COURSE OUTLINEUNIT I: THE HISTORICAL DEVELOPMENT OF HEALTH CAREDELIVERY SYSTEM1.1: INTRODUCTION TO HEALTHCARE DELIVERY SYSTEM ANDDEFINITION OF TERMS1.1.1. Introduction1.1.2. History of the Ethiopian Healthcare Delivery System1.1.3. Historical Background of Modern Medicine in Ethiopia1.2: BASIC EVENTS IN HISTORY OF ETHIOPIAN HEALTHCAREDELIVERY SYSTEM1.2.1. The Basic Health Service Period (BHS) from 1953-19741.2.2. The Primary Health Care (PHC) Period (from 1978-1991)1.2.3. Sector wide Approach Period (199…….)1.2.4. The Traditional Medicine Practice in EthiopiaUNIT II: THE CURRENT ETHIOPIAN HEALTH POLICY2.1: GENERAL POLICY2.2: PRIORITIES OF THE POLICY2.3: GENERAL STRATEGIES1.2.4. The Traditional Medicine Practice in Ethiopia
UNIT II: THE CURRENT ETHIOPIAN HEALTH POLICY2.1: GENERAL POLICY2.2: PRIORITIES OF THE POLICY2.3: GENERAL STRATEGIESUNIT III: STRUCTURE OF HEALTHCARE SERVICE ORGANIZATION3.1: STRUCTURE OF THE HEALTHCARE SERVICE ORGANIZATION3.1.1. Introduction3.1.2. Administrative Structure of the Healthcare System Organizations3.2: CONTRIBUTORS OF HEALTH CARE PROVISION IN ETHIOPIA3.2.1 The Government3.2.2 Private Providers3.2.3 Nongovernmental Agencies (NGO’s)3.2.4 International Health Agencies
UNIT IV: COMPONENTS OF THE HEALTH CARE DELIVERY SYSTEM4.1: COMPONENTS OF HEALTHCARE DELIVERY SYSTEM4.1.1. Introduction4.1.2. The Current 4 Tiers System4.1.3. Major Components and Actors of Healthcare Delivery System4.2: THE HEALTH CARE FACILITIES AND SERVICES THEY PROVIDE4.2.1. The Primary Healthcare Unit (PHCU)4.2.2. District Hospital and Services Provided4.2.3. Zonal/Regional Hospitals and Services Provided4.2.4. Referral Hospitals4.3: HEALTHCARE WORKFORCE AT DIFFERENT LEVELS OF HEALTH FACILITIES4.3.1 Human Resource (healthcare workforce) Requirement
UNIT V: HEALTH SERVICE PROGRAMS5.1: THE HEALTH POLICY, PLANS AND STRATEGIES5.1.1. Introduction5.1.2. The HSDP-III5.2: ESSENTIAL HEALTH SERVICE PACKAGE5.2.1. Introduction5.2.2. The Health Service Extension Program (HSEP)5.2.3. Family Health Services (Maternal and Child Health Care)5.2.4. Prevention and Control of Disease5.2.5. Medical Services5.2.6. Hygiene and Environmental Health5.3: HUMAN RESOURCE DEVELOPMENT5.3.1 Introduction5.4: PHARMACEUTICAL SERVICE5.4.1 Pharmaceutical Services
5.5: IEC AND HEALTH INFORMATION MANAGEMENT SYSTEM (HIMS)5.5.1. Information, Education and Communication (IEC)Health Information Management System (HMIS)5.6: MONITORING AND EVALUATION (M&E) AND HEALTHCARE FINANCING5.6.1. Monitoring and Evaluation (M&E)5.6.2. Healthcare FinancingUNIT VI: HEALTHCARE SYSTEM REGULATION6.1: HEALTHCARE SYSTEM REGULATIONS6.1.1 Introduction6.1.2. Regulation of Credentialing Health Manpower6.1.3. Professional Associations6.2. HEALTH INFORMATION SYSTEMS POLICIES AND PROCEDURES6.2.1. Introduction6.2.2. HIS Policies and Procedures6.2.3. Health Information Related I
UNIT VII: HEALTHCARE SERVICE PLANNING7.1: HEALTHCARE SERVICE PLANNING7.1.1 Introduction: definitions of key terms7.1.2 Health Service Planning7.1.3 Strategies and Approaches used in Health Service Planning7.2. RESOURCE IDENTIFICATION7.2.1 Introduction to Classification (and Identification) of ResourceTEXTBOOKS/REFERENCE BOOKS AND MANUAL1. Module Handouts are distributed to the students as textbook2. HSDP I, II,III, FMoH3. Harmonization Manual, FMOH4. Chali Jirra et al. Health service Planning and management for health science students.5. Jonathans. Rakich et.al Managing health service organization, third edition, 1992 Maryland, USA
ABBREVIATIONSAIDS Acquired Immune Deficiency SyndromeART Anti retroviral therapyBHS Basic Health Service PeriodBOC Basic obstetric careCHP Community health promotersCOC Comprehensive obstetric careCSRP Civil service reform programDACA The Drug Administration and Control AuthorityDKA Diabetic Keto acidosisEHNRI Ethiopian health nutrition research instituteEOC Emergency obstetric careEPA Ethiopian public health associationESOG Ethiopian society of obstetrics and gynecologyFP Family Planning
FMIS Financial management information systemFMOH Federal ministry of healthGO Government organizationHC Health centerHCF Health care financeHIMS Health information management systemHIV Human immune virusHOS HospitalHP Health postHSEP Health service extension programIDSR Integrated Disease Surveillance and ReportIMR Infant mortality rateLMIS Logistics management information systemM&E Monitoring and evaluation
MCH Maternal and Child HealthMCHC Maternal and child health careMDGS Millennium development goalsMIS Management information systemMMR Maternal mortality rateNAC National advisory committeeNGOS Nongovernmental organizationPASS Pharmaceutical Administration and Supply ServicesPHC Primary health carePMTCT Prevention of mother to child transitionRHB Regional Health BureauSNNPR Southern Nations and nationality peoples regionSWOT Strength Weakness Opportunity ThreatTFR Total fertility rateTLCP Tuberculosis leprosy control programU5MR Under five mortality rate
MCH Maternal and Child HealthMCHC Maternal and child health careMDGS Millennium development goalsMIS Management information systemMMR Maternal mortality rateNAC National advisory committeeNGOS Nongovernmental organizationPASS Pharmaceutical Administration and Supply ServicesPHC Primary health carePMTCT Prevention of mother to child transitionRHB Regional Health BureauSNNPR Southern Nations and nationality peoples regionSWOT Strength Weakness Opportunity ThreatTFR Total fertility rateTLCP Tuberculosis leprosy control programU5MR Under five mortality rate
1.1.1. IntroductionHealth care delivery system is a network of integrated components designed to work together coherently,to provide healthcare to a population in various settings. Concepts from general systems theory are useful inunderstanding the structure and operation of a nation’s health system. For this purpose the following must beidentified:The major actors, which can further be classified as : – healthcare users/consumers – healthcare providers – policy makers/regulatorsTheir resources, which can be further classified as: – funding – personnel – facility – technology – information
The mechanism through which they interactThe external forces which affect the processThe healthcare delivery system like all systems is dynamic with many feedbacks loops among providers, consumers and regulators, allowing for change in the system’s performance1.1.2. History of the Ethiopian Healthcare Delivery SystemEthiopia has one of the worst health statuses, with poor environmental condition and inadequate healthservices. Long periods of civil strife, rapid population growth and environmental degradation have furtheraggravated these health problems.
The country has a new health policy and strategy; the health service is to be re- organized into a more costeffectiveand efficient system that can contribute better to the overall socio-economic development effort of the country. To understand the current healthcare system we must look back to the historical background of modern medicine in Ethiopia, and the role traditional medicine plays.1.1.3. Historical Background of Modern Medicine in Ethiopia
There have been occasional contacts between modern medical practitioners and Ethiopians prior to the end of the 19th-century.A Portuguese “barber surgeon” was known to be at the courts of King Lebne-Dengel in the 15th century: then the German missionary, by the name of Peter Heiling, was at the court to Emperor Fasiledes in the 16th century, and several others have been recorded.
If we reflect back in history, the years just before and after the turn of the millennium can be considered as a centenary for health services in Ethiopia. It was just at the end of the 19th and the beginning of the 20th centuries that modern health care was introduced in the country. The first modern health care facility in the country (a Russian Red Cross Hospital) was established in Addis Ababa in 1987 with a capacity of 50 beds. It is interesting to note that the mission produced a small booklet in Amharic of 22 pages, which was to serve as a textbook for Ethiopian staff. The Russian mission stayed in the country for ten years,
and in 1906 the hospital was closed. Following that a leprosarium and hospital were opened in Harar in 1901 and 1903 respectively. In the year 1909 the first public hospital Menilik II established on the site of the Russian hospital. At the beginning it had 30 beds .The hospital has been in operation ever since on the same site and even today it’s called by its original name, “Menilik II hospital”.
