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  • 1. 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
  • 2. 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
  • 3. 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
  • 4. 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. 5.5: 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
  • 6. 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 Managing health service organization, third edition, 1992 Maryland, USA
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. 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.
  • 13. 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
  • 14. 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.
  • 15. 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,
  • 16. 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”.
  • 17. 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.
  • 18. 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.
  • 19. 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).
  • 20. 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.
  • 21. 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,
  • 22. 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.
  • 23. 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.
  • 24. 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,
  • 25. 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
  • 26. Early 1930s First health budget allocated Public latrine introduced1935  Minilk II started training the first medical auxiliariesDr Melaku Beyane the first trained Dr return to EthiopiaEthiopian Red cross society established in JulyOutbreak 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
  • 27. 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
  • 28. EPRDF Regime1991-1995 Transition time1993 Development of health policy and strategy1998-2002 Health sector development program I2003-2007… Health sector development program II
  • 29. 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.
  • 30. 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”.
  • 31. • 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;
  • 32. 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.
  • 33. 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
  • 34. 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”.
  • 35. 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”
  • 36. • 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.
  • 37. 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.
  • 38. 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.
  • 39. – The communities should be actively involved inThe assessment of the situationProblem IdentificationPriority setting and making decisionsSharing responsibility in the planning implementing, monitoring and evaluation
  • 40. 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.
  • 41. 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/
  • 42. 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
  • 43. 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:
  • 44. 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.
  • 45. 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.
  • 46. 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.
  • 47. • 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.
  • 48. – 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.
  • 49. • 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.
  • 50. • 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.
  • 51. 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.
  • 52. 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.
  • 53. 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
  • 54. “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.
  • 55. 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.
  • 56. 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.
  • 57. 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.
  • 58. 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
  • 59. 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.
  • 60. 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.
  • 61. – 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.
  • 62. – 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.
  • 63. 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;
  • 64. – 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.
  • 65. – 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.
  • 66. 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:
  • 67. – 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.
  • 68. – 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.
  • 69. • 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.
  • 70. – 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.
  • 71. • 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
  • 72. • 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.
  • 73. • 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.
  • 74. • 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.
  • 75. – 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.
  • 76. • 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.
  • 77. • 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.
  • 78. • 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
  • 79. – 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.
  • 80. – 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.
  • 81. – 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.
  • 82. UNIT III: STRUCTURE OF HEALTHCARESERVICE ORGANIZATIONUNIT OUTLINE1. Structure of the healthcare service organization• Federal• Regional• District/Woreda
  • 83. 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)
  • 84. 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.
  • 85. • 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:
  • 86. • 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:
  • 87. 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.
  • 88. • 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).
  • 89. • 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.
  • 90. • 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.
  • 91. • 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
  • 92. • 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
  • 93. – 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.
  • 94. • 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
  • 95. • 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
  • 96. • 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
  • 97. – 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
  • 98. • 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
  • 99. • 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
  • 100. 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
  • 101. 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
  • 102. 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.
  • 103. 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.
  • 104. 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
  • 105. • 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)
  • 106. 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%.
  • 107. • 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.
  • 108. 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.
  • 109. 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
  • 110. • 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.
  • 111. 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
  • 112. • 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.
  • 113. • 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
  • 114. 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
  • 115. • Zonal Hospitals (Regional Hospitals) • Beds=100 • Ts= 60 • NTs=50• Specialized Hospitals (Referral Hospitals) • 250 beds • Ts= 120 • NTS= 50• Note: Ts = Technical staff; NTs= Non- technical staff
  • 116. • 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
  • 117. 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.
  • 118. 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.
  • 119. • 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)
  • 120. 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.
  • 121. • 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
  • 122. • 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
  • 123. 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:
  • 124. • 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:
  • 125. 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).
  • 126. • 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
  • 127. 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
  • 128. 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
  • 129. • 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
  • 130. 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:
  • 131. • 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
  • 132. 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.
  • 133. • 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
  • 134. 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:
  • 135. 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.
  • 136. • 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.
  • 137. • 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
  • 138. • 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
  • 139. • 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.
  • 140. • 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
  • 141. • 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)
  • 142. • 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:
  • 143. • 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.
  • 144. • 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.
  • 145. • 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
  • 146. • Professional Category CHP HC District Hospital Regional Hospital Specialized Hospital• Specialist 0 0 0 18 51• GP 0 1 2 20 60• Clinical Officer 0 2 4 0 0• Dentist 0 0 1 2 4• Nurse 0 5 10 87 178• Midwife 0 2 2 14 21• Anesthesia Professionals 0 0 2 5 14• Psychiatry Nurse 0 0 1 4 12• Other dental professional 0 0 1 2 6• Laboratory professionals 0 2 3 12 20• Pharmacy professionals 0 2 3 8 16• Physiotherapist 0 0 1 4 8• Radiographer 0 0 2 5 11• Biomedical Technician 0 0 1 3 4• Hospital Manager 0 0 1 1 1• Public Health Officer 0 1 1 2 4
  • 147. • HIT 0 1 2 4 8• Dietician 0 0 0 2 4• Social Worker 0 0 0 2 4• Health Extension Worker 2 0 0 0 0• 2 16 33 195 426• Administrative support services• Registration clerks• accounting• Secretaries• Security personnel• Cleaner
  • 148. • 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
  • 149. • 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.)
  • 150. • 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
  • 151. • 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
  • 152. • 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.
  • 153. • 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
  • 154. • 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.
  • 155. • 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.
  • 156. • 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.
  • 157. • 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?
  • 158. • 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
  • 159. • 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
  • 160. • 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.
  • 161. • 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.
  • 162. • 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.
  • 163. • 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.
