on the part of mentors. It is

reported that piloting created confusion in process of compiling data. Some of the

visited health facilities trained personnel but the system could not be functional in all of

them.

In SNNPR, HMIS rollout has been delayed because of delayed FMOH distribution of

tools, guidelines and training manuals. Consequently, the new system is not being

introduced at Woreda or facility levels.

In Oromia, health facilities visited both in North Showa and Horo Guduru zones have not

started the new HMIS scaling up. Hence, there are no trained HMIS personnel at all

levels.

In Tigray, the health facilities visited, including the hospitals, have initiated the new

HMIS scaling up.

119. In the visited institutions, the mission found mixed results regarding use of information,

reporting gaps and inconstancies. The use of information is quite limited in most of the

Woredas and health facilities visited. Incomplete or misreported data has made the task of

assessment of progress difficult in the zones and at the regional level. Key indicators (e.g.,

reporting of absolute numbers instead of rates) were sometimes misunderstood. In some

cases, there are instances where the visited health facilities have not reported monthly or

quarterly information (e.g., Awash Araba health centre in Afar). Gaps on properly registering

and reporting performances are also observed. In Oromia, for example, though data were

available at different service units, they were not properly entered into a central database or


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properly compiled and analyzed within the health facilities. As a whole, the JRM has come to a

conclusion that data utilization for performance review and management decisions is not

progressing as expected.

120. There is a consensus both at the federal and regional levels that the scaling up effort is

not being implemented as per the plan. The main challenges faced in the scaling up effort

include problems encountered by the regional levels in hiring health information technicians,

resource constraint, particularly for printing the necessary forms and registers, and renovation

of rooms required for the HMIS. This is further compounded by the lack of concerted effort to

bring all stakeholders to have consensus on the implementation process and challenges in the

scaling up effort and in mobilizing additional funding (see box 9). There is a need to review and

re‐strategize the implementation of the scaling up process with all stakeholders. This process

can be fast tracked through the re‐vitalization of the national advisory committee. It is reported

that Oromia and Amhara have secured government funding to employ information officers for

2002 EFY and this will make it easier to scale up HMIS in these regions in the coming year.

3.7 SOME NOTES ON THE VALIDATION OF INFORMATION FLOW

121. In Horo Guduru Zone, the zonal level reported remarkable achievements in

immunization with immunization coverage exceeding 100%, for both penta 3 and measles.

Strangely, the woreda health office report shows that they achieved only 66.5% for penta 3 and

56% for measles. The health post data showed 43% and 36% coverage for penta 3 and measles

respectively. It is very hard how the zonal coverage could reach more than 100% when the

sources for the zonal data show a much lower coverage.


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4 PROGRESS IN HARMONIZATION AND ALIGNMENT

122. EFY 2001 registered remarkable progress in terms of putting the right frameworks and

agreements implement alignment and harmonization agenda one step forward. Based on the

HHM and code of conduct developed and agreed early in the implementation of HSDP III, the

IHP road map was finalized and its Compact signed at the beginning of the year. One of the

issues mentioned as a constraint on using the government systems for planning, monitoring,

financial management and procurement systems by many development partners was the lack

of consensus on the their reliability and credibility. The government and development partners

recruited independent international consultants to appraise the MDG performance fund to

review whether these systems can be used to pool resources to reduce transaction costs. As a

whole, the appraisal team found that the government systems are adequate to be used for

pooling resources but recommended an inclusion of a few actions that would strengthen some

of the weaknesses identified. Based on the finding of the appraisal team, a joint financing

agreement was prepared, agreed and signed by 7 development partners. At the initial phase,

development partners have pledged to finance about one billion ETB. Of seven development

partners, 4 of them have already transferred resources to this account (see Table 4.1).

Table 4.1: MDG Performance fund Signatories and their Disbursements

JFA signatory Development Partner

Amount of money transferred

1 DFID 3,000,000 pounds

2 Spanish cooperation 5,000,000 euro

3 WHO 600,000 dollars

4 UNICEF Have not disbursed

5 World Bank Have not disbursed

6 Italian cooperation Have not disbursed

7 UNFPA 1,000,000 dollars

123. This is one big step forward in the coordination of Ethiopian health sector financing.

However, the commitment of these seven development partners is a beginning of the long

process that requires more work and building mutual trust and understanding between the

government and development partners. The total pledged resource to the MDG PF is about 1

billion ETB. When it compared with the targets set both in HSDP III and IHP compact as well as

the amount of resources being transferred using other channels, the fund that has already been


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secured is still insignificant. The process of resource allocation and programming and

implementation using the MDG PF (with the exception of GAVI resources) has not yet been

initiated and it is currently at the cross road. If the planning and management of the resources

show visible impact on the targeted services, it is likely that more development partners could

become more comfortable to join and channel more resources using this system. On the other

hand, if the pool management system is not working as planned, it might frustrate further

alignment and harmonization efforts. In this regard, The JCCC should play a proactive role in

getting the management of MDG PF work. That could facilitate implementing the JFA action

plans. The extent to which this action plan has been implemented is presented in table 4.2.

Results on transparent, efficient and effective management of the MDG fund could be used

bases to advocate for integration of the other two pooled fund (HPF, MTDF) to be fully

integrated into the MDG PF. If this is not achieved some time in the near future, the transaction

cost of administering three pooled funds will be enormous.