After Minilk II Emperor Hilesilase I continued and the reform drive of Emperor Halile Selassie I during 1917- 1935 focused on economic and social conditions that included health expansion and management reforms. This drive was interrupted during the brief occupation of Ethiopia by the Italians. Until Soon after the liberation of Ethiopia in 1941 the period of reconstruction time that a Department called “Public Health Directorate” was established under the then powerful Ministry of Interior (MOI). The first director of the unit was a British Doctor known by the name Colonel Maclean. It was made responsible for the establishment of the first hospital, and for the general problems in the health field.
During that time, there were several Christian missions operating in the country, they provide health care to the people in addition to their religious and sometimes educational activities. In 1922 another hospital was established in Addis Abeba. An American missionary named Dr. Thomas Lambie collected money, erected a building in the Gulele area, and established a hospital with 70 beds. This hospital had 4 medical doctors and 5 nurses on its staff.
The hospital was converted into a research Institute in 1942, then into the Institutes of Pasteur in 1950. In 1964 it was converted into the central laboratory and research institute, and finally it was merged with Ethiopian Nutrition Institute (ENI), today it’s called Ethiopian Health and Nutrition Research Institutes (ENHRI).
Because of expansion of health service government has taken Major step in the autonomous development of health care which did not happen until the formal establishment of the Ministry of Public Health (MOPH) in 1948. By 1948 there were already several hospitals in the country. At that time, the majority of hospitals, and health facilities were run by different mission organizations.
In speaking of the historical development of health services in Ethiopia, one must mention the contribution of first Ethiopian medical doctors. Dr. Martin Workineh. As a child of three years he was found on the battlefield after the battle of Maqdela (1868). The boy was taken and educated in India and later in Britain, sponsored by two officers, Colonel Charles Chamberlain and Colonel Martin, and after them he was named Charles Martin. After the first aborted Italian invasion of Ethiopia in 1896,
Martin arrived in Addis Abeba, where a he pitched a tent in the center of the city and run a clinic, treating patients free of charge. During that time he learned who his parents were and found his grandmother, who told him his name was Workineh. Hakim Workineh as he was popularly known served not only as a physician but also as a diplomat, he died at the age of 84 in 1952.
The second Ethiopian medical doctor was Dr. Melaku Beyan, who early in this century obtained his medical degree at Howard University in the United States. He was chief medical officer of the Ethiopia Army during the Italian invasion from Somalia in 1935. Dr. Melaku died in exile during the Italian occupation of Ethiopia.
Whatever medical developments there was in the country, it was disrupted during the Italian occupation. After the war, another hospital was established named after Princess Tsehay who was the first Ethiopian nurse, having graduated in England during the war. Look at table 1 for the detail of historical events in the Ethiopian health care delivery system Period Date Event 1520- 1526 Foreign medical contacts with Portuguese Barber surgeon 1830s and 1840s French and British missions,
introduced vaccination Period of Unification and Independence 1856 Use of small pox vaccine officially promoted by Emperor Tewdros 1896Battle of AdewaRussian red cross mission published first medical text in AmaharicDr (Hakim) Workeneh return to Ethiopia1987 The first hospital in Ethiopia Established by the Russian red cross mission Power struggle1909 The first Government hospital Minilk II opened1930 The first public health low endorsed Emergence of Absolutism
Early 1930s First health budget allocated Public latrine introduced1935 Minilk II started training the first medical auxiliariesDr Melaku Beyane the first trained Dr return to EthiopiaEthiopian Red cross society established in JulyOutbreak of Italio- Ethiopian warFrom Libration to Revolution1941 Bureau of Hygiene established with in the ministry of interior1942 School of medical service started1947 Ministry of Health Established1948 Medical education board established1950 University collage of Addis Ababa started1952 Policy decision on developing Health center
1957-1961 The first five year development plan planed1959 Malaria eradication program launched1963-1967 The second five year plan planed1968 Planning division ministry of public health established1969/1970 Small pox eradication program launched1970 Malaria eradication program converted to control programThe Derge Period1974 Ethiopian revolution1975 Launching of the National Democratic Revolutionary program1976-1980 The 5 year rural health development program1978 Adoption of primary health care1984 Ten years perspective Development plan1991 Fall of Derge Regime
EPRDF Regime1991-1995 Transition time1993 Development of health policy and strategy1998-2002 Health sector development program I2003-2007… Health sector development program II
1.2.1. The Basic Health Service Period (BHS) from 1953-1974For Ethiopia (following the WHO recommendation), BHS was seen as a long term strategy for providing adequate and essential health care by making available a HC for a population of 50,000 and a Clinic for a population of 5,000. A new chapter in the development of health services was opened when, with the assistance of international organizations, Gondar Public Health College and training center was established in 1952.
The Institute trained three categories of health personnel; public health officers, community nurses and sanitarians, who were intended to serve in the health centers, a new type of the institution. One health center was supposed to serve 50,000 people, with the help of satellite health stations.The first organized training of health personnel can be traced back to 1945, when a six- month course was offered to all hospital orderlies, who were then upgraded to the status of “dressers”.
• The first nursing school was established in Addis Abeba by the Red Cross society in 1950. The training center for medical and health technicians was established in 1963 within Menilik II hospital. The first medical school was established in 1962.• Due to the slow development of general health services and subject to some international pressure, special projects to combat individual disease were embarked upon. The most important project is the Malaria eradication project, established in 1959;
the TB control project, a Leprosy control project, the Ethiopian nutrition institutes, and the small pox eradication service are examples of the bigger projects. Some of these projects are still in existence.
1.2.2. The Primary Health Care (PHC) Period (from 1978-1991)Change in Government from Imperial Rule to Military Rule followed by subsequent political orientation into socialist ideology after 1974 brought with it radical changes in the health policy of Ethiopia which in some ways provided the foundation for further development of health care delivery system. Also in 1977 the WHO set a goal of providing “health for all by the year 2000” which aims at achieving a level of health
that enables every citizen of the world to lead a socially and economically productive life. The strategy to meet this goal was later defined in the 1978 WHO/UNICEF joint meeting at Alma-Ata. In this meeting it was declared that the primary health care strategy is the key to meet the Goal of “Health for all by the year 2000”.
After the World Health Assembly (in 1978), Ethiopia fully endorsed that the target of governments and WHO should be the attainment of a level of health that would enable all people to lead a socially and economically productive life by the year 2000. This was commonly known as “Health for All by the year 2000”, also known as the “Declaration of Alma-Ata”
• A) The declaration of PHC• The declaration of PHC focused on the following main concepts:• 1. Equitable distribution• Health services must be shared equally, distributed by all people irrespective of their ability to pay and all (rich or poor, urban or rural) must have access to health services. Primary health care aims to address the current imbalance in health care by shifting the centre of gravity from cities where a majority of the health budget is spent to rural areas where a majority of people live in most countries.
2. Active community participation/InvolvementActive community participation/involvement is:The process by which individuals and families assume responsibility for the community and develop the capacity to contribute to their and the community’s development.A means by which communities can play a more influential role in health development, in which the emphasis is on strengthening the capacity of communities to determine their own needs and take appropriate action.
Community Involvement is the process of involving the community in the planning, implementing and monitoring and evaluation unlike participation. Communities should not be passive recipients of services everybody should be involved according to his ability and the Health system is responsible for • Explaining and advising • Providing clear information about the favorable and adverse consequences of the interventions being proposed as well as their relative cost.
– The communities should be actively involved inThe assessment of the situationProblem IdentificationPriority setting and making decisionsSharing responsibility in the planning implementing, monitoring and evaluation
3. Intra and Inter-sectoral linkagesPrimary health care involves in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communication and other sectors.
B) The four cornerstones in Primary Health CareThe four cornerstones in Primary Health Care (or Pre- requisites for PHC) are:1. Active community participation/Decentralization/2. Intra and Inter-sectoral linkages3. Use of appropriate Technology4. Political commitment /Support Mechanism made Available/
C) The Components/Elements of PHCThere are twelve elements of PHC on implementation in Ethiopia. Of these elements from number one to eight are the components by which implementation began while the last four were added later on.1. Immunization-immunization against the major infectious diseases (six childhood diseases)2. Food supply and proper nutrition-promotion of food supply and proper nutrition
Improve food supply and proper nutrition.Correction of faulty feeding practices.Treatment and rehabilitation of malnourished children.Treatment and prevention of nutritional diseases.3. Water and sanitation-an adequate supply of safe and basic sanitation.4. Prevention and treatment of locally endemic disease and injuries.5. Maternal and Child Health (MCH) and Family Planning (FP). Main functions are:
Antenatal careDelivery carePostnatal careChild careFamily planning6. Provision of essential drugs7. Health EducationFor promoting healthFor prevention of diseaseFor maintenance of healthEducation to deal with the disease.
