Health System Decentralization the Case of Ethiopia

Kenya National Health Leadership Management and Governance Conference

Nejmudin Kedir Bilal, P. Health Economist, AfDBJanuary 29, 2013

Outline

1. Background

2. How was decentralization conducted?

3. Why decentralization in Ethiopian

health system?

4. Key health systems aspects of

decentralization

5. Lessons learnt

Background• A coalition of rebel forces under the Ethiopian Peoples’

Revolutionary Democratic Front defeated the socialist government of Mengistu Haile Mariam in May 1991

• Ethiopia’s first popularly chosen national parliament and regional legislatures were convened in May and June 1995

• The current government of Ethiopia was established in August of 1995

• Since then the government has promoted a policy of ethnic federalism, devolving significant powers to subnational authorities.

THE PROCESS OF DECENTRALIZATIONPart of broader government decentralization

Phased approach• 1996 to Regional States• 2002 to Woredas (and Zones)

Not one size fits all approach

• Some with strong zones• Some with lessor role for zones• Some with no zones

9 regional state governments,

2 city adminis

Zones,

More than 850 districts

15,000 Kebeles

Health Systems Decentralization was one of the key reforms triggered by multiple challenges

High burden of disease of

preventable causes

Poor access and quality of health

care

Centralized

Low level of financin

g Shortage and

poorly motivated

health workers

Biased towards curative

care

Poor governance of health institutions

DecentralizationGovernance and Financing Reform

Health service Delivery reform

Health Planning & HIS reforms

Pharmaceuticalsreform

Health System Decentralization

• 4 tier health system organization– PHCU (health center + 5

health posts) (25,000)– District hospital (250,000)– Zonal hospital (1 million)– Specialized hospital (5

million people)

• Health Extension Programme 2003/2004

Specialized Hospital(5

million)

General Hospital

(1million)

Rural Hospital (100.000)

PHC unit=1HC+5 Satellite HP (25 million)

Roles of different levels of the health system was defined

• MOH –policy direction, setting standards and resource

mobilization

• RHBs, ZHDs and WorHOs set health priorities, deliver

services, and determine budget allocations

• WorHOs manage personnel issues, health facility

reconstruction, and procurement at PHCU

• Regions and woredas get block grants

Health Human resources management was one of the key decentralized functions

• Major universities under MoEducation• Regional collages midlevel and low level

health workers• RHBs, ZHDs and WorHOs can hire and fire• WorHOs are charged with HCs and HPs• Challenge: inter regional transfer

Health Planning Challenges in early phase of decentralization

– Global and national commitments vs decentralized decision

– Challenge of getting priorities across– Multiple plan documents– Historical budgeting not relevant to the

local contexts

The “One plan” initiative

• Priorities are set every 5 years and every year• The main Principe is ensuring vertical and horizontal

linkage of priorities and targets• Led by government via steering committees at all

levels• Combination of top down and bottom up process• Sharing and consulting with stakeholders• Endorsing the strategic and annual plans at joint

sector meeting• Joint monitoring on annual basis

11

Centralized and fragmented information system required reform

• Data collection– Too much data items 400 at

HCs, 500 at WorHo.– Irrelevant

• Reporting problems – Incomplete, Untimely– Redundancy, parallel=

administrative burden• Data analysis

– Not done at point of collection

• Uncoordinated initiatives• Poor institutionalization

Key principles were set to reform and decentralize health information system

1. StandardizeIndicators & definitionsDisease list for reporting & case definitionsClient / patient flow & data elementsRecording & Reporting formsProcedure manualInformation use guidelines

2. SimplifyReduce data burdenStreamline data management procedures

3. IntegrateData channelClient / patient information at facility

(integrated folder)

4. Institutionalize

Indicators by Category

0 5 10 15 20 25

Reproductive Health

Child Health and EPI

Malaria

TB/Leprosy

HIV/AIDS

Assets

Finance

Human Resources

Coverage and Utilization

Not only collection but use information at all levels

HF

Service delivery report

WoHO

Compiled and used/reported

RHB

FMOH

Compiled and used/reported

Compiled and used

Weekl

y

Month

l

y

Quart

erly

Weekl

y

Month

l

y

Quart

erly

Weekl

y

Month

l

y

Quart

erly

Health Service challenges: Preventable health problems as major causes of morbidity and mortality (60%-80%)

Limited knowledge of optimal care practices at the family level

Limited physical access to health services in rural communities

Poor institutionalization of PHC

Only 1% of households had ITNs (<18% insecticide treated) Only 40% of the population within 10 KM of health institution Poor utilization = 30% Children < 6 months, exclusively breastfed: 32% Children with diarrhea given ORT: 37% Delivery attended: 6% Children with fever/cough brought to a health facility: 17% Low immunization coverage

Due to

HEP: Innovative approach to deliver Preventive and Promotive Health Services

HEP

Disease Prevention and Control

Hygiene and Environmental Sanitation

MNCHHealth Education

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

Village council involves the HEWs and provides leadershipSupervisors assigned 1 HC/5 HPs for technical and logistic supportFMOH and DPs provide equipment and suppliesCustomized HMIS to track progress

HEWs assigned back to the village, train and graduate households Local government pays salary

2 trainees per village recruited by local government and community MOH and MOE collaborate to provide a 1 year trainingCommunity builds health post as a hub of operation for HEWs

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

Decentralized Governance and Health Care Financing Reform-Five Components

1. Health facility governing boards2. HFs user fee revenue retention and

utilization.3. Systematizing the fee waiver system

and exemption scheme4. Outsourcing of non-clinical services.5. Establishment of private

Clinics/wings in public hospitals

Key Lessons

1. Part of broader government decentralization

2. Sequencing decentralization makes it more

effective

3. Continuous and demand based capacity

building

4. Some things are better kept at higher levels

5. Devolution does not mean no accountability!

6. Be ware of interrupting ongoing programmes