  • 164. • 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)
  • 165. • Indicator• HSDP-I HSDP-II• Baseline Target Achievement Target Achievement• DPT3 59.3 70-80% 51.5 70 70.1• CPR 9.8% 15-20% 18.7 24%, 25.2• ANC 5% - 30 45 41.5• Assisted delivery 3.5% - 7% 25 12.4• TT2 for pregnant - - 27 70% 43.3• TT2 for nonpregnant• - - 14.8 32 25.8• PNC coverage 3.5 - 6.8 20 13.6• C) Steps taken
  • 166. 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.
  • 167. 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.
  • 168. • 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.
  • 169. – 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.
  • 170. – 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.
  • 171. • 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.
  • 172. • 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.
  • 173. • 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.
  • 174. • 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
  • 175. • 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.
  • 176. 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
  • 177. 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
  • 178. • 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:
  • 179. • 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%.
  • 180. 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.
  • 181. • Challenges with regard to implementation of TLCP are:• Shortage and high turnover of staff• Inadequacy of on-the-job training and supervision• Inadequate involvement of communities in the implementation of DOTS• Poor communication between the public and private TB care providers.• In order to alleviate these problems, there is a need to strengthen the programme implementation capacity at all levels of the health system including capacity for the efficient use of financial resources. There should be proper planning for staff allocation and regular training. Involvement of the Health Posts in TLCP implementation and improvement of community mobilization with the implementation of the HSEP is expected to enhance the effectiveness TLCP.
  • 182. • 5.2.5. Medical Services• Medical Services is one of the components in essential health service package• The goal of Medical Services is to:• improve quality of health service and utilization by the population through reorganizing the health service delivery system into 4-tier system• strengthen the decentralized management to ensure full community participation• develop and implement essential health service package and referral system• Develop health facility standards and staff and equip the health facilities accordingly.
  • 183. In line with this, there has been significant transformation of the old six-tier health delivery system into the new four-tier system spearheaded by the establishment of PHCUs (which is being revised and a proposal to use a 3 tier system is underway). A complete set of national standards for health posts, health centers and district hospitals have been prepared, endorsed, published and distributed to regions. These standards contain specifications for the building design, lists of equipment and furniture, the scope of service, detailed information on the cadres of staff required, and drug lists for each level. Essential health service package document has been finalized and referral system guideline has been drafted.
  • 184. • The Civil Service Reform Program (CSRP), which is being introduced into all public health institutions, is also showing improvements in the quality of health care. For instance, introduction of the CSRP and implementation of the Business Process Reengineering in St. Paul Specialized Hospital, Adama Hospital and Assella Hospital has shown improvements in terms of reducing the waiting time and friendly environment.• Furthermore, health service utilization rate has increased from 0.25 in 1996/97 to 0.27 in 2000/01 and subsequently to 0.36 in EFY 2003/04. Opportunities and options for curative services including inpatient care have also improved with the increasing number of private clinics and hospitals especially in urban areas.
  • 185. • The challenges with regard to medical service are delayed development of the essential package of services and referral system guidelines; delayed revision of coverage calculation system; shortage of diagnosis and treatment protocols; poor drug management system; and poor human resource management and unsatisfactory professional ethics. Therefore, the future planning should properly address these areas in order to improve the quality of care and ensure adequate utilization of the health service by the public.• 5.2.6. Hygiene and Environmental Health• A) Objectives of Hygiene and Environmental Health• Hygiene and environmental health is one of the components in HSEP and the objective of this subcomponent is to:
  • 186. • Increase the coverage of hygiene and environmental health services of the population.• Increasing access to toilet facilities from 10 % to 17%, for which the achievement was 29 % in 2003/04.• Increase access to safe water which has also improved from 23.1% in 1997/98 to 35.9% in 2003/04; while access to sanitation increased from 12.5% to 29%.• Some of the implemented activities are:• Public Health Proclamation was issued in 2000• Public Health Regulation has been prepared and submitted for endorsement.• Forty-seven technical guidelines, leaflets, and posters and related teaching aids on various issues of hygiene and environmental health were also produced and distributed to health facilities.• Based on the Public Health Proclamation, regions have endorsed Environmental Health Regulation.• National Sanitation Strategy that supports the implementation of MDGs is prepared in collaboration with the World Bank.
  • 187. • Water Quality monitoring by the public sector has reached 44 %. In collaboration with EHNRI, MoWR,• Regional Water and Health Bureaus, WHO and UNICEF, Rapid National Water Quality Assessment is underway.• Some packages that suit pastoralist communities have been prepared.• To support food-processing plants to produce safe food and be competitive in local and international market, ten food-processing plants from dairy, meat, fruit and vegetable, flour and edible oil have been selected and started implementing HACCP with support from UNIDO. Public Health Microbiology of EHNRI has been equipped at a cost of Birr 1.2 million. Controls and inspection of imported food has shown 24 % increment in 2003/04 as compared to the 2002/03.• The 75 % achievement in latrine overage of SNNPR in a year time through mobilization of communities and administrative staff at all regional levels could be sited as a best practice.• The following are major challenges encountered during the implementation of the program:
  • 188. – The service has not reached the majority of rural population and in some regions it is limited to urban areas focusing only on inspection of catering establishments.– Data on sanitation coverage are scanty and varied– Low performance in the inspection of solid waste disposal (76%) and control of water sources quality (44%) in 2003/04.– Contribution of environmental health services in prevention and control of major diseases such as malaria, TB and diarrhea diseases in children is not realized and remained un-integrated into these programs.– Hygiene education and promotional works lack systematic approaches.– There is low level of leadership and attention for environmental health services from regional health bureaus to Woreda Health Offices. Except for salary, there is no earmarked budget for environmental health in several regions and virtually non-existence at health facility level. Environmental Health is abolished from the organizational structure in one region and downgraded in others.– There is lack of career structure for sanitarians resulting in poor commitment to their job.