8. Control of communicable diseases9. Mental health10. Dental health11. Control of ARI12. Controls of HIV/AIDS and other STDs.The 1985 review of PHC implementation attempts in Ethiopia revealed the following achievements.
Expansion of health services to the broad masses especially by establishing new health station and health posts.Expansion of immunization program against six major communicable diseases.Increasing number of medical and paramedical personnelIncreased health propaganda attempts to improve health consciousness of the population by building the promotion of health information to the people.
• Problems encountered in PHC implementation in Ethiopia – Nature of community involvement (poor community participation) – Political and social organization – Political and bureaucratic unwillingness – Structure and tradition of formal health system – Lack of resource planning and management.
– difference of vision between community and health professionals– Misunderstandings:– PHC is community based care– It is only for poor people in developing countries– It is for rural area– PHC is cheap, etc.
• 1.2.3. Sector wide Approach Period (199…….)• The government of Derge is overthrown by EPRDF in 1991 and transitional government was established for 1991-1995. During this period health policy and strategy were developed.• Currently the Ethiopian government is following a twenty-year health development implementation strategy, known as the Health Sector Development Program (HSDP), with a series of five-year investment programs.
• HSDP proposes a sector-wide approach to achieve the government’s objectives.• The Health Sector Development Program, launched by the government in 1998, was devised after studying the kind of health problems that affect Ethiopia and researching their root causes. It also took into consideration emerging serious health issues such as HIV/AIDS and put a strong emphasis on the needs of the rural Ethiopia, where overwhelming majority of the country’s citizens live.
Sector wide approach-based health care delivery system is owned by the state, but its implementation is firmly based on strong partnership between the Central Government, the Regional Government, the Health Development Partners, the Private and NGO sectors. The focus of health delivery system is expansion and improvement in the quality of care and is guided by the eight components of the Health Sector Strategic Plan (HSDP) at all levels.
The eight components of HSDP are:1) Health service Delivery and Quality of care.2) Health facility Rehabilitation and Expansion.3) Human Resource Development.4) Strengthening Pharmaceutical Services.5) Information, Education and Communication.6) Health Management Information Systems.7) Healthcare Financing.8) Monitoring and Evaluation.
1.2.4. The Traditional Medicine Practice in EthiopiaLong before the advent of modern medicine, Ethiopia had its own method for combating disease. These methods are usually referred to as Ethiopian traditional medicine. Not only was a traditional medicine structure operation prior to the advent of modern medicine, but it can be said that even today the rural populations depend on it.Ethiopian traditional practitioners practiced not only curative but also preventive medicine, and the first
“Cordon Sanitaire” was established in Gondar as early as 1830 G.C. Similar actions were taken in the whole country in 1918 G.C. during the notorious influenza pandemic variolization was very widespread as a means of preventing small pox, and in certain times in the 18th century the variolization was even compulsory.
The traditional Ethiopian pharmacopoeia comprised items from the animal and vegetable kingdoms. And even some minerals (e.g. floss from iron melting). Counter-irritants (burning of the skin over the diseased part of the body), bleeding and cupping were other routinely used procedures. Several surgical procedures, including trepanation and Cesarean section, have been repeatedly reported, but probably the greatest skills were observed in bone- setting (‘Wegesha’), including even operations and insertions of sheep’s bone.
In connection with traditional medical practices, one has to mention some harmful procedures that have been widely practiced in the country, such as female circumcision, removal of tonsils by means of a nail, uvula cutting, and pulling healthy children’s teeth.In recent times the Ministry of Health has been making an effort to integrate traditional medicine into the general network of health services, particularly since the skills of certain healers are known to be effective.
Among the most prominent practitioners, bone- setters (wogeshas), herbalist’s (kitel betash), traditional birth attendants and particularly different types of “spiritual healers” can be useful in general, and the people appreciate their services.Formal recognition to traditional medicine in Ethiopia was given in 1942 (Proclamation 27), where legitimacy of the practice was acknowledged as long as it does not have negative consequence on health.
Despite the relatively rapid expansion of modern medicine, traditional medicine (TM) is still the predominanthealth care resource in Ethiopia. World Health Organization estimated that 80% of the population in developingcountries and as many as 90% of the Ethiopians use TM for their illnesses
UNIT II: THE CURRENT ETHIOPIANHEALTH POLICYIntroductionIn the first unit of the module we have seen the historical development of health care delivery system inEthiopia period by period from early exposure of medical practice to the current sector wide approach.In this unit we will see the general policy, priories of policy and general strategies of the policy in Ethiopia context.
ObjectivesOn completion of this unit students should be able to:State the ten points on general policyIdentify the general strategies of health policyState the eight health policy priorities2.1: General Policy – Democratization and decentralization of the health service system. – Development of preventive and promotive components of health care.
– Development of an equitable and acceptable standard of health service system that will reach all segments of the population within the limits of resources.– Promoting and strengthening of intersectoral activities.– Promotion of attitudes and practices conducive to the strengthening of national self-reliance in health development by mobilizing and maximally utilizing internal and external resources.– Assurance of accessibility of health care for all segments of the population.– Working closely with neighboring countries, regional and international organizations to share information and strengthen collaboration in all activities contributory to health development including the control of factors detrimental to health.
– Development of appropriate capacity building based on assessed needs.– Provision of health care for the population on a scheme of payment according to ability with special assistance mechanisms for those who cannot afford to pay.– Promotion of the participation of the private sector and nongovernmental organizations in health care.
2.2: Priorities of the Policy Information, Education and Communication (I.E.C) of health shall be given appropriate prominence to enhance health awareness and to propagate the important concepts and practices of self- responsibility in health Emphasis shall be given to:The control of communicable diseases, epidemics and diseases related to malnutrition and poor living conditions;The promotion of occupational health and safety;The development of environmental health;The rehabilitation of the health infrastructureThe development of an appropriate health service management system;
– Appropriate support shall be given to the curative and rehabilitative components of health including mental health.– Due attention shall be given to the development of the beneficial aspects of Traditional Medicine including related research and its gradual integration into Modern Medicine.– Applied health research addressing the major health problems shall be emphasized.– Provision of essential medicines, medical supplies and equipment shall be strengthened.– Development of human resources with emphasis on expansion of the number of frontline and middle level oriented training shall be undertaken.
– Special attention shall be given to the health needs of:The family particularly women and children;Those in the forefront of productivity;Those hitherto most neglected regions and segments of population including the majority of the rural population, pastoralists, the urban poor and national minorities,Victims of man-made and natural disasters.
2.3: General StrategiesDemocratization within the system shall be implemented by establishing health councils with strong community representation at all levels and health committees at grass-root levels to participate in identifying major health problems, budgeting, planning, implementation, monitoring and evaluating health activities.Decentralization shall be realized through transfer of the major parts of decision-making, health care organization, capacity building, planning, implementation and monitoring to the regions with clear definition of roles.Intersectoral collaboration shall be emphasized particularly in:
– Enriching the concept and intensifying the practice of family planning for optimal family health and planned population dynamics.– Formulating and implementing an appropriate food and nutrition policy.– Acceleration the provision of safe and adequate water for urban and rural populations.– Developing safe disposal of human, household, agricultural, and industrial wastes, and encouragement of recycling.– Developing measures to improve the quality of housing and work premises for health.
– Participation in the development of community based facilities for the care of the physically and mentally disabled, the abandoned, street children and the aged.– Participating in the development of day-care centers in factories and enterprises, school health and nutrition programmes.– Undertakings in disaster management, agriculture, education, communication, transportation, expansion of employment opportunities and development of other social services.– Developing facilities for workers’ health and safety in production sectors.
• Health Education shall be strengthened generally and for specific target populations through the mass media, community leaders, religious and cultural leaders, professional associations, schools and other social organizations for: – Inculcating attitudes of responsibility for self-care in health and assurance of safe environment. – Encouraging the awareness and development of health promotive life-styles and attention to personal hygiene and healthy environment. – Enhancing awareness of common communicable and nutritional diseases and the means for their prevention.