Table 4.2: Progress in Implementation of the JFA Action Plans

Systems Actions Responsibility Timing Status of achievements

Add staff members to PPD to meet additional requirements for sector

planning and coordination (2 staff in PPD, 2 accountants in finance and

supply dept, 3 internal auditors)

FMoH Human

Resource

Management Dept

March 2009 The BPR has ensured assignment of personnel.

PPD and finance are strengthened with more

personnel. TORs are ready to recruit an

accountant for the MDG fund.

Complete review of the streamlining coordinating bodies for the health

sector

PPD, in consultation

with DPs

June 2009 No information

Start revitalizing the governance structures for HSDP No information

Institutional and

Governance

Conduct the Joint Review Mission as Independent Monitoring

Mechanism as envisaged by the IHP compact and agree on the

timeframe

PPD Dec 2009 This report is part of this joint review mission

Carry out an assessment of the current inventory control procedures for

medical supplies held at facilities and make recommendations for

strengthening

Implement recommendations to strengthen inventory control

procedures at medical facilities

Ensure that internal audit plan provides sufficient time to audit

inventory control at health facilities

Dec 2009 A TOR was developed; and a steering committee

and technical working group have already been

established to oversee and support this activity

Financial

Management and

Audit

Complete a survey of the asset management systems and controls

operating in FMOH and PFSA. Propose manual solutions to resolve

immediate and urgent key control weaknesses. Make

recommendations regarding computer based solutions for the longer

term

Dec 2009 The health commodity tracking survey is

underway.

Update PFSA Proclamation to make explicit the financial management

processes and reporting requirements to be adopted by PFSA

FMoH End of 2001 EFY Update for the proclamation is complete and will

soon presented to government for further action

Develop integrated IBEX reporting in standard formats for all donors

and government requirement

FMoH, MoFED,

Donors

Nov 2008 No information

Appoint the Federal Auditor General as the external auditor for the

MDG fund

FMoH Nov 2008 Federal Auditor General is requested to

undertake the audit of the last two years

Commission the external audit of the exiting MDG Fund (GAVI

contribution) and share the report

FMoH & OFAG ? The auditor will be appointed once the two years

expenditure is collected. Expected to be

operational in July 2009


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Systems Actions Responsibility Timing Status of achievements

Establish links with PPA and reach agreement on annual procurement

audit arrangements for the MDG performance fund by PPA

PFSA End of 2008 No information

Agree TOR and then contract expertise for the Supply chain

management expert and the procurement planning expert

PFSA March 2009 TOR has been developed and the consultants will

be recruited through PBS funding

Procurement

Finalize PFSA manual (including procurement thresholds) PFSA March 2009 It is prepared as part of the various manuals

Organize joint annual planning meetings between DPs and FMOH

Departments (including PFSA) at the core planning stage and prior to

finalizing the national annual plan.

PPD July 2009 On progress

DPs to notify annual financial commitments to the JCM to facilitate

annual planning and resource mapping.

DPs & CJSC Dec Only five DPs notified through the resource

mapping exercise amounting.

Lobbying/outreach strategy developed for attracting more DPs to MDG

fund through strengthening planning processes

PPD and DPs 2009 New dimensions are included in the planning

process to assist this process

Finalize the performance based contracting guideline in consultation

with DPs.

PPD and DPs 2009 No information

Link the annual plan (including the procurement plan) with the

budgeting in the second business plan meeting.

PPD 2009 On process. The first business meeting were

carried out and preparation is underway for the

second business meeting.

Planning and

Reporting

Integrate the procurement plan and the TA in the overall national

annual plan.

PPD 2009 On process

Build the capacity of existing PPD staff on Planning and Program

coordination (e.g. provide short term trainings, exposure visit etc).

PPD 2009 On job correspondence training will soon

initiated for few of PPD staff

Undertake TA need assessment of PPD and strengthen PPD capacity

through coordinated TA.

PPD 2009 The TA needs of the FMOH for EFY 2002 is being

worked on, including PPFR directorate

Finalize the TA guideline in consultation with DPs. PPD and DPs On process

Revitalize the National advisory committee for HMIS and continue to

meet regularly to follow the role out of the new HMIS strategy.

PPD 2009 On process

Conduct two studies of impact of HSDP on social inclusion and equity

(including the monitoring of the impact of the health extension

program and health care financing strategy on equity)

PPD Regular Included in the EFY 2002 plan

Surveys undertaken to understand the Gender desegregation of health

service utilisation, morbidity and mortality

PPD Regular Some information could be generated from the

household expenditure and utilization survey that

is being carried out at part of the NHA 4.

Launch and progressive implementation of a comprehensive Human

Resources strategy

The draft strategy is submitted to the top

management and review and further actions

Human Resource

Review of DP initiatives supporting HR efforts to identify any

duplications or gaps.

PPD and DPs Recently joint meeting held among many DPs

supporting HR to communicate among each other

about their support


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124. In the IHP compact, development partners

committed to: increasing external aid to the

sector, reducing transaction costs by using one

plan and one monitoring framework, and

providing predictable development assistance. As

part of collecting the desired data for this joint

review mission, a questionnaire was circulated to

all development partners to report on their

progress in alignment and harmonization. 9 DPs

filled in and submitted the questionnaire for

analysis. Using the baseline collected as part of the

MDG appraisal mission for 2000, in what follows,

status of progress in planning, budgeting,

monitoring and in increasing resources is presented.

