1.8 Dr. N. Kedir Bilal Presentation LMGConference 29 Jan13
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1.8 Dr. N. Kedir Bilal Presentation LMGConference 29 Jan13

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LMG in Devolved Health Systems: Learning from International Experience

LMG in Devolved Health Systems: Learning from International Experience

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  • Potential advantages decentralizationDecisions made locally are based on better informationFaster decisionsGreater accountability

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  • 1. Health System Decentralization the Case of Ethiopia Kenya National Health Leadership Management and Governance Conference Nejmudin Kedir Bilal, P. Health Economist, AfDB January 29, 2013
  • 2. Outline1. Background2. How was decentralization conducted?3. Why decentralization in Ethiopian health system?4. Key health systems aspects of decentralization5. Lessons learnt
  • 3. 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.
  • 4. THE PROCESS OFDECENTRALIZATIONPart of broader governmentdecentralization 9 regional state governments,Phased approach 2 city adminis • 1996 to Regional States • 2002 to Woredas (and Zones) Zones,Not one size fits all More than 850approach districts • Some with strong zones 15,000 Kebeles • Some with lessor role for zones • Some with no zones
  • 5. 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 Low Biased level of towards Health service financin Health PlanningGovernance and curativeDecentralization Delivery reform Shortage HIS reforms Financing Reform g & care and Pharmaceuticals poorly Poor governance of Centralized motivated reform health health institutions
  • 6. Health System Decentralization• 4 tier health system Specialized organization Hospital(5 million) – PHCU (health center + 5 health posts) (25,000) General – District hospital (250,000) Hospital (1million) – Zonal hospital (1 million) – Specialized hospital (5 million people) Rural Hospital (100.000)• Health Extension Programme 2003/2004 PHC unit=1HC+5 Satellite HP (25 million)
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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 11
  • 12. Key principles were set to reform and decentralize health information system1. Standardize Indicators by Category Indicators & definitions Disease list for reporting & case definitions Client / patient flow & data elements 0 5 10 15 20 25 Recording & Reporting forms Procedure manual Reproductive Health Information use guidelines Child Health and EPI2. Simplify Malaria Reduce data burden Streamline data management procedures TB/Leprosy HIV/AIDS3. Integrate Data channel Assets Client / patient information at facility (integrated folder) Finance Human Resources4. Institutionalize Coverage and Utilization
  • 13. Not only collection but use information at all levels FMOH Compiled and used RHB WoHO Compiled and used/reportedHF Compiled and used/reported Service delivery report
  • 14. Health Service challenges: Preventable health problemsas major causes of morbidity and mortality (60%-80%) 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 Limited knowledge of optimal care practices at the family level Limited physical access to health services in rural communities Poor institutionalization of PHC
  • 15. HEP: Innovative approach to deliver Preventive andPromotive Health Services Hygiene and Disease Environmental Prevention Sanitation and Control HEP MNCH Health Education
  • 16. HEP: Process & Roles defined for Training, Deployment &Support on Implementation 2 trainees per village recruited by local government and community MOH and MOE collaborate to provide a 1 year training Community builds health post as a hub of operation for HEWs HEWs assigned back to the village, train and graduate households Local government pays salary Village council involves the HEWs and provides leadership Supervisors assigned 1 HC/5 HPs for technical and logistic support FMOH and DPs provide equipment and supplies Customized HMIS to track progress
  • 17. Capacity building: Accelerated scaling up of HRH and infrastructure to support HEP
  • 18. Decentralized Governance and Health Care Financing Reform-Five Components1. 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
  • 19. Key Lessons1. Part of broader government decentralization2. Sequencing decentralization makes it more effective3. Continuous and demand based capacity building4. Some things are better kept at higher levels5. Devolution does not mean no accountability!6. Be ware of interrupting ongoing programmes