– Inculcating attitudes of participation in community health development.– Identifying and discouraging harmful traditional practices while encouraging their beneficial aspects.– Discouraging the acquisition of harmful habits such as cigarette smoking, alcohol consumption, drug abuse and irresponsible sexual behavior.– Creating awareness in the population about the rational use of drugs.
• Promotive and Preventive activities shall address: – Control of common endemic and epidemic communicable and nutritional diseases using appropriate general and specific measures. – Prevention of diseases related to affluence and ageing from emerging as major health problems.• Prevention of environmental pollution with hazardous chemical wastes
• Human Resource Development shall focus on:• Developing of the team approach to health care.• Training of community based task-oriented frontline and middle level health workers of appropriate professional standards: and recruitment and training of these categories at regional and local levels.• Training of trainers, managerial and supportive categories with appropriate orientation to the health service objectives.• Developing of appropriate continuing education for all categories of workers in the health sector.• Developing workers within their respective systems of employment.
• Availability of Drugs, supplies and Equipment shall be assured by:• Preparing lists of essential and standard drugs and equipment for all levels of the health service system and continuously updating such lists.• Encouraging national production capability of drugs, vaccines, supplies and equipment by giving appropriate incentives to firms, which are engaged in manufacture, research and development• Developing a standardized and efficient system for procurement, distribution, storage and utilization of the products.• Developing quality control capability to assure efficacy and safety of products.• Developing maintenance and repair facilities for equipment.
• Traditional Medicine shall be accorded appropriate attention by:• Identifying and encouraging utilization of its beneficial aspects.• Coordinating and encouraging research including its linkage with modern medicine.• Developing appropriate regulation and registration for its practice. – Health systems Research shall be given due emphasis by: • Identifying priority areas for research in health. • Expanding applied research on major health problems and health service systems. • Strengthening the research capabilities of national institutions and scientists in collaboration with the responsible agencies. • Developing appropriate measures to assure strict observance of ethical principles in research.
– Family Health Services shall be promoted by: • Assuring adequate maternal health care and referral facilities for high risk pregnancies. • Intensifying family planning for the optimal health of the mother, child and family. • Inculcating principles of appropriate maternal nutrition. • Maintaining breast-feeding and advocating home-made preparation, production and availability of weaning foods at affordable prices. • Expanding and strengthening immunization services, optimization of access and utilization. • Encouraging early utilization of available health care facilities for management of common childhood diseases particularly diarrhoeal diseases and acute respiratory infections. • Addressing the special health problems and related needs of adolescents. • Encouraging paternal involvement in family health. • Identifying and discouraging harmful traditional practices while encouraging their beneficial aspects.
• Referral System shall be developed by:• Optimizing utilization of health care facilities at all levels.• Improving accessibility of care according to needs• Assuring continuity and improved quality of care at all level.• Rationalizing costs for health care seeders and providers for optimal utilization of health care facilities at all levels• Strengthening the communication within the health care system.
• Diagnostic and Supportive Services for health care shall be developed by: • Strengthening the scientific and technical bases of health care. • Facilitating prompt diagnosis and treatment. • Providing guidance in continuing care.• Health Management information system shall be organized by: – Making the system appropriate and relevant for decision making, planning, implementing, monitoring and evaluation. – Maximizing the utilization of information at all levels – Developing central and regional information documentation centers.
• Health Legislations shall be revised by.• Up-dating existing public health laws and regulations.• Developing new rules and regulations to help in the implementation of the current policy and addressing new health issues• Strengthening mechanisms for implementation of health laws and regulations
– Health Service Organization shall be systematized and rationalized by:• Standardizing the human resource, physical facilities and operational systems of the health units at all levels.• Defining and instituting the catchments areas of health units and referral systems based on assessment of pertinent factors.• Regulating private health care and professional development by appropriate licensing.
– Administration and Management of the health system shall be strengthened and made more effective and efficient by: • Restructuring and organizing at all levels in line with the present policy of decentralization and democratization of decision-making and management. • Combining departments and services which are closely related and rationalizing the utilization of human and material resources. • Studying the possibility of designating under secretaries to ensure continuity of service. • Creating management boards for national hospitals, institutions and organizations. • Allowing health institutions to utilize their income to improve their services. • Ensuring placement of appropriately qualified and motivated personnel at all levels.
– Financing the Health services shall be through public, private and international sources and the following options shall be considered and evaluated. • Raising taxes and revenues. • Formal contribution or insurance by public employees. • Legislative requirements of a contributory health fund for employee of the private sector. • Individual or group health insurance. • Voluntary contributions.
UNIT III: STRUCTURE OF HEALTHCARESERVICE ORGANIZATIONUNIT OUTLINE1. Structure of the healthcare service organization• Federal• Regional• District/Woreda
2. The roles of various agencies in health promotion• Government• Multi-laterals (e.g. WHO [world Health Organization ])• Bi-laterals (e.g. USAID [United States Agency for International Development ])• NGOs (e.g. AMREF [African Medical and Research Foundation])• Private providers (PO’s)
3.1: Structure of the Healthcare Service Organization3.1.1. Introduction• The mechanism through which health services are organized and delivered in Ethiopia function as a complex system, in which providers, consumers and regulators of the health service interact. The system responds to changes in the external environment which include changes in:• Medical knowledge and technology,• Political and economic situation of the country,• Social norms and values• Population health and disease processes.
• Understanding the work of the major players within the national health system and the many ways in which they interact provides a basis for managing the system to improve accessibility, quality and cost of the services .The health care delivery system in Ethiopia is a universal national system and in order to understand the system the major actors within the system must be identified, the resources on which these actors depend must be identified and the external environment which affects these actors must also be identified. The major actors are:
• the healthcare providers• the healthcare consumers• the policymakers and regulators• The resources used by these actors include:• funding• facility• personnel• technology• Information• The various components are organized into the following structures:
3.1.2. Administrative Structure of the Healthcare System Organizations• The health service organization and management used to be centralized with very little community participation.• This had an undesirable impact on efficiency, resource allocation, human resource development, and utilizationof health services.
• A decentralized system was put into place when in 1990, under the transitional government , Ethiopia became a Federal Democratic Republic composed of 9 National Regional States (NRS) which are; Tigray, Afar, Amhara , Oromia, Somalia, Benishangul-Gumuz, Southern Nations Nationalities and Peoples Region (SNNPR),Gambella, and Harari, Administrative states (Addis Ababa city administration and Dire Dawa council).
• The national regional states as well as the two cities administrative councils are further divided into six hundred eleven woredas and around 15,000 kebeles (5,000 Urban and 10,000 Rural).• Arguably, the most significant policy influencing the Health Sector Development Program (HSDP) design and implementation is the policy on decentralization. This is well articulated within the constitution and in a number of major and supplementary proclamations, and provides the administrative context in which health sector activities take place.
• Important steps have been taken in the decentralization of the health care system. Decision-making processes in the development and implementation of the health system are shared between the Federal Ministry of Health (FMOH), the Regional Health Bureaus (RHBs) and the Woreda Health Offices (WHO). As a result of recent policy measures taken by the Government, the FMoH and the RHBs are made to function more on policy matters and technical support, while the woreda health offices have been made to play the pivotal roles of managing and coordinating the operation of the primary health care services at the woreda levels.
• The powers and duties of the Ministry of Health (MOH) according to proclamation 4/87 are to: – Cause the expansion of health services• Establish and administer referral hospitals as well as study and research centers• Determine standards to be maintained by health services; except insofar as such power is expressly given by law to another organ, issue licenses to and supervise hospitals and health services established by foreign organizations and investors
• Determine qualifications of professionals required for engaging in public health services at various levels; issue certificates of competence to same• Cause the study of traditional medicines; organize research and experimental centers for same• Cause research to be undertaken on traditional medicines and, for this purpose, organize centers for research and experiment• Devise and follow up the implementation of ways and means of preventing and eradicating communicable diseases• Undertake the necessary quarantine controls to protect public health
– Structure of the Ethiopian Health SystemI. Structure of Federal Ministry of Health (FMoH)• The FMOH is responsible for setting the health policy and giving technical support. The organogram below represents the administrative structure of the FMOH.