Progress in using one plan

125. In EFY 2000, all DPs integrate their support with the government strategies and

priorities (100%). Of the support integrated with the government plan, about 44 % of their

support was on plan. 70% of DPs requires a separate planning document to provide their

support in addition to the government led Woreda based planning process. While only 17 % of

DPs are involved in the Woreda based planning process, about 92 % have been participating in

the development of HSDP III. It seems that they are involved more in strategic documents

(easier to align to) than to operational plans (difficult for they require reorientation of donor

rograms and projects). p

126. Noting the difference between the numbers of DPs responded to the baseline and the

progress this year (12, for 2000; 9 for 2001), the missing DPs response could significantly affect

the results in any direction. It seems that there was improvement regarding involvement in the

annual planning process (78%) and less DPs (56%) are requesting separate planning document.

Table 4.3: progress in alignment to planning

INDICATOR Overall DPs’ response In %

Box 9: Italian and Spanish cooperation

These development partners, unlike others are not

used to aligning to government procedures.

Through the efforts of the in‐country efforts to

influence their headquarters, they managed to join

the MDG pooled fund. Spanish development

cooperation is one the first to disburse funding to this

account. Their good example is expected to inspire

other development partners to follow suit.


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Yes no no clear cut answers

ONE PLAN

The DP plan is integrated with Government plan at national and sub national levels

9 0 0 100%

The DP is NOT requesting the Government for separate planning documents

5 4 0 56%

The DP is participating in the annual planning process

7 2 0 78%

The DP is participating in the development / review of HSDP

7 2 0 78%

According to the DP, main health sector development strategies, HMIS and HRD, finalized and implemented according to plans.

2 4 3 22%

127. DPs have committed to use ‘one plan’. However, there are some constraints for some of

the development partners not to fully drop their own planning system has been the lack of

activity details in the annual plan compatible with agencies planning formats. The effort of EFY

2002 plan to include activities will help alleviate some of these concerns. In this regard, DPs

should work hard to change their systems in compliance with the Paris declaration and IHP

Compact. This requires change at DP HQ and may take time. In the mean time, it is also

necessary for Planning, Policy and Finance directorate to sit with development partners

requiring separate planning formats to review and assess their requirements and seek solutions

therein in the planning format for EFY 2003.

Progress in using budgeting framework

128. In EFY 2000, the average number of years of commitment for many DPs (mode as an

average) was about 3 years. There was no established circular on the timing of communicating

indicative support to help the development of resource mapping. Most provide from May to

August. 84% of the support provided to the sector was earmarked. Only two DPs provided

some sort of un‐earmarked support in addition to earmarking. Of all the supports provided to

the sector, only 24 percent was channeled through government preferred modalities, both

pooled funding and channel one. Only five development partners disbursed to the MDG PF. Of

the total commitment indicated in their plan, only 30 percent was disbursed during the year.

Most of the technical assistances provided were demand driven; technical assistants are hired


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as per the request of the government.

129. In EFY 2001, 44 % of DPs provided three year long term resource commitment; 67% of the

DPs reported to have channeled the resources as per the agreed schedule; about 56 % of them

used government preferred modalities, and about the same percentage of DPs reported as

having provided government with financial reports but only 22% of DPs reported to have received

financial report from government.

Table 4.4: progress in budgeting

Overall DPs’ response INDICATOR


In %

The DP has provided funding commitments for a period of at least 3 years

4 4 1 44%

The DP has confirmed its annual commitment by program and geographic area within the time set by MoH / JCCC

7 0 2 78%

Percentage of funds channeled through the Government preferred modalities

0 0 0 0%

According to the DP, based on the MDG Fund appraisal, the improvement plan for financial management system is being implemented.

4 0 5 44%

Percentage of funds from DP disbursed as per the agreed schedule.

6 0 3 67%

The DP receives financial reports from the Government as per agreed schedule.

2 4 3 22%

The DP is using Government preferred modalities for procurement

5 4 0 56%

According to the DP, based on the MDG Fund appraisal, the improvement plan for procurement system is being implemented.

3 0 5 33%

Proportion of TAs hired based on the request of the Government

6 0 3 67%

The DP submit financial reports to the Government as per agreed schedule

5 0 4 56%


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Progress in using one monitoring framework

130. In EFY 2000, 75% of all DPs require the use of their own reporting format. Only DFID,

Irish aid and RNE were the ones that had given up their reporting forms in favor of available

government reporting formats. AfDB, RNE and WHO did not report any agency specific reviews

that is carried out in the reference period.

131. In 2001, 56% of DPs do require separate reports for their support and none did conduct

its own review mission. Two development partners did have three project management units

that implement activities.

Table 4.5: Progress Using One Monitoring and Reporting Framework

Overall DPs’ response INDICATOR


In %

The DP is NOT requesting separate reports 4 5 0 44%

The DP is NOT conducting its own review missions 9 0 0 100%

The DP is participating in coordination meetings between FMOH, MOFED and Partners

7 1 1 78%

The DP requests implementation and reporting on a single result based framework for all funding streams.

