Building On Ethiopia’s Health Care Success

Over the past decade or so, Ethiopia has been in the limelight of global health for its impressive achievement in the health sector. The country’s flagship health extension program has received numerous accolades as innovative, pragmatic, and comprehensive service delivery platform. Ethiopia has also expanded its network of primary health centers at an unprecedented pace. The number of nurses, midwives, health officers, and other health professionals who staff these centers has increased by many folds.

The country is also known for spending donor resources wisely; it has used vertically available resources to finance investments in health system building blocks. Community mobilization has been effectively used to combat communicable diseases such as HIV and Malaria, and improve utilization of maternal health services.

Despite the impressive progress the country has made, Ethiopia has still one of the highest numbers of preventable maternal and child deaths. Health inequality is also a big problem. There is a huge disparity in health outcomes between urban and rural, rich and poor, literate and illiterate households. There is a growing concern on the quality of health services as well.

In fact, under my leadership, a visioning exercise has been carried out to map the strategic areas that need special emphasis. In this exercise, regions, academia, the private sector, and local and international partners have participated. During that exercise, six strategic areas were prioritized for current and future health sector investments.

The current organized community mobilization, the health development army, should continue, evolve and be tailored according to the need of the majority. We have witnessed genuine interest and engagement of the community, particularly women groups to end the scourge of maternal death and morbidity. This engagement, for example, resulted in the construction of maternity waiting homes in many rural health centers across the country and financial contribution for the procurement and operational cost of ambulances.

The key question in empowering the community in a sustainable and effective manner is “how can we keep the community engaged and interested in health?” This requires pragmatic leadership and continuous dialogue at all levels of the system. The ultimate objective of community empowerment is to ensure community ownership of the health system through meaningful participation of community members. Various strategies, including community representation in health facility governance boards, establishing patient (community) councils to support health facilities, innovative social accountability platforms including town hall meetings with health facilities need to be put in place to galvanize and consolidate the popular movement of our communities throughout the country. This will ensure that individuals, families, and the community at large are empowered to produce their own health and contribute to the vision of healthy society.

As the size of urban and middle-class population increases, there will be a continued pressure on the health sector to focus on setting up big hospitals and specialized services. This will be a less effective path to achieve good population level outcomes. The experiences from South Africa, the United States, and many other countries do not inspire confidence to move in this direction, which will be a costly and less effective endeavor for population level outcomes despite relatively better individual level outcome.

In order to build an affordable and sustainable health system, it is critical to emphasize the importance of having a high performing primary health care. Reviewing the functionality this and redefining it accordingly in a wider health sector context is essential to address the evolving need and expectation of the community.

This requires the expansion of the essential health service packages, expanding and sustaining numbers of functioning health facilities, establishing effective management and governance systems and networking with higher health care facilities, repositioning the role of health extension workers to catalyze community ownership and drive social accountability programs. It is of paramount importance to invest in quality of care at the primary health care level. This is through developing a quality continuum from quality planning to quality control and quality improvement processes, team-based approach, elevating knowledge and skills of the primary health care staff, developing a well-functioning supply chain of medicines and medical equipment, and use of appropriate technology and enhance capacity to handle public health emergencies.

We have to ensure that adequate and appropriate skill mix of the health workforce remains the backbone of the health system. Investments need to be made to strengthen mechanisms for production and retention of health workers. It should be deployed to improve the quality of training of health professionals, supporting growth along defined career paths, fostering competency, and strengthening the human resources information system for evidence-based decision making in planning, implementation, monitoring and evaluation of the human resource development. This, in turn, should be guided by a long-term strategic roadmap and periodical revisions to cope with the existing and anticipated health needs of the nation.

In this ever-changing global development landscape, international development assistance will fall significantly over the next few years. Leveraging non-state resources is an opportunity to narrow the gaps of resource constraints as well as improve access to the health services. The role of private sector needs to be enhanced to improve access and choices to health care services. Policies to bring down the drivers of cost in private health sector should be introduced to encourage private providers to improve access to better health care with affordable cost. This requires developing capacity within the Ministry of Health to manage arrangements for public-private partnerships, strengthening regulatory capacity, and encouraging the private sector to take advantage of an enabling policy environment to invest in health. It needs to increase the engagement of professional associations, civic society and non-governmental organizations in the health sector and provide due attention to traditional or alternative medicine.

There is a need for more money for health and more health for the money if the country is to achieve the ambitious goals it has set in its development plans. Financial constraints are among the challenges to avail quality health services to all in need of them. Adequate funding for health addresses financial barriers to equitable access and is a vital lever to move in the direction of universal health coverage by eliminating or markedly reducing catastrophic out-of-pocket expenditures. This requires innovative domestic health care financing strategies to be put in place, introduce efficiency gains in the health sector, fostering for mutual accountability of donor funding for health, developing forecasting and monitoring tool for internal and external funds for health including primary health care, and developing health insurance models.

Developing leadership capability will be instrumental in transforming the health sector in Ethiopia. Nurturing leadership capability at policy, programmatic, operational and community level will be instrumental in harmonizing and aligning investments as well as redressing health inequalities in different settings. Institutional capacity building should aim at improving the performances of institutions and organizations. It includes a comprehensive capacity of institutes including human as well as intellectual capital, supplies, infrastructure, and capacity to innovate to cope with the ever-increasing demand and emerging circumstances. Starting from the institutional needs ensures that initiatives at the individual level will be meaningful for the institution and the system in general.

If these are strategically prioritized and invested in over the coming years, with flexibility to be responsive to the changing needs and demographics of the population, great gains can be had in improving the health status of the Ethiopian population.

By Kesetebrihan Admasu (MD)
A public health specialist and Minister of Health between 2012 and 2016

Published on Jan 17,2017 [ Vol 17 ,No 872]



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