• organogram of the federal ministry of health• Minister of Health• Vice Minister• Legal and Medico-legal Service• Public Relation Service• Plan and Program Department• Pharmaceutical Supply and Administration Service• Disease Prevention and control Dept.• Malaria and vector borne disease prevention team• HIV/AIDS and other STD prevention and control team• TB and leprosy prevention and control
• Other diseases prevention and control team• Hygiene and Env’tal Health Dept• Water quality and sanitary control team• Food, drink and herbal preservation control Team• Quarantine service team• Industrial and other institution health control system• Family Health Dept• Health and Nutrition Research Institute• Health Service team• Specialized hospitals• Health psychosocial educator and training team• Health Educator Center• Panel of assessors• Babies, children and yo
• Family planning team• Women’s healthcare team• Health Service and Training Dept• Audit Service• Organization and Management Service• Women’s Affairs Department• Administrator and Finance Service• Service Delivery Administrative Population
– Ethiopian health facilities, their administrative bodies and the population served by them• Health Centers (PHCU) Woreda Health Office 25,000• District Hospitals Zonal health department 250.000• Zonal Hospitals Regional health bureaus 1,000,000• Specialized Hospitals Ministry of health 5,000,000
• II. Structure of Regional Health Bureau (RHB)• Organogram of regional health bureaus• Bureau Head• Advisor• Regional Laboratory Auditing service• Administration and Logistics Planning and Programming service• Hospital Desk Assistance• Disease prevention and Health programs Department• Surveillance team• Child Health Team• Pharmacy and Traditional med. Team
• Health workers Training School• Maternal and Reproductive Health team• Health service organization and Expansion team• Training Team• Health sanitation• Coding and Processing Team• TB and HIV/AIDS and STI prevention Team• Family Health Department• Health service organization and Expansion Department• Training Health coding and Guideline Head• Public relation• Deputy Bureau Head• Regional Laboratory
III. Structure of District/Woreda Health Office (WrHO)Organogram of district/woreda health offices• Woreda health office Head• Deputy Woreda health office Head• Maternal and child health team• Communicable disease and surveillance team• HIV control team• Environmental health team• Malaria control team• Health extension program• Logistics and pharmacy unit• Planning and program unit
3.2: Contributors of Health Care Provision in EthiopiaIntroduction• The main healthcare providers in Ethiopia are:• the Government• Private providers• Non-government• International Health Agencies: – Multilateral Agencies – Bilateral Agencies
3.2.1 The Government• For many countries, especially in the developing countries, it is very likely that the government remain the• largest single provider of health care giving an impression of dominating health care provision.3.2.2 Private Providers• Private providers work for profit and increasingly the private providers are getting involved in the delivery of health services. Nearly all pharmacies (drug stores) are privately owned. The role of private hospital and clinics and medical services is growing especially in urban areas and those who afford can be managed there and help in reducing load at government facilities.
3.2.3 Nongovernmental Agencies (NGO’s)• NGO’s are sometimes known “people to people” aid; their activities are sometimes very specific, for example targeting Trachoma and cataracts. Where as some have more general agendas, for example aid for orphans.• They are usually funded by voluntary donations although some act under contract to governments and other agencies. The largest and NGO is the international Red Cross which has national offices within most countries.• Other well known NGO’s are USAID, CDC, Oxford Famine Relief (OXFAM), Care international, save the children.
3.2.4 International Health Agencies• International Health agencies play an auxiliary role. They are funded by member governments.• A) Multilateral Agencies• The leader among such agencies is the World Health Organization (WHO), which began its work in 1948• in Geneva under the United Nation (UN) .Its headquarters, is in Geneva. It has six regional offices and• representatives in most of its 200 member countries. Its tasks are:• to review and approve policies and program initiatives• to coordinate and promote technical cooperation among countries• facilitate training and technical assistance• assimilate, analyze and disseminate health related data
• A good example of its achievement is the way it leads in the eradication of smallpox in 1979.• Other such multilateral agencies are:• UNICEF – a program concerned with the healthcare of infants and children• United Nation Development Program (UNDP)• World Bank (WB)• UNAIDS – is a program for HIV/AIDS• Food and Agriculture Organization (FAO)• United Fund for Population Activities (UNFPA)
B) Bilateral Agencies• The most industrialized nations provide aid on a country to country basis, attempting to match the recipients need with the donor’s objectives and capacity to assist, usually subjects to political considerations. The United States links aid to democratic reforms and human rights.• In 2004 only five countries met the United Nations target of contributing 0.7% of gross national product in official development assistance. These countries are Norway, Denmark, the Netherlands, Luxembourg, and Sweden. In contrast to the United States provided only 0.16% and the UK 0.36%.
• Donor countries often rely on their own expertise through competitive bidding to design, implement, and• monitor projects funded under bilateral agreements, sometimes requiring that the donors own products and services be used. It is critical that such development assistance is effectively placed, and fairly counted, so as to help build sustainable capacities for all the people of the world.
UNIT IV: COMPONENTS OF THEHEALTHCARE DELIVERY SYSTEMIntroduction• The universal goal of any health systems is to ensure access to high-quality services to all members of its society for as little cost as possible. The decentralized health policy has different levels of health care delivery systems (Primary health care unit, district hospital, zonal hospital and referral hospital). In this unit we will deal with the components of health care delivery system level by level and see the activities carried out in each level.
4.1: Components of Healthcare Delivery System4.1.1. Introduction• The universal goal of any health systems is to ensure access to high-quality services to all members of its society for as little cost as possible. This involves three key areas:• accessibility• quality and,• cost efficiency
• Efforts to increase access to care within the system may lead to higher costs, while efforts to limit health-care costs may have adverse effects on access. In order to address gaps in the accessibility and quality of healthcare services new strategies have been implemented by replacing the old six tier system in to the new four tier system. There are efforts to reorganize the 4 tier system into 3 tiers, but this has not been finalized.
4.1.2. The Current 4 Tiers System• The current 4 tiers system is organized as:• First tier: Primary Healthcare Unit (which is made up of 1 health center and 5 health posts, serving 25,000 people)• Second tier: District Hospital (serving 250,000 people• Third tier: Zonal hospital (serving 1 million people)• Fourth tier: Referral Hospital.• Health care tier system with their basic parameters – Zonal/Regional Hospital (ref) 1,000,000 population – District Hospital 250,000 populations – Primary health care unit (PHCU) With 5 CHPs 25,000 population – Referral Hospital 5,000,000 population
• Main Issues Addressed by the Pyramid• The above figure depicts the basic parameters and levels of health care interactions within the pyramid and out of the pyramid. It illustrates the referral linkages and administrative supervisory linkage pathways with the population served at each level of health care unit.• The base of the pyramid is formed by primary health care unit that consists of a single health center with five health posts and supervised by Woreda Health Office (WrHO) and expected to report to the supervising woreda. Also the referral system linkage in the primary health care unit is arranged in such a way that all the five health posts refer their patients/cases to the Health Centers (HC) for better management and cases that need referral from HC are referred to District Hospital.
• At the second line of the pyramid is district hospital. It is accountable to receive referral from HC and should give feedback to them, and cases that cannot be managed at district hospital level are referred to Zonal hospital and the last level of referral system within the country will last at the level of specialized hospital Administrative accountability is shown by a broken line arrow at the right side of the pyramid. Regarding to the supervision and administrative support in the hierarchy of FMOH, FMoH supervises RHB, and RHB supervises WrHO through delegated actor known as zonal Health Departments (ZHD). And the ZHDs supervise WrHO and woreda Health office supervise PHCU
4.1.3. Major Components and Actors of Healthcare Delivery System• The major components and actors of the healthcare delivery system are:• The health facilities• Health Posts• Health Centers• • Beds=10• • Ts+13+15• • NTs=12• District Hospitals (Primary Hospitals)• • Beds=50• • Ts=33• • NTs=35
• The health workforce/personnel• Medical staff: Are the personnel consisting of physician who have received extensive training and granted to give clinical service.• Administrative staff: staffs who are involved in leadership and management like Chief Executive Officer• (CEO), Chief Financial Officer, Chief Information Officer Etc…• Supportive staff: clinical supports are activities carried out by pharmaceutical service, food and nutritionservices, Health Information management, social work and social service, patient advocacy service, purchasing central supply and material supply management services
4.2: The Health Care Facilities and Services they Provide• In order to properly implement the delivery of health services the role of each type of health facility/institution is determined. This in turn determines the professional mix of the staff assigned to each type of health facility.
4.2.1. The Primary Healthcare Unit (PHCU)• The PHCU consists of Health Post and Health center. The Health Sector Development Program document of the Ministry of Health (MOH) describes PHCU is an important component of the Health System in Ethiopia.
• A comprehensive PHCU services is to be delivered through community-based health services by the HealthExtension Program (HEP) at Health Posts (HP) and household levels, and further through Health Centers(HC) and p. Basically the PHCU is the health service delivery organized and managed at District level withinthe decentralized system of the Ethiopian Government at the Woreda Health System (WHS)
A) Health Posts• The Health Post (HP) represents the first contact of the health care system and it is considered the first contact level between the service provider and the client. The HP provides mainly preventive and Promotive services (health education), but also some limited services of very basic curative care. Most cases are referred to the next level, the Health Center, which is still within the first tier (i.e. within the PHCU). The HP provides its services to a catchment population of approximately 3,000-5,000.