4 4 1 44%

OVERALL HARMONIZATION AND ALIGNMENT PROCESS 0 0 0 0%

Number of DP’s parallel project management units 2 0 0 22%

The DP has signed the Ethiopia IHP+ Compact 6 3 0 67%

The DP has signed the MDG Fund Joint Financing Arrangement 6 3 0 67%

The DP is providing untied aid 6 3 0 67%


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5. OVERALL CONCLUSIONS AND RECOMMENDATIONS

132. This JRM covered only six regions and within them a few selected areas identified by the

Regional Health Bureau to represent ‘strong’ and ‘weak’ performers and in a way they should

not be considered as a representative sample. Its findings and recommendations presented

below should thus be interpreted with caution. The JRM report should not thus be taken with

the caveat that it was not a nationwide investigation. As explained in the methodology it has

some limitations. With this in mind, this section will try to bring together the main findings,

conclusions and recommendation of this mission.

Maternal health

Findings

133. Progress in maternal health service (family planning, ANC, skilled delivery) is not even

across regions. While Some regions have performed in one of the services better than other

regions, other regions perform exhibit better results in some other areas. For example, Tigray

has done well in skilled deliveries while the performance of SNNPR is quite impressive in family

planning and ANC services. progress was made in implanon scaling up using the HEWs. With the

exception of Tigray, improvement in skilled delivery was found to be poor in almost all the

regions. However, important steps are being taken that will positively affect its outcome in the

coming years. The on‐going phenomenal expansion of health centers, the efforts to implement

health workforce performance improvement, and the endeavor to strengthen financing of

maternal health are just a few examples.

134. When the 2500 under‐construction health centers are completed, they will bring

delivery service closer to the community. The challenge that the sector should work on in the

medium term is upgrading some of these facilities to provide emergency obstetric services.

Recognizing the skills gap, efforts are being made to strengthen human resources. Some of the

important measures taken recently were the accelerated training of HEWs, midwifery, health

officers, MSc in Integrated Emergency Obstetrics Surgery. A referral guideline is being

developed to address unnecessary referrals. The inclusion of maternal health as one of the

priorities to be financed through MDG PF created the favorable environment for increased

financing. It is ,however, important to bring the different directorates on board on how to

access resources from MDG funding and encourage them to be involved in JCCC during the

decision making process.


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Challenges

135. That little progress has been made in increasing deliveries by skilled professionals is

major finding of this JRM.. Of the six regions visited, only one is reported to be on track to

achieve its 2001 EFY targets; two regions are likely to perform below their targets while the

remaining three might perform lower than baseline levels. This is a reflection and effect of the

weak health systems in the country.

136. Demand side constraints: There are many challenges that limited achievements in

skilled deliveries. First, traditional beliefs and emotional support provided in the family do

encourage mothers to deliver at home. Second, the distance that a labouring mother has to

travel to get functional delivery services as well as the time it takes to organize travel is too

long: at times, there are incidents where mothers deliver along the way. Third, though the

essential health packages defined in 2005 delineated delivery at health centre as one of

exempted services, in practice, mother are forced to buy gloves, drugs and IV‐f fluids as their

supply is often inadequate. This is the financial barrier to accessing maternity services for all but

more so for low income families.

137. Supply side constraints: There are also supply side challenges that the health systems

should address if skilled delivery is to increase. Fourth, the shortage of skilled midwives

remains the major bottlenecks for accelerating skilled deliveries in the health system. In many

facilities, there is insufficient skill to handle obstetric complications. There are only about 1,200

midwives in the health system, far lower than the standard recommended level: 1 midwife to

5,000 people. The potential for the training institutions to train the required amount of the

midwives with their current intake capacity even in the medium term does not seem promising.

The government’s strategy to train and deploy to 823 functional health centres nurses with a

midwifery skill in the next financial year seems the only pragmatic approach. The potential to

train and utilise health extension workers for clean delivery at community level has not been

adequately exploited. Fifth, in addition to its shortage, the delivery room environment in health

facilities and the attitude of the health workers is not conducive for mothers to come to health

facilities. Six, inadequate availability of BEOC and EmONC equipment in most of the hospitals

and health centres reduced their ability to provide quality delivery services. Finally, most of the

health facilities especially health centres visited do not provide a fully functional 24 hours a

week services.

Recommendations:


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138. HSDP IV should develop strategies that will allow a balanced development of both

community (clean) and facility based (safe) delivery services to achieve early success in

reducing maternal deaths at relatively low cost. As progress in skilled attended delivery may

take time; it might thus be prudent to exploitthe potentials of HEP to effect visible changes in

this service. The training of HEW to provide clean delivery should therefore be scaled up as an

interim solution while at the same time accelerating the training of midwives. Overall, the

sector should create the necessary commitment to mobilise adequate resources, to put the

right strategies, structures and interventions in the design of HSDP IV to accelerate the

achievement of the MDG 5. As part of the overall government drive for universal coverage,

HSDP IV should consider creating universal access to safe motherhood services through:

a) providing 24 hours a week delivery services in health centres nation‐wide with detailed

analysis of the required inputs and mobilising resources especially for under‐served

regions and areas within regions;

b) provision of comprehensive Emergency Obstetric Care (CEOC) at all hospitals and

selected health centres by putting up functional maternities, nurseries, maternity

theatres and laboratory services;

c) scaling up the competency training for HEW to bring clean delivery closer to the

community;

d) continued effort to ensure availability of family planning commodity in health facilities

(commodity security and distribution);

e) development and implementation of a functional Referral Strategy;

f) continued demand creation for health services through HEP;

g) introducing free of charge deliveries in all health facilities, including hospitals, by

possibly designing a mechanism to reimburse hospital for their forgone (lost) revenue

from other sources of funding like the PDG PF; and

h) development of a strategy and strengthening program to enhance the health sector’s

capacity to maintain its health infrastructure at all levels of the system; this is especially

important in view of the unprecedented expansion of primary health services that is

being carried out in the country.

