Ethiopian Health Care
System
Lecture 2
Ethiopian Health Care System
Lecture Outline
2
Introduction
History of modern medicine
Structure of the HC system at different
periods
Current health care system including
Health Policy
Health Sector Development Program
Ethiopian Health Care System
Learning outcomes
3
Describe the history of modern medicine
Describe
the
healthcare
strategies
followed under consequent periods
Introduce the current healthcare strategy
Ethiopian Health Care System
Introduction
4
Modern health care delivery movement in Ethiopia has come
a long way from its traditional medicine base to the present
system.
The historical development of modern medicine in Ethiopia is
predominantly public/state-based.
To date public provision of health care account for 80% whilst
the remaining 20% is shared between the private-for-profit
and NGO sectors.
Ethiopian Health Care System
History of Modern Medicine
5
Modern medicine reportedly started in the 16 th century Reign of Atse Lebnadengel (1520 -1526)
Many travelers, religious and diplomatic missions. E.g.
Bruce arrived in Gondar in 1770 and:
Treated
thousands for malaria, syphilis, small pox and
others.
Promoted
prophylactic use of quinine in unrefined
cinchona bark form for preventing malaria.
Ethiopian Health Care System
History
6
All white men considered to be physicians (hakims) until
the Italian occupation
Preventive medical measures
Cholera control in the army of Emperor Tewodros
Smallpox vaccination during the time of Emperor
Yohannes IV
Ethiopian Health Care System
History
7
Emperor Menelik II (1889-1913)
Modern health care considered a privilege to the royal
family prior to the establishment of the first hospital.
Russian Red Cross mission established the first hospital
with a modern pharmacy in Addis Ababa (1897)
Health and pharmaceutical services became more accessible
to the public at the beginning of the 20th century.
Ethiopian Health Care System
History
8
The first government sponsored health facilities 1st
decade of the 20th century
Hospital
in Harar by Ras Mekonen and
Menelik
II Hospital in Addis Ababa
Department dealing with health created in 1908 G.C in the
Ministry of Interior.
Ethiopian Health Care System
History
9
Emperor Haile Sellasie I (1930 -1974)
Prewar period (up to 1935)
Reforms in economic and social conditions including
health service expansion
12 hospitals and 35 clinics
The 1st health legislation issued in 1930
Ethiopian Health Care System
History
10
This drive was interrupted during the brief occupation of
Ethiopia by the Italians (1935 1941)
Italians converted all health service facilities into army
medical clinics to use for their military
The benefit to the population was insignificant
Postwar period
Public Health Directorate was established under the Ministry
of Interior In 1941.
Ethiopian Health Care System
History
11
Ministry of Public Health established in 1948
following health legislation of 1947.
Major steps taken in the autonomous development of
health care
Different approaches followed for the provision of
healthcare to the public.
Ethiopian Health Care System
Structure of HC system/MCM at different periods
12
Modern Medical Care Model (pre-1954)
Mostly urban-centered and hospital-based care for the very
few & couldnt address the health needs of the majority in
developing countries.
Few health clinics operated in some of the peripheral towns.
Health services were largely inaccessible:
Geographic
Economic and cultural barriers
Ethiopian Health Care System
Structure
13
Basic Health Services (BHS)
Progress in development was to be measured by peoples
access to the basic needs to sustain life
Adequate food, shelter, clothing, drinking water, and health.
The aim therefore was to organize a health delivery system
that is able to meet the most urgent health care needs of the
major section of population.
Ethiopian Health Care System
Structure/BHS
14
The WHO-recommended BHS approach advocated:
The extension of peripheral health centers (HCs) & health
stations (HSs)
The utilization of auxiliaries as strategies for solving the
problems of availability, accessibility and appropriateness of
health services
Improving access to health care was achieved to a greater
extent by taking services to where people live (home visits,
prison health services, etc.).
Ethiopian Health Care System
Structure
15
For Ethiopia, BHS was seen as a long term strategy for
providing adequate and essential health care.
The Health Center Team Training Program (1954)
Produced a new cadre of health professionals assigned at
the district level to perform mainly community oriented
health activities.
Health officers: leaders of the district team and
Performed clinical activities at the health center
Ethiopian Health Care System
Structure/BHS
16
Were
responsible for all health related activities within
the district
Community nurses:
Participated
in the team with the health officers
Conducted
home visits to provide health education and follow
up of mothers and newborns.
Environmental health worker /sanitarian
Coordinated various activities related to basic sanitation and
safe water supply.
Ethiopian Health Care System
Structure/BHS
17
The organization and management of health services at the
time can be considered a 4-tier system
Four 5 year consecutive plans prepared & implemented:
1st 5 Year Plan.
8 HCs, 3 hospitals & 100 govt HSs established
2nd 5 Year Plan major polices and strategies
Emphasis on preventive measures
Expansion
of basic health services
Ethiopian Health Care System
Structure/BHS
18
Long term objectives set for HCs and HSs
1 HC for 50,000 population and supervise 10 HSs
1 HS for 5000 population
3rd 5 Year Plan focused on:
Malaria eradication service
Emphasis on expansion of health services and training of health
professionals
Establishment of Provincial Health Departments to
Ensure close supervision of health activities and
Enhance preventive function
Ethiopian Health Care System
Structure/BHS
19
4th 5 YDP
Re-emphasized the importance of public health services
Targeted to raise the health service coverage from 15 30%
This plan did not materialized due to change of government.