  • 189. • B) Access to services• To improve healthcare service accessibility, health facility construction and expansions are underway. This will expand the network of health posts and health centers, while at the same time ensur¬ing that they are adequately equipped.• One strategy in this component is to implement the accelerated expansion of Primary Care services by constructing new health posts and health centers and upgrading health stations to health centers. A related key activity for Woreda Health Offices is to supervise the construction, equipping and furnishing of new health posts and new and upgraded health centers.
  • 190. • To reach HSDP III targets:• 13,635 health posts and 3,200 health centers are needed.• These facilities must be staffed with 30,000 health extension workers and 5,000 health officers• Facilities also need to produce accurate information about their work through a Health Management Information System. Woreda and regional health offices/bureaus provide a vital role in supporting these facilities.• 5.2: Trends in increase of selected categories of Health Human Resource in Ethiopia during• HSDP I and II as compared to 1989 E.C.• Human Resources• Category• Average Number of yearly graduates• Difference at 1997 as compared to 1989 Before HSDP• 1989• HSDP I• 1990-1994• HSDP II• 1995-1997
  • 191. • All physicians 244 205 387 59% increase• Specialist physicians 68 63 127 87% increase• General practitioners 176 142 260 48% increase• Public health officers 46 137 251 45% increase• Nurses (except midwifes) 683 667 2601 81% increase• Midwifes (Senior) 90 50 75 17% decrease• Pharmacists 32 34 59 81% increase• Laboratory technician 190 214 382 101% increase• 5.3: Human Resource Development • State the objectives for human resource development • Identify major challenges to human resource development
  • 192. • 5.3.1 Introduction• The major objective of the human resource development sub-component is to train and supply qualified health workers. The specific objectives are to:• supply skilled manpower in adequate number to new health facilities• improve the capacity of the existing health manpower working at various levels• initiate and strengthen continuing education and in-service training• review and improve the curricula of some categories of health workers• rationalize the categories of personnel• In order to meet these objectives, the training capacity of teaching institutes was increased and strengthened.
  • 193. • For instance, two already existing MOE institutions with health worker training programmes (Alemaya and• Dilla) started operating diploma and degree level training programmes in 1990 EFY. New training programmes and schools under RHBs were started in Arbaminch, Gambella, Jijiga, Borena and Benishangul Gumuz; a number of training institutions were expanded and rehabilitated; training materials were provided to training institutions; teachers were provided with pedagogic training; and several training curricula were revised.
  • 194. • Health Human Resource Development Plan was developed with projection of the required human resource by category and strategies of improving the quality of training and human resource management. The number of graduating health human resource and availability of all categories of health professionals has also improved over time, the most remarkable improvement being in health officers and nurses (see table 2.2 and 2.3).• Moreover, the achievement in the training of primary health care workers was 133% and overall, the number of health workers of all categories trained in 2003/04 was 2,876, which shows an increase by nearly 64 % as compared to the 2002/03 (1,758).
  • 195. • The major challenges in relation to human resource development are:• Poor deployment and retention of all health professionals• Poor human resource management• Challenges in areas of training of midwives• Poor quality of training due to frequent changes in the modality of training• Lack of national exam to assess the trainees• Shortage of budget, staff and training materials for RTCs• Irregularities of continuing educations and on the job training• Absence of clear guideline on deployment and transfers of health professionals at national and inter-regional levels in order to avoid the subsequent illicit behavior impacting staff morale
  • 196. • 5.3: The ratio of health workforce to population before and during HSDP I and II as compared to 1989 E.C.• Human Resources Category• Availability to population• Before HSDP 1989 End HSDP I 1994 HSDP II• Total• No.• Ratio to population• Total• No.• Ratio to population• Total• No.• Ratio to population
  • 197. • All physicians 1,483 1: 38,619 1,888 1:35,603 2,453 1:29,777• Specialist 314 1:182,396 652 1:103,098 1,067 1:68,457• General Practitioner 1,169 1: 48,992 1,236 1: 54,385 1,386 1:52,701• Public health officers 30 1: 1,909,085 484 1:138,884 776 1:94,128• Nurses (BSc + Diploma except midwifes) 3,864 1:14,822 11,976 1:5,613 17,300 1: 4,222• Midwifes (Senior) 250 1:229,090 862 1:77,981 1,509 1: 48,405• Pharmacists 156 1:367,131 118 1:569,661 191 1:382,427• Pharmacy Tech. 317 1:180,671 793 1: 84,767 1,428 1: 51,151• Environmental HW 657 1: 87,173 971 1: 69,228 1,312 1: 55,673• Lab. technicians and technologists 621 1:92,226 1,695 1:39,657 2,837 1: 25,747
  • 198. • 5.4: Pharmaceutical Service – Describe the Ethiopian drug system. – Identify an updated list of essential drug – Identify challenges in pharmaceutical services• 5.4.1 Pharmaceutical Services• The objective of the pharmaceutical services sub-component is to ensure a regular and adequate supply of effective, safe and affordable essential drugs, medical supplies and equipment in the public and the private sector and ensuring their rational use. The Drug Administration and Control Authority (DACA) and Pharmaceutical
  • 199. • Administration and Supply Services (PASS) of the Federal Ministry of Health are the two responsible bodies in the pharmaceutical sector. DACA is responsible for the overall policy implementation and administration of the sector while PASS is responsible for the procurement and supply of medical equipments and drugs to health institutions.• DACA has concluded the total revision of National Drug Policy (NDP) and the subsequent development of the master plan in 1996-98. The 1987 National Essential Drug List has been revised and is ready for printing.• In addition, two studies entitled “Assessment of the Pharmaceutical Sector in Ethiopia (FDRE/WHO, 2003)” and the “Drug Supply and Use in Ethiopia (HCF Secretariat, 2002)” have been published. One of the most important recommendations of these studies is institutional strengthening including the availability of qualified pharmacists.