Neonatal and child health

Findings

139. The performance of the regions visited in immunization seems satisfactory. Provided

that that their implementation trend exhibited in nine months surveyed continues with the


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same pace for the remaining three months, there is every indication that most are either on

target or very near to meet both pentavalent and measles coverage . Many respondents that

the JRM talk to attribute this improvement to the active involvement of health extension

workers and community volunteers in mass mobilization. However, there is a room for serious

concern that many health facilities are not providing IMNCI services. With the number of health

facilities and health workers the sector has, it is extremely difficult to reach all children with

pneumonia and other common childhood problems.

Challenges

140. Despite high National Neonatal Mortality rate, 39/1000LB (EDHS‐2005), in general, there

is lack of focus and capacity for newborn health at all levels. There is no national target set

separately to track progress towards reducing neonatal mortality rate and there is no indicator

in the new HMIS designed to monitor the national effort made towards addressing the three

major killers of newborn babies: neonatal infection, birth asphyxia and prematurity and low

birth weight. As a result, this JRM report was not able to obtain data on the number of children

provided with any of the new borne care and treatment services. Most of the Regional and

Zonal hospitals do not have any kind of neonatal unit where sick newborns can be admitted

separately in a special unit. At the same time, in most of the hospitals and health centres

including referral hospitals, delivery and maternity rooms lack a separate newborn corner

inside the labour room with thermo‐neutral environment. With the current trend of low

newborn health care coverage at both national and regional level, it will be difficult to achieve

MDG 4 as the neonatal problems contribute to about 30% of the under‐five mortality.

Recommendation for HSDP IV design

141. It will be prudent to use the human potential existing at the community level by taking

child health services, particularly pneumonia treatment to the community.. This requires

further training of HEWs on how to assess, classify and manage common childhood problems

including pneumonia and common newborn problems as well as providing adequate regular

follow up and supportive supervision. It is necessary to explore the potential of HEP as well as

its required costs in terms of additional burden to the HEWs and their training and other

related activities during the design of HSDP IV.


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142. It is also imperative to provide adequate focus and attention to newborn health and

enable all health facilities offer basic health service for this group. This JRM would like to

recommend that HSDP IV should consider:

a) Introducing a separate target and indicator for tracking progress made to improve the

coverage of high impact neonatal interventions that addresses mainly the major killers

of newborn;

b) Establishing newborn unit in all regional and zonal referral hospitals and making sure

health workers with appropriate skill are assigned and have the necessary supplies to

provide essential newborn care;

c) Establishing newborn health corner in all delivery rooms and maternity wards of all

health facilities in order to provide essential new born care including neonatal

resuscitation.

d) Scaling up skill based training of HEWs in clean and safe delivery including training on

essential newborn care.

e) Increasing the coverage of home based postnatal care using the available community

based health cadres( the HEWs); and

f) Harmonizing community maternal, neonatal and child health activities by different

partners to synergize the ongoing efforts and avoid duplication of activities.

Nutrition

Findings

143. The national Nutrition Program (2009‐2013) has been developed, approved and

launched very recently. So has the iodization of salt. A draft Code of Breast Milk Substitute

(BMS), envisioned form a legal framework, has been prepared. Micro‐nutrient Guideline has

been revised. National Nutrition Coordination Body (NNC), the highest policy making organ had

its inaugural meeting in of December 2008. The other coordinating organs are yet to be

established. Nutrition agenda has now moved higher in the ladder of priorities within

government. Through EOS/TSF, seven million children and 1.5 million pregnant and lactating

women are screened for malnutrition every six months and referred to Targeted

Supplementary Food (TSF) and Therapeutic Feeding Program (TFP). These all are encouraging

signs/developments. On a negative note, it was found that that there was a significant delay

between referrals and actual provision of the TSF. The national capacity for management of

SAM has increased to over 90,000 severely malnourished patients every month. 560 Woredas


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have either started or will soon start implementing preventive community based nutrition

activities.

Recommendation

144. This JRM strongly believes that the following measures will help achieve the targeted

outcomes of the nutrition strategy and program: (i) training the HEW and VCHWs/model

households with necessary practical skills in all aspects of promotion, care and referral related

to nutrition; (ii) making sure that the supervisors trained are adequately supported to move

around and provide mentoring and coaching to the HEWs; (iii) strengthening the health centres

to provide timely and appropriate treatment to those referred to them, (iv) building the

capacity of the Woreda health Offices to manage and supervise the programs; (v) provision of

fund to support the implementation of the service delivery components of the NNP; and (vi)

financing the training and deployment of critical mass of human resources, particularly

nutrition practitioners and/or nutrition focal persons at different levels as per the HR study.