• All community-based health services provided at outreach site and house hold level services and at the HP are administratively supervised by Woreda Health Office and Kebele Council and technically by the Health Centers in the catchments area. A health post is run by two Health Extension Workers (HEWs). Summary of Job accomplished by HEW
• Provide health education• Promote community nutrition• Provide Antenatal Health Care (ANC)• Provide Postnatal Care (PNC)• Promote and provide family planning service• Implement hygiene and environmental health service• Provide first aid and basic clinical service• Provide delivery service• Implement immunization service• Collect and maintain population health data
B) Health Center• The Health Center (HC) with its five satellite Health Posts, is designed to render integrated promotive, preventive, basic curative and rehabilitative services. The Health Centre (HC) represents the first level of the health care system for curative services, and serves a catchment population of 25,000. A standard HC has a capacity of 10 beds and provides 24 hour emergency medical care services, treatment of common medical problems, basic obstetric care, basic laboratory and pharmaceutical services. The medical conditions that are expected to be managed at this level are handled by:
• Clinical officers/Health Officers• Nurses and,• Midwives.• The function of the Health Center is organized into five components based on the Health Service Extension Program. – Family health service: Family Health Services that are expected to be provided at this level include:
I. Maternal and newborn care services including:• antenatal care (ANC),• delivery and newborn care services,• postnatal care (PNC), and• family planning (FP)II. Child health services including:• Integrated management of childhood illnesses (IMCI)• Growth monitoring and promotion• Immunization• Adolescent reproductive health services (ARH) and• Promotion of essential nutrition action (ENA).
• Communicable Disease Prevention and Control Services: services provided under this component are related to the following major categories:• Tuberculosis and Leprosy: – Clinical diagnosis and treatment, – Management of complications and adverse drug reactions, – Training, advice and treatment of leprosy patients on disability, – Refer cases to the HP for follow up when supported by established mechanism of information and patient flow systems
b) HIV/AIDS and STI: the services provided at the HC level are: – IEC on transmission and prevention of HIV/AIDS and STI, – Support and guidance to families on home-based care, – Condom promotion and distribution, – VCT and PMTCT services, – Treatment of common opportunistic infections such as TB, PCP, toxoplasmosis, and candidiasis in diagnosed HIV/AIDS cases – Identification and referral of patients eligible for ART, – Follow up of ART patients with no complications, – Provide Syndromic management of STI
c) Epidemic diseases: Ensure adequate and timely preparedness, Investigate, confirm and provide free treatment to cases of epidemics of all the reportable epidemic prone disease.• Epidemic prone diseases – Cholera – Diarrhea with blood (Shigella) – Measles – Meningitis – Plague – Viral hemorrhagic fevers – Yellow fever
• Diseases targeted for elimination/eradication• Acute flaccid paralysis(AFP/Polio)• Measles• Neonatal Tetanus• Leprosy• Dracunculiasis (Guinea worm)• Other diseases of public health importance• Pneumonia in children less than 5 yrs of age• Diarrhea in children less than 5 yrs of age• New AIDS cases• Malaria• Onchocerciasis• Sexually transmitted infections(STIs)• Trypanosomiasis• Tuberculosis
d) Rabies:• Provision of full course of anti rabies vaccination,• Refer clinical cases of Rabies• Basic Curative Care and Treatment of Major Chronic Conditions and injuries: Under this category the major services that are expected are: – First Aid for common injuries and emergency conditions, – Treatment of major chronic condition, – Treatment of mental disorders and – Treatment of common infections and complications4. Hygiene and Environmental Health Services: activities under this component are mainly related to giving technical assistance and supportive supervision to HEW on various environmental health service issues including:
• School health education,• Prison health service,• Control of rodents and insects,• Provision of water quality control,• Personal hygiene and others.• 5. Health Education and Communication: Similar to the previous component, the major activities under this component is to provide technical assistance and supportive supervision to HP in the provision of IEC materials
4.2.2. District Hospital and Services Provided• The district hospital represents the third level within the PHCU, of the health system and has the capacity of 30-50 beds and provides 24 hour emergency service for a population of 250,000. It serves as a referral center for the five Health Centers under its catchments and will have the capacity of providing treatment of basic acute and chronic medical problems, Comprehensive Emergency Obstetric Care (CEOC), basic emergency surgical interventions, dental and mental health services. These hospitals will also serve as a training site for clinical officers and mid level health workers.
• In addition to the following services, District Hospital provides all of the essential health services that are provided by the Health Center.• Comprehensive Essential Obstetric Care – Provision of basic emergency obstetric care services – Provision of obstetric and gynecologic procedures including (minor and major procedures)2) Emergency Surgical Procedures: – Basic life saving procedures – emergency major procedures and minor procedures)3) Emergency Medicine, like:• Diabetic ketoacidosis (DKA)• Acute poisoning• Severe and complicated malaria• Status asthmatics• Seizure disorders and others
4) Laboratory and pharmacy services4.2.3. Zonal/Regional Hospitals and Services Provided• Generally these hospitals have the capacity of 150- 200 beds and provides 24 hours service. It will have the four major departments:• Internal Medicine• General Surgery• Paediatrics and• Gynaecology and Obstetrics• Additional specialities such as Ophthalmology, Radiology, Orthopaedics, Dentistry and Psychiatry.• These hospitals serve as a training site for medical doctors and other healthcare workers. The major services at this level include:
a. Management of Childhood Illnesses• The Hospital provides outpatient and in-patient management of infant and child health, in accordance with. National Standard Treatment Guidelines at Hospital Level. This includes preventive, curative (assessing, classifying and treating) promotive, and rehabilitative care.b. Adult Medical Service• The Hospital provides outpatient and in-patient management of adults in all life stages in accordance with the Standard Treatment Guidelines for hospital care. This includes the provision of preventive, curative, promotive, and rehabilitative care.
• As much health care as possible is provided in ambulatory basis;• Patients are admitted and kept in hospital only when this is absolutely essential, for physical, medical, mental or social reasons.• The hospital provides the second level of inpatient admissions for hospitalized care.• Ongoing management of patients referred to or from the health centers and Primary Hospitals are provided.
• c. Women’s Medical Service• The Hospital provides that part of the comprehensive package of promotive, preventive, curative and rehabilitative reproductive health services for women who requires medical and special resources not found in health centers or clinics. The hospital provides a 24-hour service for acute gynecological and obstetric problems and deliveries of most high- risk pregnancies. The focus of the outpatient clinic is on taking referrals from health centers and clinics and referring patients back with information and advice
• d. Trauma and Emergency Surgical Service• The hospital provides:• A 24 hour emergency, resuscitation service, advanced trauma and cardiac life support• Treatment and observation of medical and surgical and emergencies• Treatment and reporting of accidents, gunshots, and physical abuse• Referral of patients to specialized hospitals.• Arrangements to deal with disaster situations.• Surgery for minor and serious conditions• Common major elective surgeries
• e. Pharmaceutical service• The pharmaceutical service supplies and dispenses essential drugs and medical supplies. It selects drugs and medical supplies, purchases these from an identified supplier to maintain adequate quantities, receives, records, stores them and ensures appropriate controls are in place. It dispenses prescribed drugs, encouraging rational use by the prescribers as well as patient compliance and appropriate use.
• f. Laboratory Service• The basic functions include:• Conducting all the routine tests including quality control and some tests that the hospital activity requires• Taking specimens and sending them• Helping in training technician assistants with further technical supervision• Preparing reagents and recording them• Keeping equipments in a good status• Preparing a monthly report about the lab activities• Taking safety measures in the laboratory
• 4.2.4. Referral Hospitals• In addition to the services in the general hospital, specialized hospitals have additional departments like• Pathology, Anaesthesiology, ENT, Dermatology and sub-specialities. Such level of hospitals will also serve as a teaching centre for medical doctors and different types of specialists. In Ethiopia we have five hospitals to such level (Tikur Anbesa, St Pawlos, Amanuel, St Petros and ALERT)
• 4.3.1 Human Resource (healthcare workforce) Requirement• The other major component of the healthcare delivery system is the healthcare work force. They play a crucial role based on the service delivered at the facilities. Number and type of personnel required varies depending on the type of facility they are posted at. The human resource requirement for each level of care is established based on the expected services at each level, the workload and service standard by using the Workload Indicator for Staffing Needs (WISN) method. The average HRH requirement for each level of care is summarized in the following Table (look at table 4.1). However, as the work load may vary across facilities, each facility need to develop its staffing requirement on case by case basis.• The make-up of the healthcare work force can be categorized as:
• Medical staff• Administrative staff• Supportive staff• A) Medical Staff• Medical staff includes the professional occupations such as:• Physicians of all categories: – in Ethiopia there is shortage of medical doctors, and also concerns about the distribution of doctors across geographic areas. There is also misdistribution over rural verses urban areas.• Nurses – constitute the largest healthcare profession. The primary paths to becoming a nurse are by obtaining a BSc or a diploma in nursing. Their responsibilities include performing patient assessments, providing nursing care, and administer patient care services.