Despite the efforts by the imperial govt.:
The services continued to remain largely institutionalized &
The rural population was usually inhibited by socio-cultural
factors preventing it from utilizing
Ethiopian Health Care System
Structure/BHS
20
Belief that those most in need of health care must participate
in its delivery to:
Generate any impact on the diseases afflicting them and that
Community involvement can ensure that culturally acceptable
care is provided to those who are under-served.
Changing theories of development that linked health to other
sectors
Gave rise to the principle of inter-sectoral
collaboration in health work.
Ethiopian Health Care System
Structure/BHS
21
WHO and UNICEF in 1978 came up with the Alma Ata
Declaration Primary Health Care (PHC) approach
PHC defined as :
An essential HC based on practical, scientifically sound and
socially acceptable methods and technology,
Made universally accessible to individuals and families in the
community through their full participation and
At a cost that the community and country can afford to
maintain at every stage of their development in the spirit of
self-reliance and self-determination.
Ethiopian Health Care System
Structure/PHC
22
The key factors for the implementation = are real political commitment,
active community participation, inter-sectoral collaboration, equitable
distribution, focus on prevention, and utilizing appropriate technology.
PHC approach subsequently introduced into Ethiopia 10 Years
National Perspective Health Sector Plan (1985 -1994) based on the
principles of PHC.
The ambitious goals of the health plan included:
Strengthening and expansion of mother and child (MCH) services.
A target coverage of 80% by 1993/1994
Ethiopian Health Care System
Structure/PHC
23
The plan emphasized community participation, inter-sectoral
collaboration, the gradual integration of vertical programs and
specialized health institutions.
Development of a 6-tiered health services structure.
This called for the development of 36,000 community health services,
each run by a community health agent (CHA) and a trained
traditional birth attendant (TBA).
The achievements of the 10-year plan were low compared to the
ambitious targets.
Ethiopian Health Care System
Structure/PHC
24
The main reasons for the low achievements were the:
Low level of community involvement, both in supporting and
utilization of services
Limited inter-sectoral collaboration
The structure of the MOH did not extend below the level of the
RHD and hence the absence of a planning, management and
evaluation mechanism at the awraja level, and
Managerial weakness at every stage of the health system.
Ethiopian Health Care System
Organization of the Ethiopian health
delivery system during various periods
25
Level of
Care
MC
BHS
3
3
2
Hosp
1
1
1
Clini
c
Reg.
Hosp
Dist
Hosp
Dist. HC
HS
PHC (Derg)
PHC (EPRDF)
Cent Ref
Hosp
Cent Ref
Hosp
Reg. Hosp
Reg. Hosp
Rural Hosp Zonal Hosp
HC
HC & HS
HS
Comm.
Ethiopian Health Care
System
Health
Comm.
Health
PHC post EPRDF & Health
Policy
26
Current structure (strategy) of the health
care
The National Health policy (1993)
Main objective is to provide a comprehensive and integrated PHC
in health institutions at the community level.
The Health Policy mainly focuses on:
Democratization and decentralization of the health system;
Ensuring accessibility of health care to all population;
Ensuring a basic package of quality PHC services, which should
include preventive, promotive and basic curative services.
Ethiopian Health Care System
PHC/Health Policy
27
Promoting inter-sectoral collaboration
Promoting and enhancing national self-reliance in health
by mobilizing and efficiently utilizing internal and
external resources.
The health policy has also identified the priority
intervention areas and strategies to be employed to
achieve the health policy issues.
Ethiopian Health Care System
PHC/Structure-post EPRDF
28
Health services are managed according to the decentralized
government structures of the country as a whole.
Overall responsibility for the countrys health policy rests on the
FMOH, while responsibility for the management of health
services delivery falls with the respective RHBs.
RHBs have been supported in the management functions by ZHD
and later on by WHOs.
A 5-tiered health services structure followed until HSDP.
Ethiopian Health Care System
Health sector development program (HSDP)
29
HSDP launched in 1998 in response to the prevailing and newly
emerging health problems in Ethiopia and the weaknesses
observed in the existing health delivery system.
HSDP has been implemented as part of reformation
process in the framework of the governments Sector
Wide Approach program (SWAP).
SWAP is owned by the state, but its planning is based on strong
partnership between the federal govt, the regional govts, the
Health Development Partners, the Private and NGO sectors.
Ethiopian Health Care System
HSDP
30
HSDP set long term plans for the sector and the means to attain
them by way of a series of phased, medium term plans
20 year plan to be implemented in 4 phases of 5 years each.
The focus of health delivery system improvement is guided
by the 8 components of HSDP at all levels.