Tuberculosis

Findings

145. The overall national TB detection rate still remains very low. It is estimated that the

achievement will not be more than 35 percent. With the exception of the Afar and Gambella,

the detection rate of all other regions remains very low as compared to their targets. Even

experimental research in a Woreda of SNNPR with a lot of inputs managed to improve the rate

up to 70 percent only. The main reason reported for lack of progress is inability of the sector to

exploit potential areas for improving detection rates, including (i) lack of integrating TB

detection in all OPDs as part of the provider initiative testing (PICT), (ii)failure to adequately

involve community health extension workers to refer those with signs of the disease to the

health facilities; (iii) inability of all health facilities in providing service; (iv) the tendency to give

more focus to the training and supervision of improved success rate than detection rate; (v)

lack of functional laboratories in many of the visited health facilities and (vi) inadequate skill in

some of the laboratory technicians on how to do proper microscopic examination using the AFB

staining.


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Health systems

Infrastructure

146. The overall target for 2001 EFY was to fully construct all the required health posts

throughout the country and constructing 1391 health centers. Significant progress has been

made towards achieving these targets but it is unlikely that these targets will be fully met. Of

the total HC construction requirement of 2561, 1392 (54%) was to be financed through the

contribution of external funding mobilized by FMOH and 1169 (46%) was to be financed

through the regional allocation as matching health centers. According to the information

generated from the PMU, the construction of 477 HC (19%) has been completed, 1795 (70%)

health centers are under construction. The financing of 411 health centers that were expected

to be financed through the regional governments have not yet been secured; 37% of them are

in Oromia, 22% in Amhara, 14% in Somali, 13 % in SNNPR, 9% in Afar, 2% in Benishangul Gumuz

and 1 percent in Gambella regions. On the other hand, Tigray, Gambella, Harari and Dire Dawa

were able to allocate resources for all health centers that should be financed through regional

budget.

147. Of all the total FMOH financed HC, 86 % are either completed or under constructions. Of

the remaining 14 % (197 health centers) whose construction is yet to be initiated, 82 percent of

will be located in Amhara, Oromia and SNNPR. Of the total regional financed HC, 65 % of health

centers’ budget have been allocated, and of these 90 % are now either under construction or

completed. Of the total projected regional financed HCs, 59 % of health centers are under

construction. While construction and upgrading of health facilities are important in improving

access to primary health service, making them fully functional remains a challenge. Cases were

reported during this JRM where heath facilities have started functioning without being fully

equipped (e.g., Oromia and Tigray). Most health posts constructed in many regions have

started to provide service without being fully furnished due to shortage of woreda health

budget. Furthermore, majority of the HPs are not yet equipped with HP Kits.

148. The health sector should continue lobbying for greater political leadership and

commitment at woreda levels to allocate adequate budget to furnish constructed health posts.

The follow up of PFSA procurement of equipment of HP and health centers by the FMOH might

fast track the process. The role and responsibility of the zonal health office in following up

construction of HC need to be defined and supervision capacity be strengthened to ensure

quality and accelerate the speed of the constructions. The taskof synchronizing health facilities


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construction with equipping and staffing as per the national standard should be carefully

planned and implemented. Concerted efforts are required between the government and

development partners to speed up procurement and distribution of such essential medical

equipments.

Logistics and pharmaceutical supplies

149. The institutional transformation of the profit making PHARMID to service provider PFSA

was completed. The business process re‐engineering and the focused and committed

leadership at the agency, the proactive support by the CSMS, PEPFAR financed project, both

technically and financially, have contributed to this fast transformation. The agency was able to

procure all health commodities through RDF and program funds as per its plan. One of the

contributing factors for meeting this target was reported to be the capitalization of PFSA. The

support of GAVI, GFTAM and PBS increased the RDF capital to $21.5 million and is expected to

be raised by another $10 million with further support of PBS phase II. It was reported, with the

same specification and origin of supply, the PFSA procurement of these health center

equipment were found to be more cost effective than the previous arrangement with UNICEF.

The agency was also reported that it was able to procure Anti‐TB and HIV/AIDS testing kits

within 90 days under normal government procedures. This is indeed an efficiency gain if

adequate measure was taken in ensuring transparency and accountability during this

procurement process. Though improving, the low RDF capital that the agency has (given the

WHO recommended $2/capita requirement=$150 million for Ethiopia) will, however, remain

one of the major challenges for the agency to provide adequate and demand responsive health

commodities in the country.

150. The procurement of essential health commodities through RDF has been made through

central demand projection without involving health facilities. It is reported that this method will

be used for the coming financial year as the capacity of the health facilities to properly quantify

their needs is yet to be developed. The procurement of program commodities funded through

program funding (not RDF funding) and distributed to health facilities. The frequent stock‐out

of these commodities is partially related to supply driven system being implemented. The JRM

would like to recommend (i) strengthen the capacity of the programs to forecast commodity

requirements and (ii) the programs to institute demand driven supply system by learning from

the essential health commodity supply. Achievements are recorded in strengthening of PFSA in


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terms of ware housing, distribution human resources and information and LMIS. This needs to

be strengthened further.