  • 200. The local production of pharmaceuticals and medical supplies has increased consistently. By the end of 2003, three of the 13 pharmaceutical manufacturers have received DACA’s licenses for export. The number of importers has also increased from 49 in 2001/02 to 70 in 2003/04. Except for the drug shops that show increment from 250 to 381, the number of pharmacies has decreased from 304 to 276 and rural drug vendors from 1950 to 1787 for the period 2000-2004 (1992-97EFY). Drug formulary and standard treatment for different levels of health facilities have also been developed. In general, the availability of drugs in the health facilities has improved.
  • 201. • With regard to pharmaceutical human resource,• The number of diploma schools for druggists and pharmacy technicians has increased• A school of pharmacy opened in Jimma University in 1994 EFY at a degree level, and in the same year the school of Pharmacy in AAU started two postgraduate courses.• Several trainings have been conducted on different topics and guidelines were produced• A drug information bulletin is being published regularly.• The national availability of essential key drugs (based on a survey result published in 2003) was:• 75% for public facilities, with an 8% general average for presence of expired drugs• 85% for regional drug stores, with a 2% general average for presence of expired drugs• 95% for private retail drug outlets with a 3% general average for presence of expired drugs
  • 202. • The challenges encountered are:• High attrition rate of pharmaceutical personnel to the private sector.• Weakness in the drug management, monitoring and evaluation system• Weakness in the implementation of proclamation and some elements of NDP• Low budget allocation to drugs• Lack of proper stock management at health facilities as revealed by lack of stock control tools• Lack of linkage between the drug registration process with inspection of manufacturing sites abroad• Inadequate in-service training of health workers and shortage of stores.• Therefore, the future direction should be:• strengthening the overall drug management system,• improving the implementation of policy/proclamations in order to achieve the objectives set under the pharmaceutical component• Revision of some aspects of the National Drug Policy (NDP) as indicated by DACA• Strengthening the medical equipment maintenance system.
  • 203. 5.5: Information, Education and Communication (IEC) and Health• Information Management System (HMIS)• List two objectives of Information, Education and Communication sub component• List the objectives of Health Information Management System (HMIS) sub component• List the enabling factors for implementation of HMIS• State major challenges for implementation of HMIS5.5.1. Information, Education and Communication (IEC)• The objective of the IEC sub-component is to support the development and implementation of a national IEC plan and strategy whose goals include:• Improve health KAP (knowledge, attitude, practice) about personal and environmental hygiene and common illnesses and their causes
  • 204. • Promote community support for preventive and promotive health services through educating and influencing planners, policy makers, managers, women groups and potential collaborators• The major constraints to the implementation of IEC/BCC (behavioral change communication) are:• The delay in developing behavioral change communication strategies for national and regional levels focusing on: – youth - HIV/AIDS, reproductive health, personal – married couples- family planning, safe motherhood, nutrition – health workers - interpersonal communication and counseling
  • 205. • Inadequate technical capacity of staff at all levels of the health system; • Inadequate budgetary allocation for IEC • Poor coordination of the many players both within the government and NGOs on IEC • Inadequate quality monitoring system for IEC • Inadequate capacity and ineffective system for planning, implementing, monitoring and evaluation of• IEC/BCC activities at all levels of the health system leading to ineffectiveness of IEC/BCC efforts to serve as vehicles through which behavioral change can be effected.
  • 206. • 5.5.2. Health Information Management System (HMIS)• Management information system (MIS): is a system designed by an organization to collect and report information on a program and which allows managers to plan, monitor and evaluate the operations and the performance of the program• A Health management Information System (HMIS) is a management information system that is directed towards health.• The major objective of this subcomponent is to: – improve knowledge and skills in the areas of policy formulation, planning and budgeting, financial management, programme implementation and M&E for staff of FMOH, regions and woredas – Enhance community involvement in the management of health facilities and community based health interventions.
  • 207. • Health management is implemented by:• Appointment of health mangers with appropriate skills• Establishment of management boards, health councils, etc at all levels• Revision of Programme Implementation Manual (PIM).• Staffing of woreda health offices for the effective implementation of decentralized health system.• Hospital management boards have also been established in federal and some regional hospitals as part of hospital reform activities.• Several regions carry out planned supervisory visits, and have developed supervision manuals that are available to health management staff at the zonal, woreda and facility levels.• Result Oriented Performance Evaluation System (ROPES) that has been initiated in some regions
  • 208. • The objectives of HMIS are to:• establish/ strengthen HMIS at all levels of health service delivery system• establish HMIS units at all levels (FMOH, RHB, woreda health offices and HF levels)• Establish/strengthen the database at FMOH, RHBs, woreda and health facilities.• HMIS is implemented by:• Reducing the number of reporting formats from 25 to 12 and efforts are also being made to establish networking between FOMH and RHBs.• A national HMIS advisory committee (NAC) has been established with representation from different stakeholders. The NAC is established to facilitate the development of a national policy and strategy on
  • 209. • HMIS and M&E. term of reference (TOR) and plan of action for NAC and for integrated HMIS, M&E and Information Communication Technology (ICT) application in one package has also been completed.• FMOH and some regions are publishing the annual Health and Health related Indicators.• Networking through email has been implemented in 30 Woredas in Tigray. SNNPR RHB has also adopted a generic reporting system, produced guideline, trained staff at all levels and instituted a computerized data system. Most of the regions have adopted reporting systems on major health indicators and health sector activities based on formats developed jointly by the FMOH and the regions.
