Health System Decentralization the Case of Ethiopia Kenya National Health Leadership Management and Governance Conference Nejmudin Kedir Bilal, P. Health.
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Health System Decentralization the Case of Ethiopia
Kenya National Health Leadership Management and Governance Conference
Nejmudin Kedir Bilal, P. Health Economist, AfDBJanuary 29, 2013
OutlineOutline
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
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
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
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Weekl
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Month
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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
Disease Prevention and Control
Hygiene and Environmental Sanitation
MNCHHealth Education
HEP: Process & Roles defined for Training, Deployment & Support on Implementation
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 LessonsKey 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
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