Planning

151. The ownership of the plan is being increasingly strengthened at lower levels, particularly

from regional down to woreda levels. That the planning process is being considered as best

practice for the public sector both at the federal and regional levels is reflective this

encouraging trend. There is relatively better collaboration between the finance and health

offices at the woreda level in planning and budgeting. On the other hand, albeit these gains,

there are issues and concerns on deepening ownership, participation of stakeholders and

improve the feasibility of targets set. First, the participation of the health facilities, NGOs,

HEWs in the development of Woreda targets was very limited. Second, because of limited

facility involvement and capacity of the Woreda health offices to negotiate, top‐down target

setting appears to pre‐dominate the process. Third, quality of the plan still leaves much room

for improvement. The plan was not able to be used as operational tool to guide intervention

priorities at all levels. Last but not least, planning is reported to be too long and its transaction

cost high.

Human resources

152. There is little progress in getting HRH strategy endorsed. Still, though in some of the

human resource activities there are important gains. 2,289 HO have graduated in the

accelerated health officers training. Training of Health officers on emergency obstetric care

was initiated in three Universities that enrolled 53 HOs. An initiative is on going to upgrade

HEWs training from level 3 to 4 through distance (with Open University) and regular training.

Consultation was initiated to scale up and enroll 300 midwives per year. A plan is in motion to

start training of health information officers for two years. The newly established HRH

directorate has started taking leadership on the development and implementation of plans and

strategies related to the human resource for health. However, it still lacks the necessary skill

and capacity, and the directorate need to be supported with three types of technical assistants:

human resource development, human resource management and human resource information

system. These technical assistances will serve as anchor for the three critical areas of human

resource for health.


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Rollout of the HMIS system

153. Although some of the preparatory works like training of master mentors, printing the

necessary tools and forms were carried out, the HMIS was only rolled out to all federal and

regional hospitals. The regional findings show that progress in uneven. In regions using the new

HMIS, the mission was not able to get the nine months’ performance report. In regions where

training was given to all health center and hospital staff to initiate the new HMIS in all facilities,

implementation is lagging behind. In terms of use of information, there are good examples like

health post and Health Centre, as is case in Shebedino Woreda Health Office, that can be

considered as best practice. On the other hand, use of information is quite limited in most of

the Woredas and health facilities visited. There is a consensus both at the federal and regional

levels that the scaling up effort is not being implemented as per the plan. The main causes of

delay include the inability of regions to employ health information technicians as per plan; lack

of concerted effort to bring all stakeholders to have consensus on the implementation process

and to mobilize additional funding. There is a need to re‐strategize the implementation of the

scaling up process with all stakeholders. This process can be fast tracked through the re‐

vitalization of the national advisory committee.

Alignment and harmonization

154. In this area, there was significant progress. The signing of the IHP+ compact and JFA

took place this financial year. The MDG Pooled fund is now established and working. Many of

the indicators set to measure alignment and harmonization (planning, budgeting, and reporting

frameworks) seem to have improved. This information, though based on the few development

partners’ responses to the JRM questionnaires, is indicative of significant change by the

development partners. The harmonization of the community level intervention (training,

supervision, strategies for implementation) by all actors in the health sector should be a priority

for action as its transaction cost to the community health workers is found to be too high.

Lessons learnt On the Joint Review process

155. Getting the JRM process started is in itself one step forward. The process was able to

bring government (both federal and regional) as well as development partners to go to the field

and jointly assess the progress the sector made in implementing its annual plan and to identify

the main challenges and constraints that needs to be tackled. The mission has come out with

some concrete findings and recommendations. The sector has to assess the value added by this


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JRM, review its strengths and weaknesses, and take corrective actions to make it more relevant

and effective.

156. The Joint review mission process was rushed particularly during the questionnaire

design and preparation that resulted in many gaps both in the design of questionnaires. The

mission was carried out before the end of the year and using information ranging from six to

nine months of the annual performance. This has reduced the effectiveness of the validation of

the annual health sector performance through this process. Some partners were not able to

provide the technical expert that they pledged, making some of the regional teams under‐

resourced in terms of number and skill mix. The federal team members in particular were

engaged in various competing tasks and were not able to undertake the process on time and

consolidate their report.

157. Based on this experience, it is recommended that the next JRM should

a) Continue selecting thematic areas for the mission. However, it is important to support

the JRM thematic areas selected with experts to ensure production of relevant and

quality report.

b) Undertake the mission after the completion of the annual HMIS report from the regions.

It is recommended that JRM takes place in September each year just before the annual

review meeting.. This requires forgoing presenting a published JRM report at the Annual

review meeting but providing the benefits of covering the validation process for the

whole year and presenting fresh findings just from the field.

c) Ensure that the agencies providing technical experts for the mission communicate to the

organizers their limits in participation. The withdrawal of CDC seconded experts at the

last minute has affected the quality of this JRM.

6. ANNEXES

6.1 Summary of Development partners’ response to the alignment and harmonization questionnaire Italian Coop World Bank UNFPA RNE WHO Cida HMN Irish Aid UNICEF

INDICATOR YES N

O YES NO YES NO YES NO YES NO Yes No YES NO Yes No Yes No

ONE PLAN

The DP plan is integrated with Government plan at national and sub national levels

V √ x X x Yes √ x

The DP is NOT requesting the Government for separate planning documents

V √ x X x No √ x

The DP is participating in the annual planning process

V √√ x X No √ x

The DP is participating in the development / review of HSDP

V √ x X No √ x

According to the DP, main health sector development strategies, HMIS and HRD, finalized and implemented according to plans.