  • 210. • Challenges faced in relation to HMIS are:• Lack of coordinated effort and leadership• Lack of strategy and policy, shortage of skilled human resource and lack of guideline.• Timeliness and completeness of HMIS reporting remains poor, and such delays contribute to the failure (at all levels) to use data as the basis for informed decision- making in planning and management.• Parallel reporting mechanisms persist with programmatic and donor-supported initiatives resulting in multiple reporting formats and an increased administrative workload
  • 211. • 5.6: Monitoring and Evaluation (M&E) and Healthcare Financing – Define Monitoring and evaluation – State prerequisite for monitoring and evaluation implementation – State the objectives of Health care financing sub component – Identify the budget source for health care financing in Ethiopia
  • 212. • 5.6.1. Monitoring and Evaluation (M&E)• Definition:• Monitoring and evaluation• Monitoring is the systematic and continuous assessment of the progress of a piece of work over time.• An evaluation is the assessment at one point in time of the impact of a piece of work and the extent to which the stated objectives have been achieved.• The major objective of the M&E component is to strengthen the M&E system at federal and regional levels and establish a system in all woredas. The specific objectives were to:
  • 213. • Develop/strengthen a M&E system that functions at regional and woreda levels,• Standardize M&E guidelines, harmonize supervision guidelines for RHBs and woreda health offices• Regularly monitor progress and achievements of HSDP components as a whole and improvements in service delivery, quality of care and financial performance• Evaluate the impact, effectiveness and cost- effectiveness of HSDP II components.• Monitoring and Evaluation is implemented by:• The establishment of joint steering committees, at both central and regional levels, to oversee implementation,• Regular reporting by regions and FMOH departments
  • 214. • 5.6.2. Healthcare Financing• A) Source of financing for the health care delivery system in Ethiopia• Financing the formal Health care delivery system is highly dependent on government tax revenue (more than 60%), followed by external assistance (bilateral, multi-lateral, UN Agencies) which the later grew over the years from 25% in the 1960s to around 35% to date.• The central government is hoping to increase the share of external support to health to at least 40% or more for the effective implementation of the MDG- based HSDP III.• Other sources of health care financing are less significant (user charges, insurance schemes, charities, the private sector…etc)
  • 215. • Looking back, the Ethiopian Dollar value of health expenditure between 1940 to 1943 averaged about• Million and between 1944 to 1946 about 3.56 million.• By 1953, 3.4% of the government’s Budget was devoted to public health.• Total health expenditure in 1965-66 averaged to some Birr 77 million (USD 30.0 million). This expenditure included foreign aid support, expenditure on medical school, the Gondar Public Health College, private medical practice, and the traditional practitioners.• For the same years, the average annual health budget including health represented about 5% of the total
  • 216. • Government budget, averaging about USD 0.37 per capita on health care. This was one of the lowest per capita expenditure even by the standard of many African countries at the time.• Total government budget in the 2003-04 reached to an average of about 1.3 Billion Birr per year. A significant amount of external support has been mobilized, perhaps equivalent to government allocation, over the last three years for special programs such as HIV/AIDS and other priority areas.
  • 217. • B) The Healthcare Financing Strategy• The objectives of the Health Care Financing (HCF) component are to:• Mobilize increased resources to the health sector, which implies:• local retention of revenue• cost–sharing• reduced resource leakage from high waiver• expand special pharmacies• user-fees revision and risk-sharing. – Promote efficient allocation of resources and develop a sustainable health care financing system.
  • 218. • To implement the above objectives, the following steps have been taken: • Background studies have been conducted • Complimentary reforms have been closely monitored • Reform implementation strategy/action plan has been designed • A study on National Health Accounts (NHA) was also conducted using the 1995/96 EFY data. • Local training in health care financing and management, outsourcing, and hospital management efficiency were done. • HCF strategy orientation workshops were conducted in all regions and over 1,100 people were sensitized
  • 219. • Establishment of private practitioners/providers association, facilitated by Ministry of Health, is encouraging the involvement of the private sector in the realization of the Health Care Financing Strategy.• The draft Health Service Delivery, Administration and Management Proclamation and five regulations (fee waiver and exemption, hospital management board, out-sourcing of non-clinical services, fee retention at facility level and establishing private wings in government hospitals) have been completed. The Proclamation and the regulations will soon be presented to Parliament for endorsement.
  • 220. • UNIT VI: HEALTHCARE SYSTEM• REGULATION• Introduction• In the previous units of the module we have seen the historical development of health care delivery system in Ethiopia, Structures and component, Health service programs. And in this unit we will see the health system regulation that includes health related legislation, and facts about accreditation, licensing, certification and historical back ground of professional association. Also the unit includes Health information policies and procedures
  • 221. • Unit Outline• 1. Healthcare System Regulation• 1.1 Major health related legislations• 1.2 Regulation of Credentialing Health Manpower• Accreditation• Certification• Licensure• 1.3 professional associations• 2. Health Information Systems Policies and Procedures
  • 222. • 6.1: Healthcare System Regulations• At the end of this lesson, the students should be able to:• Identify health legislations• State proclamations related to health• Discuss differences among licensing, certification and accreditation• Identify the responsible body for accreditation, certification and licensure• Describe professional associations and the purpose they serve6
  • 223. • 6.1.1. Major Health Related Legislations• Some of the major health related legislations are:• The first health decrees were vaccination against smallpox by Emperors Yohannes and Menelik II, during the smallpox epidemic in 1886.• However, modern medical legislation could be traced back to the coronation of Emperor Haileselassie I in 1930.• On July 18, 1930 a law was passed to regulate the practice of doctors, dentists, pharmacists, midwives and veterinarians. The law specified that no one could practice these professions without a relevant Diploma.• Formal recognition of Traditional Medicine was given in 1942 (proc. 27). This was reaffirmed in 1943 and 1948 (proc. 100) as part of the medical registration proclamation.
