Presentation Title

Abt Associates Inc.

In collaboration with:I Aga Khan Foundation I Bitrán y AsociadosI BRAC University I Broad Branch AssociatesI Deloitte Consulting, LLP I Forum One CommunicationsI RTI International I Training Resources Group

I Tulane University’s School of Public Health

HSS Training for USAID DLIs

Nejmudin Bilal

Health Systems 2020 Abt Associates

(August 28, 2011)

Health Systems StrengtheningEfforts: The Case of Ethiopia

Objective

To see a country case on HSS effortsto make it responsive to the needs:Ethiopia

General Background

Population: 80 million

Population growth rate:2.7% /year

Rural population:84%

Geographic size: over 1.1million Km. Sq.

 GDP $220/capita

 U5 mortality:123/1000

 MMR 470/100,000

High burden ofdisease ofpreventable causes

Centralized

Low level offinancing, leakage

poorly motivatedhealth workers

Biased towardscurative care

Poor access andquality of healthcare

Decentralization

Facility Governance and

HCF Reform

Health Extension

Programme

Challenges and HSS interventions: Before and After

1. Decentralization of Health System

4 tier health system organization

Prioritized primary health care

MOH –policy direction and resource mobilization

Regional Health Bureaus, District Health Offices---managingservice delivery

Community participates and strengthens CHS

Decentralization of Health….

Decentralization set the stage for the resultsI share in the next two reforms

2. Governance and Health Care FinancingReform-Five Components

1.Health facility governing boards

2.HFs user fee revenue retention and utilization.

3.Systematizing the fee waiver system andexemption scheme

4.Outsourcing of non-clinical services.

5.Establishment of private Clinics/wings in publichospitals

Facility governing boards play critical managementrole

•Ensure proper implementation of the reforms

•Review and approve plans

•Approves budget and follow up on utilization

•Ensure that the activities of the hospital are carried outwith transparency and accountability

Improved responsiveness to local needs

Increased accountability to public funds

Improved resource mobilization

Increased role of local community ---good governance

Created sense of ownership by management

86 hospitals and 1,600 HCs have establishedfacility governing boards

Governance and Health Care FinancingReform-Five Components

1.Health facility governing boards

2.HFs user fee revenue retention and utilization.

3.Systematizing the fee waiver system andexemption scheme

4.Outsourcing of non-clinical services.

5.Establishment of private Clinics/wings in publichospitals

Revenue retention led to improved quality ofcare

Foundation for all health care financing reformagenda

Facilities' ownership to control leakage

Generates additional resource

Invested strictly on quality improvement

Safe water Supply for health facility: Wolaita Sodo HC

Before the reform

After the reform

http://farm3.static.flickr.com/2204/2219238736_a6c9c389fa_o.jpg

Uninterrupted supply of medicine

New Microscope: improving diagnosticcapacity of health institutions

$C:\Documents and Settings\Edemissie\My Documents\My Pictures\Picture\Picture 006.jpg$

Modern Dental equipment: Arba Minch Hospital

$C:\Documents and Settings\Edemissie\My Documents\My Pictures\Picture\Picture 037.jpg$

Beautiful Environment motivates staff andencourages patients to use health institution: Awassa HC

New Generator: ensuring safe storage of medicineand uninterrupted functioning of diagnosticequipment

Shashemene Hospital

Health Care Financing and GovernanceReform

1.Establishment and operation of governingboards.

2.HFs user fee revenue retention and utilization.

3.Systematizing the fee waiver system andexemption scheme

4.Outsourcing of non-clinical services.

5.Establishment of private Clinics/wings in publichospitals

Fee waiver is a key to financial risk protectionfor the poor

Screening by Village Committees

Criteria for poverty certificate

Waiver system reform is step forhealth insurance-SHI and CBHI

2 Health Care Financing and GovernanceReform

1.Establishment and operation of governingboards

2.HFs user fee revenue retention and utilization.

3.Systematizing the fee waiver system andexemption scheme

4..Outsourcing of non-clinical services.

5.Establishment of private Clinics/wings in publichospitals

Non-clinical services are outsourced

Outsourcing enabled healthfacilities to:

 Focus on core competencies

Tapping into external expertise

Improved Quality

Reduce and control operatingcosts.

Overview of outsourced gardening: Mizan Teferi Hospital/SNNPR/: .

Health Care Financing and GovernanceReform

1.Establishment and operation of governingboards

2.HFs user fee revenue retention and utilization.

3.Systematizing the fee waiver system andexemption scheme

4..Outsourcing of non-clinical services.

5.Establishment of private Clinics/wings

Private wings motivated staff and providedtreatment options for patients

Established in public facilities

Higher payments than thenormal fee

Amount of time in private wingis limited

Staff and health institutionshare the revenue

Abt Associates Inc.

I Tulane University’s School of Public Health

3. The Health Extension Programme(HEP)

HEP is an evidence based intervention

Limited knowledge of optimal care practices at the family level

 Limited physical access to health services in rural communities

Due to

 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

HEP tackles the major causes of ill-health in Ethiopia

2 HEWs/village

On 16 packages of healthinterventions in 4 major areas

Disease prevention and control(Malaria, HIV/AIDS, TB etc)

Family Health (FP, ANC, DS,PNC)

Hygiene and Environmental healthservices (personal and envhygienic, rodent control ..)

Information EducationCommunication

Salaried employees

House to house (75%)

20Karo%20Duss%20bed%20net%202%20DSC_0098%20-%20low%20res

$C:\Users\NKB\Documents\ARM\ARM 2009\ARM 2009 Presentations\final 2009 ARM report presentation\new-arm-presentation-2-7\data\repo\9765.jpg$

$C:\Users\NKB\Documents\ARM\ARM 2009\ARM 2009 Presentations\final 2009 ARM report presentation\new-arm-presentation-2-7\data\repo\9767.gif$

$C:\Users\NKB\Documents\ARM\ARM 2009\ARM 2009 Presentations\final 2009 ARM report presentation\new-arm-presentation-2-7\data\repo\9813.jpg$

$C:\Users\NKB\Documents\ARM\ARM 2009\ARM 2009 Presentations\final 2009 ARM report presentation\new-arm-presentation-2-7\data\repo\9750.jpg$

Why are they all female?

Support structure for HEWs---strengtheningthe system

1 HP/village- equipped

1 supervisor/10 HEWs

Community based HMIS

1 HC/5 HPs for technicaland logistic support

Village council-leadership

$C:\Users\NKB\Documents\ARM\ARM 2009\ARM 2009 Presentations\final 2009 ARM report presentation\new-arm-presentation-2-7\data\repo\9751.jpg$

Health Outcomes Associated withHealth Systems Strengthening

Maternal Health service coverage

Child Health service coverage

Results Achieved… (HIV/AIDS & Malaria)

Malaria

Increasing Expenditure in Health

$C:\Users\NKB\Documents\ARM\ARM 2009\ARM 2009 Presentations\final 2009 ARM report presentation\new-arm-presentation-2-7\data\repo\9763.jpg$

Partnership with USAID’s in HSS

Health Financing and Governance Reform

Supported the training and deployment of HEWs andHealth Officers

Supply Chain Management System

Design and scaling up of HMIS and DHS

Abt Associates Inc.

I Tulane University’s School of Public Health

Thank you