V √ x ?? HMIS and HRD mostly no

No These are still in progress

x

ONE BUDGET HSDP in general yes,

The DP has provided funding commitments for a period of at least 3 years

V √ x X no √ x

The DP has confirmed its annual commitment by programme and geographic area within the time set by MoH / JCCC

V * x X Yes √ x

Percentage of funds channeled through the Government preferred modalities

100% (channel II)

√ 70 0% through MDG Fund

13 100 0% 77% ALL

According to the DP, based on the MDG Fund appraisal, the improvement plan for financial management system is being implemented.

V √ x No update received

Not enough information to see progress yet

x


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Italian Coop World Bank UNFPA RNE WHO Cida HMN Irish Aid UNICEF INDICATOR

YES N YES NO YES NO YES NO YES NO Yes No YES NO Yes No Yes No O

Percentage of funds from DP disbursed as per the agreed schedule.

#### * x 100% 100 100% 100% NA

The DP receives financial reports from the Government as per agreed schedule.

V √ n/a No No Usually delayed

x

The DP is using Government preferred modalities for procurement

V √ n/a X But also WB/PBS

x No √ x

According to the DP, based on the MDG Fund appraisal, the improvement plan for procurement system is being implemented.

V √ n/a To early to tell

x Not enough information to see progress yet

Not sure

Proportion of TAs hired based on the request of the Government

#### * n/a 100% (only via HPF)

100 n/a 100% √ 100%

The DP submit financial reports to the Government as per agreed schedule

V n/a X Yes √ X To MoFED

ONE M&E REPORTING SYSTEM

The DP is NOT requesting separate reports


The DP is NOT conducting its own review missions

V √ x X x Yes √ x

The DP is participating in coordination meetings between FMOH, MOFED and Partners

V √ x X No √ x

The DP requests implementation and reporting on a single results based framework for all funding streams.



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Italian Coop World Bank UNFPA RNE WHO Cida HMN Irish Aid UNICEF INDICATOR

YES NO

YES NO YES NO YES NO YES NO Yes No YES NO Yes No Yes No

OVERALL HARMONIZATION AND ALIGNMENT PROCESS

Number of DP’s parallel project management units

1 √

two 0 none

none none zero None

The DP has signed the Ethiopia IHP+ Compact


The DP has signed the MDG Fund Joint Financing Arrangement


The DP is providing untied aid V √ x X x No √ x

6.2. List of JRM team Members

Teams Name of the member Contribution in the JRM Agency

Goitom G/Medhin Member Tigray RHB

Dr. Abera Bekel Team Leader WHO

Tigray

Mengistu Tadele Member FMOH

Dr Wondimagegn Kegne Team Leader WHO

Teferi Mokonen Member CDC

Damtew Bekele Member FMOH

Tesfu Alemu Member UNFPA

Afar

Dr Afework Ayele Member UNICEF Ato Wagaw Member RHB

Ato Gebru Abuhay Member RHB

Muchie Kidanu Members UNICEF

Dr Wondimu Teferi Sub team leader CDC

Selamawit Aklilu Members FMOH

Dr Atnafu Getachew Overall team leader WHO

Mohammed Aleye Member FMOH

Clio Sozzani Member Italian Cooperation

Amhara

Laura Leonard Member Irish Aid

Dr. Gebreselassie Okubagzhi Overall tea leader World Bank,

Hiwot Tadesse North Shoa sub‐team leader Irish Aid

Kyoko Okamura Huru Gudru sub tea leader UNICEF

Hiwot Solomon Member (FHOH‐HEP)

Dursit Abdushekur Member UNFPA

Dr. Qais Sikandar Member UNFPA

Oromia

Dr. Assefa Member Oromia RHB

Assaye Kassie SNNPR overall team leader UNICEF

Asainew Assefa Member UNFPAS

Abebaw Bekele Member FMOH

Tamiru Alemayehu Member SNNPR RHB

SNNPR

Richard G Member DFID

Mr Teame G/Mariam (FMOH) Member FMOH

Mr Manemuon Kuyok Member Gambella RHB

Mr Wondimagegn Fanta Member UNFPA

Gambella

Dr Degu Jerene Team Leader WHO

Roman Tesfay Member FMOH

Dr Teodros Bekele Team Leader FMOH

Dr Marina Madeo Member Italian cooperation

FMOH

Dr Muna Abedella Member UNICEF


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Consultant assisting the process

Abebe Alebachew Consultant Consultant

Members of the Technical Working Group leading the JRM process

Name Position Institution

1 Roman Tesfay FMOH Chair person

2 Dr Teodros Bekele FMOH Member

3 Dr Gebresellasie Equabegzi World Bank Member

4 Dr Assaye Kassay UNICEF Member

5 Dr Marina Madio Italian Cooperation

Member

6 Dr Muna Abedella UNFPA Member

7 Hiwot Taddesse Irish Aid Member

Documents

The Joint Review Mission Report - UHC2030...were deployed in six Regional States of Tigray, Amahara, SNNPR, Oromia, Afar and Gambella including the Federal Ministry with a mission