  • 224. • Between 1941and1950 some 27 Public Health enactments were made available, some of them were: – Public Health Proclamation Negarit Gazeta (NG 26, 1942, 5-6) – Medical Registration proc. (NG 27, 1942, 6-7) – Pharmacists and druggists Proc. (NG. 34, 1943, 38-39). – Proclamation to systematize and regulate Missionary health activities (May 28, 1945) – Public Health Proclamation (NG 91, 1947, 66-68) – Medical Practitioners Registration Proclamation (NG 100, 1948, 1-3) – Establishment of the Ministry of Public Health, 1948 – Decree on Health tax (NG 20th, No. 11, 1960).• Pharmacy regulation (NG 288/1964)
  • 225. – National Research Institute of Health Established (NG 271/1985)– Establishment of Ethiopian Pharmaceutical Manufacturing Factory NG 167/1994– Council of Minister of regulation established regulation no (NG 174/1994) to provide for licensing and supervision of Health service Institution.– Establishment of the Pharmaceutical and Medical supplies import and wholesome sale enterprise(NG 176/1994)– Nutrition Research Institute Established under council of ministry of regulation( NG 4/1996)– Establishment of Health Education Center NG 40/1998– Establishment of Ethiopian Health Professional Council (NG 76/2002
  • 226. • 6.1.2. Regulation of Credentialing Health Manpower• In requiring compliance with a well-developed set of quality standards, the processes of accreditation licensure and certification provide a means of evaluating and determining not only technical performance, but provide facilities and caregivers with important information on practices that improve the delivery of care. In fact, accreditation and certification act as public “seals of approval” of the technical practices delivered by health care facilities or personnel, respectively.
  • 227. • The regulation of credentialing health manpower occurs in three forms:• Accreditation of educational programs• Certification of personnel by the profession• Licensure of personnel by a government agency. (Table 6.1 depicts the differences between these three forms.)• Characteristics Licensing Certification Accreditation• Applied to Healthcare personnel Healthcare personnel Educational institutes• Granting body Government agency Peer organization or Government agency• Required for Entry into practice Professional status Professional status• Purpose
  • 228. • Restricts entry into field to personnel who can’t meet the standard• Recognized qualification to practice at higher level• Public assurance of desired level of quality of care• Duration Permanent Permanent or fixed term Fixed term• Indicates high quality No Yes Yes• Performance based No Sometimes Yes• Administration Simple Moderate Complex• Renewal Automatic (possible exam) Continuing education (possible exam) Complete reinspection
  • 229. • A) Accreditation• Accreditation refers to a process of quality control and assurance whereby, as a result of inspection or assessment, an institution or its programmes are recognized as meeting minimum standards (Adelman, 1992). In most developing and developed countries, health science education training institutions are controlled by the national health rather than educational authorities. However in Ethiopia the responsibility designated to MOH encompasses the accreditation of health facilities (e.g. Hospitals, Health Centers, Health Post, etc.) licensing of practitioners and specialty certification while institutional and program accreditation is determined by a semiautonomous body: Higher Education Relevance Quality Agency (HERQA). The MOE established HERQA as a sector support unit through the Higher Education Proclamation (No. 351/2003). It is directly accountable to the MOE.
  • 230. • Purpose of Accrediting Educational Institutions:• Establishing criteria for professional certification and licensure;• Assisting prospective students in identifying acceptable programs;• Creating goals for self-improvement and stimulating higher standards among institutions; and• Helping to identify institutions and programs for the investment of public and private funds and providing bases for determining eligibility for governmental assistance.
  • 231. • 6.1 characteristic differences between licensing, certification and accreditation• B) Certification• Certification is essentially synonymous with accreditation, except that certification is often applied to individuals (such as certifying a medical specialist), whereas accreditation is applied to institutions or programs (such as accrediting a medical education program). It is recognized as an important and beneficial component of career development for providers as it consist of the completion of a training program in different health science professions. Certification enables the public to identify those practitioners who have met standards of training and experiences set above the level required for licensure.
  • 232. • In developed countries such as the U.K. and Australia, national medical councils control primary certification indirectly through the process of accrediting the medical school curriculum. While in the U.S. and Canada, national examinations following academic requirements play a major role in primary certification (Hafez 1997).• Regardless of either approach, there is common ground in terms of certification being assessed and determined by non governmental bodies.
  • 233. Primary certification in Ethiopia is mandatory, although it does not guarantee employment. Examinations are conducted at the national level by the MOE, of which health professionals have to score at least 60% on the qualifying exam to be certified and registered as professional in a specified health field. Specialty certification is conducted by the MoH. However, both areas are lacking as certifying bodies are outside of the influence of professional societies/ organizations and assessment of competency through examination following graduation is not being applied. Additionally, issues of recertification and Certifying medical education to date have not been explored.
  • 234. • C) Licensure• Licensure is a regulation of health manpower by a government agency that verifies that health providers meet the basic minimum standards of competency to perform their work safely and effectively. As licensing functions as a work permit, it is mandatory for institutional or independent practices in public /private/nongovernmental organizations. Upon certification of personnel by the profession, a professional may be registered for a licensure.• In 2007 the MOH designated Regional Health Bureaus the authority to conduct licensing for all certificate and diploma level health professionals. Currently licensing at these levels is being conducted in 5 different regions.
  • 235. • It is the wish of the MOH that all regions provide periodic licensure for any certificate or diploma level health practitioner to practice within their specific region upon being certified, competent and that there is demand.• The licensing of degree level and above remains the responsibility of the MoH as the equitable distribution of high level health professionals remains pertinent.