Health service delivery & quality of care
Facility rehabilitation & expansion
Human resource development
Ethiopian Health Care System
HSDP
31
Strengthening pharmaceutical services
IEC
HMIS
Health care financing
Monitoring and Evaluation
Ethiopian Health Care System
HSDP 32
Level of
Care
4
3
2
1
Health care tier system
(until HSDP III)
Health facilities and the
Spec. Ref. Hosp (5,000,000)
Zonal Hosp. (1,000,000)
District Hosp. (250,000)
PHCU (25,000)
Health Posts
HC (25,000)
(HPs) (5,000)
Ethiopian Health Care System
HSDP/HSEP
33
Health Service Extension Programme (HSEP)
HSEP introduced in recognition of failure of essential services to
reach the people at the grassroots level (HSDP II).
It is a family and community-based intervention, which target
households to improve the health status of the families and their
members.
Considered as a key program for achieving the healthrelated
Millennium Development Goals
Health Extension Package- is package of services that include:
Ethiopian Health Care System
HSDP/HSEP
34
Provision of immunization,
Prevention, control and treatment of malaria,
Prevention of HIV/AIDS/STDs,
Prevention and control of Tuberculosis,
Provision of oral contraceptives,
Deliveries, follow up of high risk pregnant mothers,
First Aid,
Sanitation services including excreta disposal, insect and rodent control, safe water supply, housing
construction and overall environmental issues within the rural context.
Ethiopian Health Care System
HSDP/HSEP
35
HSEP includes 17 packages in four main areas:
Hygiene and environmental sanitation
Disease prevention and control
Family health services
Health Education and Communication
The HEP has been divided into
Agrarian area (Tigray, Amhara, Oromia and SNNPR)
Urban area (Harari, Addis Ababa and Dire Dawa)
Pastoralist area (Afar, Somali, Benishangul Gumuz and Gambella)
Ethiopian Health Care System
Some achievements HSDP III
36
Some achievements from HSDP III:
34,382 Rural HEWs deployed by the end of EFY 2002
5,918,714 model households graduated in EFY 2002
(80%)
2,596,031 households build latrines in EFY 2002 (58%)
As well in MCH, HCT, malaria, TB, .
Ethiopian Health Care System
HSDP III/Accelerated Expansion of PHCFs
37
Expansion of HCs is critical for achievement of the planned
universal PHC coverage:
To achieve the 100% PHC coverage, the target of HSDP III was
3,200 HCs by EFY 2002, BUT
they provide curative services and also
support the HEP (referral and TA for HEWs).
2,142 HCs available by EFY 2002 (67% cf. target).
99 HCs planned in A.A but only 2 available (2% cf. target)
14,192 HPs were constructed at the end of EFY 2002, (89.6%
cf. target) of which 12,527 equipped (79.1% cf. target)
Ethiopian Health Care System
HSDP III/Service utilization
38
The level of service utilization, in terms of OPD consultations
per capita, declined from 0.3 in EFY 2001 to 0.29 in EFY 2002
(<< target for HSDP III, 0.66).
Achievement was also much lower cf. target norm set for
developing countries (2.5 visits/person/year).
Wide variations were observed across regions, ranging
between 0.11 visits per capita in Gambella and 0.68 in Addis
Ababa.
Underreporting or decrease
in OPD service utilization???
Ethiopian Health Care System
HSDPIII/Essential pharmaceutical services
39
Regulatory activities
The Proclamation on Food, Medicine and Health Care Facilities has
been approved. The Model Proclamation that enables regions to
prepare their own legal framework on inspection of food, drugs and
health care facilities has been prepared and distributed to regions.
Pharmaceutical supply
PFSA carried out forecasting, procurement, distribution, fleet
management, warehouse infrastructure and capacity building
activities.
Procurement package worth ETB 3.04 Billion, and direct
distribution to health facilities on bimonthly basis.
Ethiopian Health Care System
Ethiopian health tier system (end of HSDP
III)
Specialized
Hospital
3.5 5.0
Million
Tertiary level health
care
General hospital
(1000000-1500000)
people
Primary hospital
Health
center
40000
Secondary level health
care
60000-100000
Health center
15000-25000
Health post
3000-5000
40
Ethiopian Health Care System
Primary
level health
care
Bibliography
41
Derso A (2011). History of Modern Health Care in Ethiopia (a
PowerPoint presentation obtained from the internet).
FMOH (2010).HSDP III: Annual performance report for EFY
2002, Addis Ababa, Ethiopia.
FMOH (2010). Guideline for implementation of a patient
referral system, Addis Ababa, Ethiopia.
Haile Mariam D and Kloos H (2005). Modern Health Services.
In: Berhane Y, Hailemariam D, Kloos H eds, The
Epidemiology and Ecology of Health and Disease in Ethiopia,
Shama Books, Addis Ababa.
Ethiopian Health Care System
Bibliography
42
Kloos H (1997). Primary health care in Ethiopia
under
three
political
systems:
community
participation in a war-torn society. Soc Sci Med 46:
505-522.
Pankhurst R (1965). The beginnings of modern
medicine in Ethiopia. Ethiop Observer 9: 114-160.
Ethiopian Health Care System