• Health Officers – receive their training through a university-based program, and have expanding responsibilities with the healthcare delivery system• 4.1: Average number and professional types required at different health facility levels• Other professional components of the health workforce include dentists, dental hygienists, social workers, pharmacists, therapists, nutritionists. The application of medical technologies and equipment requires additional technicians with specialized skills, such as radiology technicians, laboratory technicians, and pharmacy technicians.
• B) Administrative Staff• The leader of the administrative staff is the medical director, who is going to be replaced by Hospital CEO’s according to the new human resource development strategy. The CEO is responsible for coordinating the health services provided at that facility. While department staff nurses are accountable to the head nurse, the head nurses are accountable to the matron. The matron is in turn accountable to the medical director of the hospital.• C) Support Staff• Support staff provides support services to patients, medical staff, and employees.• Clinical support staff• Food and nutrition services• Health record services• Social services• Central supply services
• UNIT V: HEALTH SERVICE PROGRAMS• Introduction• The first Health Sector Development Program (HSDP) was launched in 1977 and currently we are on the third HSDP. In this unit we will deal with health service programs of Ethiopia. A key aspect of health service program is the Essential Health Service Package (EHSP), which specifies the basic services that should be available at a certain level of the health system.• Unit Outline• 1. Health policy, plans and strategies• 2. Essential health service package• 1. The Health Service Extension Program (HSEP)• 2. Family health service• 3. Prevention and control of disease• 4. Medical Services• 5. Hygiene and environmental health• 3. Human resource development• 4. Pharmaceutical service• 5. IEC and HMIS• 6. Monitoring and evaluation and health care financing
• 5.1: The Health Policy, Plans and Strategies• Lesson objectives• At the end of the lesson the learners should be able to:• 1. State major goals of HSDP• 2. Explain the current Ethiopian health policy• 5.1.1. Introduction• As a means of achieving the goals of the health policy (refer Ethiopian health policy), the government has formulated a twenty-year health sector development strategy, which is being implemented through a series of five-year plans. The implementation of the first Health Sector Development Program (HSDP) was launched in• 1997, and now the third HSDP is under way. (Please refer to the HSDP III manual.)
• 5.1.2. The HSDP-III• The ultimate goal of HSDP-III is to improve the health status of the Ethiopian people through provision of adequate and optimum quality of promotive, preventive, basic curative and rehabilitative health services to all segments of the population. Contributing to this overall goals, there are 3 sub-goals. These are: – To improve maternal health – To reduce child mortality• To combat HIV/AIDS, malaria, TB and other diseases
• 5.1: Summary of HSDP III focus areas and outcomes• Focus areas Outcome Vehicles Bloodlines• Maternal health• MMR 871 to 600• CPR> 60%• 30,000 HEWs• Health Officers: 5,000• Health Posts: 13,635• Health Center: 3,200• Train GP’s• Improve QA• • HMIS• • Logistics• • Human resource• • Finance harmonization
• Child Health – U5MR 123/1000 to 85/1000 – IMR 77/1000 to 45/1000 – Immunization >85%• HIV/TB * Maintain prevalence of HIV at 3.5%• Malaria * 20 million ITNs• The above table describes nation-wide priorities. “Priorities” means activities that have been selected as the most important and urgent for improving the health of Ethiopians. When resources are in short supply – money, staff, managers’ time, drugs, etc. – then they will be allocated first to the priority activities.
• In other words the 5 targets related to family planning, immunization, HIV/TB, and the distribution of nets to be used in malaria prevention are the most important priorities in the Ethiopian healthcare delivery system.• These broad sub-goals are then described in more detail through 8 major objectives: – To cover all rural kebeles with HEP to achieve universal primary health care coverage by 2008 – To reduce the MM ratio to 600 per 100,000 live births from 871 – To reduce the under 5 mortality rate from 123 to 85 per 1,000 live births and the infant mortality rate from 77 to 45 per 1,000 population – To reduce the total fertility rate from 5.9 to 4 – To reduce the adult incidence of HIV from 0.68 to 0.65 and maintain the pre-valence of HIV at 3.5% – To reduce morbidity attributed to malaria from 22% to 10% – To reduce the case fatality rate of malaria in age groups 5 years and above from 4.5% to 2% and the case fatality rate in under 5 children from 5% to 2% – To reduce mortality attributed to TB from 7% to 4% of all treated cases
• These objectives are then re-structured as 8 implementation components, to reflect the way in which healthservices are delivered and financed: • Health service delivery and quality of care • Access to services: health facility construction, expansion and transport • Human resource development • Pharmaceutical service • Information, education and communication (IE&C) • Health management information system • Monitoring and Evaluation • Health care financing.
• In effect, components 1 describe the main health service delivery activities and components 2 -7 are the inputs and activities required to provide these services.• In addition to the HSDP, Ethiopia is in the process of implementing the Millennium Development Goals• (MDGs). The MDGs came out of the UN Millennium Declaration, assuring the right of each person on the planet to health, education, shelter and security. The important role health plays in achieving the MDGs is clearly reflected.
• The 8 MDG Goals are: • Eliminate Poverty and hunger • Ensure primary education for all • Promote gender equality and • Reduce juvenile mortality • Better maternal care • Combat HIV/AIDs, Malaria and other diseases • Ensure a sustainable environment • Build a global partnership for development• Of the above MDGs, goal 4, 5, and 6 are addressed by the health sector.
• 5.2: Essential Health Service Package• Lesson Objectives:• At the end of this lesson the learners should be able to: • Describe the five components of Essential Health Service Package (EHSP) • Identify the components of packages that will be carried out by the Health extension workers • State the goal of Family health services • Mention the goal of medical service • Identify diseases which are of top priority • State the priority activities/interventions area in HIV/AIDS and malaria Prevention and Control Programme • Explain the need for TB and Leprosy Control Programme (TLCP) • Identify the role of each facility level in TB leprosy Control program • Identify the objectives of hygiene and environmental subcomponents • List the diseases given due emphasis in HSDP II program • State minimum standard expected in health care delivery at different levels • Describe the importance of having base line information on key indicators like TFR, MMR, U5MR?
• 5.2.1. Introduction• The best way of understanding the healthcare delivery system is to break down the “Essential health Service Package” provided at hospitals, health centers and health posts.• A key aspect of this component is the Essential Health Service Package (EHSP), which specifies the basic services that should be available at a certain level of the health system. EHSP consists of an essential package for the community level, plus basic curative care and the treatment of major chronic conditions to be provided at health centers. The EHSP has five components: • The Health Service Extension Program (HSEP) • Family health service • Prevention and control of disease • Medical Services • Hygiene and environmental health
• 5.2.2. The Health Service Extension Program (HSEP)• The HSEP is a community based healthcare delivery system which focuses on preventive health service. This basic healthcare coverage is implemented at the health post level. Each health post has a catchment of 5000 people, and is staffed by 2 HEWs. The HSEP has 16 major packages which fall into the 4 major components:• Hygiene and environmental sanitation• Family health services• Disease prevention and control• Health education and communication
• 5.2.3. Family Health Services (Maternal and Child Health Care)• The goal is to reduce deaths and illnesses associated with pregnancy, childbirth, and early childhood diseases.• This is done by educating mothers and community midwives on birth spacing, contraception, antenatal care, delivery practices, child health and nutrition.• Health workers also diagnose and provide basic clinical treatment for common childhood illnesses including respiratory infections, measles, malaria, pneumonia, and diarrhea. Childhood vaccines, vitamin A, oral rehydration treatment, tetanus vaccines to pregnant women, and anti-malarial drugs are provided.
• A) Maternal Health• Nearly half (49.7%) of Ethiopia’s population is female, of which 47% are in the range 15-49 years of age. Total Fertility Rate (TFR) is estimated at 5.9. According to data from health facilities across the country, pregnancy related problems account for 13.8% of in-patient mortality among women of child bearing age. The Maternal mortality Rate (MMR), estimated at 871 per 100,000 live births, is one of the highest in the world. The major causes of maternal mortality include delivery, other pregnancy related complications and abortion.