  • 236. • 6.1.3. Professional Associations• The purposes of professional associations are many, but to site a few, they are:• To devise peer review systems• To participate in the setting of professional standards and provide continuing education in their respective fields• To serve as referral points in policy and development issues.• A number of professional associations are in existence in Ethiopia, to cite a few:
  • 237. A) Ethiopian Nurses Association (ENA): established in July 1952, it is the oldest and pioneer professional association in Ethiopia. Its Objectives are:• To improve Nursing service to the benefit of the society, standing for the right of Nurse and Clients• Advance Nursing Education, practice, management and research to ensure quality Nursing care to the people of Ethiopia• Promote positive practice environment in the work place
  • 238. • B) Ethiopian Traditional Medicine Practitioners Association: established in 1991, its objectives are:• To provide a forum for exchange of ideas and experiences among traditional medicine practitioners
  • 239. C) Ethiopian Medical Association (EMA): established in July 1969, its objectives are:• To promote the science and art of medicine and the improvement of public health• To keep a high standards of professional ethics and etiquette• To promote the professional excellence of its members in preventive and curative medicine and medical research• To promote and maintain intellectual and professional freedom• To provide professional and technical advice to the Ministry of Health and other concerned organizations• To initiate and maintain professional linkage with similar associations within and outside Ethiopia• To provide a forum for the exchange of professional ideas, knowledge and experience• To encourage and support the establishment of specialized societies in medicine• To monitor the quality of medical services rendered to the public
  • 240. • D) Ethiopian Pharmaceutical Association (EPA): established in 1974, its objectives are:• To promote the pharmaceutical profession• To promote the rights of its members• To provide a forum for exchange of ideas and experiences among professionals• To work with similar associations for the improvement of the health services• To encourage and assist research and development programs in the field• To ensure an acceptable standard of the profession in Ethiopia• To maintain the honor and ethics of the profession
  • 241. • E) Ethiopian Public Health Association (EPHA): established in August 1989, its objectives are:• To bring together professionals to promote public health science• To review and recommend issues related to health policies, planning, training and management• To promote the professional interest of its members• To advance research in public health• To disseminate information on public health
  • 242. F) Ethiopian Dental Professionals Association: established in February 1992, its objectives are:• To promote dental profession• To formulate forums for exchange of ideas among professionals on the global scientific progress of dentistry.• To keep high standard of professional ethics and etiquette of Ethiopian dental professionals• To safe guard the interests of its members• To provide professional and technical advice to health institutions
  • 243. • G) Ethiopian Society of Obstetricians and Gynecologists (ESOG): established in March 1992, its objectives are:• To ensure a high standard of obstetrical and gynecological practices• To play an advisory role in the training of obstetrics and gynecology• To protect and safeguard the professional interest of members• To promote friendship and exchange ideas among professionals• To initiate and maintain professional linkages with similar societies within and outside Ethiopia
  • 244. • H) Radiological Society of Ethiopia: established in October 1994, its objectives are:• To ensure highest possible standard of professional competence• To serve as an advisory body in the field• To protect and safeguard professional rights and interests of its members• To foster fellowship among members and other allied professionals
  • 245. • 6.2: Health Information Systems Policies and Procedures• 6.2.1. Introduction• Delivering healthcare services to the population is dependent on information for proper planning. To have a properly functioning Health Management Information System (HMIS), there must be policies and procedures which are adequately enforced.
  • 246. • 6.2.2. HIS Policies and Procedures• Legal, regulatory and planning context of health information is a key resource for effective Health Information System (HIS). It enables the establishment of mechanisms to ensure data availability, exchange and quality.• Legal and policy guidance is needed to elaborate specifications for access, to protect confidentiality, etc• In Ethiopia, there is legislation providing the framework for health information covering specific components, such as notifiable diseases, private sector data, confidentiality, fundamental principles of official statistics, etc. With regard to vital statistics, starting from the 1960 Civil Code of Ethiopia, the country has declared different legislations at different times to implement the legal and official registration of births and deaths .However, no significant progress has ever been made to put this in to action.
  • 247. • Currently, Ethiopia is in the stage of publicizing the registration law, creating organizational and administrative structure and establishing local registration offices and training of registrars. Ethiopia does not have a regular system for monitoring of the performance of HIS. The National Advisory Committee (NAC) of the HMIS is in charge of coordinating the health information system although it has a limited mandate and resource to run the activity on a regular basis.• NAC was initially founded in 2005 with an objective of assisting in the review of the existing HMIS and M&E system, development of a comprehensive HMIS and M&E strategy as an implementation tool for monitoring and evaluation of HSDP III and beyond.
  • 248. Ethiopia has limited capacity in core health information sciences to meet health information needs. There is a functional central HIS unit in the Ministry of Health which plays a significant role in coordinating, strengthening and maintaining the national HIS, including the ongoing HMIS reform. However, it lacks adequate resources to effectively maintain and upgrade the status of HIS to a level that meets the health information requirements of the country. The problem progressively increases as we move down to the Woreda health offices. To make things worse, at all levels of the health system, the professional mix is poor and the attrition rate is very high, which calls for major intervention in the area of HIS capacity building activities.
  • 249. • 6.2.3. Health Information Related Initiatives• The HMIS related initiatives are best understood in light of the overall objectives of the Health Management Information System, which are:• Develop and implement a comprehensive and standardized national HMIS and ensure the use of information for evidence based planning and management of health services.• To review and strengthen the existing HMIS at federal, regional, woreda, health facility and community levels and ensure use of health information for decision-making at all levels.• To achieve 80% completeness and timely submission of routine health and administrative reports.• Achieve 75 % of evidence based planning.
  • 250. • The strategy for implementation of HMIS objectives is:• Institutionalize HMIS at all levels.• Build capacity of health workers to analyze, interpret and use health information for making decisions.• Introduce appropriate HMIS technology at all levels of the health system in collaboration with the concerned bodies such as the National ICT Authority.• Define the minimum standard of inputs required for HMIS at different levels of the health system.• Initiate and sustain regular programme review and feedback system.• The breakdown of the plan is detailed according to what activities are carried out by the various levels in the healthcare system. These being:
  • 251. • A) The key activities at the Woreda Health Offices level are:• Establishment of HMIS posts and assignment of appropriate personnel in the organizational structure of woreda health office and health institutions as per the national standard.• Determination of the qualification requirements, job descriptions, career path, and incentive package standards for personnel working on HMIS.• Ensure the proper reporting and feedback mechanism is laid out beginning form the health extension workers to the HMIS personnel• Provide the necessary health and administrative reports to the RHBs as per the guideline.• Allocate funds for HMIS and provide the necessary facilities for the HMIS units/personnel• Implement and monitor the pilot HMIS in collaboration with the RHBs.• Collaborate on the expansion of the geographic information system and woreda connectivity.