• B) Child Health• Like in many developing countries, children less than 15 years of age constitute 44.7%; of this around 40% are under five years of age, and 8% are under one years of age.• In year 2000, the under-five mortality rate (U5MR) was estimated at 166, while infant mortality and neonatal mortality rates were estimated at 97 and 49 per 1000 live births respectively. Assuming a steady annual decrease, the U5 MR is currently estimated at 146.6.
• The major causes of under-five mortality have been pneumonia (28.9%), malaria (21.6%) and diarrhea (6.7%), all types of pneumonia and malaria are the major causes of death among infants, with each accounting for 39.7% and 21.1% of deaths respectively. High maternal fertility, especially early first pregnancy and short birth intervals, have also been strongly associated with increased under-five mortality.• Malnutrition has been a major underlying cause of an estimated 57% of deaths, while HIV/AIDS underlies 11% of deaths, particularly those due to pneumonia, according to FMOH documents. Half of Ethiopia’s children under-five are stunted (52%), while 11% are estimated to be wasted.
• The government has adopted an Integrated Management of Childhood Illnesses (IMCI) as its key strategy towards reducing under-five mortality and morbidity, and promoting healthy growth and development of children. The strategy focuses on key child survival interventions, proven to be effective in reducing childhood mortality. These interventions include:• Improved birth interval,• improved antenatal care coverage both for TT2 and measles• improved coverage of skilled delivery• prevention of mother to child transmission of HIV/ AIDS• promotion of exclusive breast feeding in the first 6 months, complementary feeding after 6 months and continued breast feeding• treatment of fever, ARI and diarrhea• vitamin A supplementation• delivery of safe drinking water and sanitation• provision of insecticide treated nets (ITNs)
A National Reproductive Health Taskforce with technical working group for Making Pregnancy Safer (MPS), family planning, nutrition, STIs/HIV, logistics and adolescent RH have been formed to assist the programme with resource mobilization, monitoring and development of appropriate policies and guidelines.
Making Pregnancy Safer was launched in 2001 and implemented in four regions on pilot basis. Health workers were also trained on basic emergency maternal and newborn lifesaving obstetric services, EOC, cesarean section and anesthesia. 10 hospitals and over 40 HCs were equipped with basic essential equipment and supplies, and vehicles were procured and distributed to enhance programme implementation and the referral system. The review of the programme conducted in year 2003 revealed improvement in the quality of service and handling of obstetric emergencies that stimulated the rapid scaling up of the programme coverage.
• 5.2: Summary of Targets and Achievements during HSDP-I and II in Maternal and Child• Health Services – With regard to child health, IMCI was adopted nationally in 1997 as a major strategy to reduce childhood mortality and morbidity and promote childhood development. It has three components : – improving the skills of health workers, – improving health systems, – Improving family and community practices.• The main activities under IMCI are prevention and control of ARI, diarrhea, malaria, malnutrition, measles and HIV/AIDS.
– Interagency Coordination Committee (ICC) has been established and meets regularly to address issues on improving routine EPI, supplementary immunization activities and disease surveillance. This committee also plays a key role in resource mobilization for EPI.– In addition to the scheduled vaccination programs, supplemental immunization of polio, measles and neonatal tetanus was introduced in order to reach the remote areas of the country, strengthen the routine immunization activity and eradicate/eliminate the 3 vaccine preventable diseases.
– Training was given to mid-level managers and cold chain technicians using Midlevel Managers and Immunization in Practice Modules. The programme has also replaced the reusable syringe by AD syringe and all injection vaccines were given using the disposable syringes and safety boxes.– Introduction of the Reaching Every District (RED) strategy, where most woredas have been developing micro-plans.
• Major constraints encountered during the implementation of MCH programmes were: – understaffing and high turnover of both technical and managerial staff at all levels – inadequate follow-up and supportive supervision – shortage of transportation – lack of motivation of service providers – poorly functioning of outreach sites and weak referral system – high vaccine wastage rates, – critical shortage of basic equipment for the management of emergency obstetrics at facility level – Short supply of contraceptives and vaccines.
• The following are the future directions towards the improvement of MCH service.• Operationalize the harmonization of maternal and child health programs with the Health Extension Programme.• Accelerate capacity building at the Regional and District level for planning, training, follow up and support supervision.• Building the capacity of training institutions to scale-up IMCI pre-service training through training of instructors and provision of financial and material support.• Involve NGOs and the private sector to scale up maternal and child health interventions.• Strengthen the collaboration and integration among relevant programs like RBM, EPI, Nutrition, MPS, IMCI and HIV/AIDS etc., to avoid duplication of efforts and maximize the impact.• Optimally utilize the opportunity of the child survival initiative to scale up maternal and child health interventions.• Introduce new vaccines against Hepatitis B and Haemophilus Influenzae.
• 5.2.4. Prevention and Control of Disease• The health service program gives priority to the prevention and control of HIV/AIDS, malaria, tuberculosis, leprosy, blindness and onchocerciasis.• A) HIV/AIDS Prevention and Control Programme• It is now more than two decades since the HIV/AIDS epidemic started in Ethiopia. HIV/AIDS was recognized as top priority from the very beginning of HSDP. There is a National HIV/AIDS Policy supporting disease prevention and case management (including home-base care), strengthen IEC/BCC, mobilization of resources and coordinating multisectoral effort to ensure proper containment of the spread of the disease and reduce its adverse socio-economic consequences.
• The priority intervention areas are:• IEC/BCC,• Condom promotion and distribution,• Voluntary counseling and testing (VCT),• Management of sexually transmitted infections (STIs),• Blood safety,• Infection prevention/universal precaution,• Prevention of mother to child transmission of HIV (PMTCT),• Management of opportunistic infections,• Care and support to the infected and affected,• Legislation and human rights and surveillance and research
• In order to facilitate the implementation of these interventions, a number of guidelines, manuals and other relevant documents have been prepared on counseling, case management, home-based care and other areas.• The policy on supply and use of anti retroviral drugs has been implemented within the framework of the existing HIV/AIDS Prevention and Control Policy and Strategy. In addition, intensive and continuous advocacy has been conducted leading to the involvement of more and more NGOs, UN and Bilateral Organizations, CBOs and the community at large in the prevention and control of HIV/AIDS.
Six strategic issues have been identified in the HIV/AIDS prevention and control strategic plan, these are:• Capacity building• Community mobilization and involvement• Integration with health programmes• Leadership and mainstreaming• Coordination and networking• targeted responseChallenges faced in the implementation of the program are:• Weak coordination and communication at all levels• Inadequate implementation of blood safety procedures• Scarcity and insufficient implementation of guidelines related to HIV/AIDS• Shortage of supplies required to provide care and support
B) Malaria and Other Vector-borne Diseases Prevention and Control• Malaria is the leading cause of morbidity and mortality in the country. Three quarters of the landmass of the country is malarious and around two-thirds of the population is at risk of infection. Considerable attention has been given to malaria in order to reduce the overall burden of the disease. The prevention and control of malaria is achieved by:• Distribution of effective drugs to all health facilities, including health posts• Distribution of insecticide treated bed nets• Provide health education to communities to maximize use of bed nets• Spraying of DDT as per plan• Training of health professionals in malaria control and prevention
• C) Tuberculosis and Leprosy Control Programme (TLCP)• The general objective of the TLCP is to reduce the incidence and prevalence of TB and Leprosy as well as the occurrence of disability and psychological suffering related to both diseases and the mortality resulting from TB to such an extent that both diseases are no longer public health problems. The general objective has been specified for the various TLCP activities as follows:
• Case detection: to diagnose TB and Leprosy patients at an early stage of the disease to the extent that the case detection rate of new smear positive pulmonary TB patients is at least 70% of the estimated incidence and the proportion of disability grade II among new leprosy patients is less than 10%.• Treatment: to achieve and maintain success rate of at least 85% of newly detected smear positive pulmonary TB patients (PTB+) and extra pulmonary TB patients treated with DOTS. For Leprosy, treatment should achieve a treatment completion rate of at least 85% and prevention of Leprosy related disability during chemotherapy should be below 3%.
DOTs/MDT is expanded to all regions. For instance, 86% of woredas in the country and 50% of the government health facilities are implementing DOTS/MDT (32% in 2000). The treatment success rate, which is the main indicator of programme effectiveness, has reached 76%. The treatment defaulter rate has also decreased from10% in 1998/99 to 7% in 2000/01 and then to 5% in 2003/04 for patients on short-term chemotherapy. Additionally, encouraging results were seen in the areas of integration of DOTs/MDT into the routine health service delivery. Standardized national treatment manual and basic microscopy services are also put in place.