  • 252. • B) Key Activities at the Regional Health Bureaus Level:• Adapt and implement qualification requirements, job descriptions, career path and incentive packages for personnel working on HMIS at different levels of the health system.• Adapt and implement National HMIS Strategy, manuals and standards developed at national level.• Conduct regular on-the-job training to HMIS focal personnel, programme managers and health workers.• Equip HMIS units at all levels.• Implement HMIS on pilot basis in collaboration with the FMOH.• Collaborate on the establishment of electronic network from federal to woreda level as part of implementation of HMIS.• Initiate and sustain the development of Health and Health Related Indicators in the regions.• Advocate the allocation of adequate funds for implementation of National HMIS in woredas.
  • 253. C) Key Activities at the Federal Ministry of Health Level are: – Assign a multidisciplinary team at Planning and Programming Department /MOH and provide the – necessary facility so that it will be able to spearhead the development and implementation of HMIS at national level. – Develop and popularize the National HMIS Strategy and user-friendly manuals. – Develop and popularize qualification requirements, job descriptions, and career path and incentive packages for personnel working on HMIS at different levels of the health system. – Standardize HMIS indicators; harmonize the reporting system and collect gender disaggregated data. – Develop, adapt and implement HMIS user-friendly guidelines and revise International Classification of – Disease ICD coding system.
  • 254. – Initiate pre-service training on HMIS in health professional training institutions.– Implement HMIS on pilot basis before nationwide replication.– Conduct system analysis for the application of ICT to HMIS, pre test and implement the application and– expand geographic information system.– Mobilize funds for implementation of National HMIS.– Monitor the implementation of program review and research recommendations through HMIS.– Publish Health and Health Related Indictors bulletin annually.
  • 255. UNIT VII: HEALTHCARE SERVICE PLANNING7.1.1 Introduction: definitions of key termsA) What Is Planning?• A plan is defined as a map, a preparation, or as an arrangement. Planning defines where one wants to go, how to get there and the timetable for the journey. Planning can also identify the journey’s milestones. Complete planning sets out indicators for tracking progress and ways to measure if the trip was worth the investment.• Planning is future oriented process of determining a direction, setting goals, and taking actions to reach those goals. Planning is all about making changes and is basic management function that is essential to the success of all levels of an organization.
  • 256. B) What Is Health Planning?• Health planning is a process to produce health. It does this by creating an actionable link between needs and resources. Its nature and scope will depend upon the:• Time allowable• Assessing need• Resources available to support the process• Broader political and social environment.
  • 257. 7.1.2 Health Service Planning Healthcare service planning is a core activity of public health professionals and managers. It is not as such a linear process, but a continuous improvement process. It involves gathering data, translating it into useful information, and using that information to make decisions. A generalized model includes the following stages:• Needs assessment• setting goals and objectives• developing interventions• implementing the interventions• evaluating the results
  • 258. • Charting a course, navigating and keeping a travel log are all parts of a good planning process. Broad elements of planning are:• identifying a vision and goals• undertaking strategic planning• evaluation• The Health Planning Process follows the same basic steps any planning process follows. In the health planning process the following factors must be taken into consideration in each planning cycle:• the definition of what constitutes health, and what are the new definition of society’s health goals• integration of new technologies that are available to create, restore, or support health• emerging unforeseen health conditions (e.g. rapidly spreading infectious diseases)• changing economic conditions• correction of past oversights
  • 259. • The planning process• The planning process has 7 basic steps, best depicted in the following diagram• Step One: Surveying the Environment/Situation Analysis• This often involves extensive information gathering to determine the health or illness profiles and experiences of the population of interest. It is meant to identify the current state of the issue under consideration.• Step Two: Setting Directions/Setting Goals• This involves setting goals and objectives, and it also involves establishing the standards against which current health/illness profiles, or current organizational or system performance will be compared. This step is meant to identify the desirable future state (expressed as outcomes if possible)
  • 260. • Step Three: Problems and Challenges• This involves identifying and quantifying the difference between what is and what ought to be.• Step Four: Range of Solutions• This involves identifying the range of solutions to each identified problem or challenge. This step should also include assessing each possible solution in terms of its feasibility, cost and effectiveness. So alternate solutions can be compared with each other. This step often requires significant creativity, since no off-the- shelf solutions may be available for some problems and challenges.
  • 261. • Step Five: Best Solution(s)• This step involves a choice of the solution, or set of solutions, that should be implemented to address the problems or challenges identified in step three. The choice may need to take into account financial, political and other limitations.• Step Six: Implementation• This step involves implementation of the chosen solutions, and often begins with development of an implementation plan.
  • 262. • Step Seven: Evaluation• This step involves evaluation of the results of implementation to determine whether the implemented solutions are effective in achieving their goals. It also involves evaluating the environment to see if it has changed, thereby rendering the solutions less effective, more effective or irrelevant. This step may begin with development of an evaluation plan well before evaluation actually takes place. It may also involve development of ongoing monitoring methods to be used to continuously identify and assess the intended and unintended consequences of implementation actions.
  • 263. • 7.1.3 Strategies and Approaches used in Health Service Planning• There are various types of health planning, and the approaches used are:• Strategic planning and,• Operational planning• A) Strategic Planning• A strategic planning process is used when there is a broad and open question to be answered, and many paths are on the table - for example, identifying the desired model for delivery of children’s health services in rural settings and determining how to move to that model. Usually a strategic planning process assumes a new look at an issue, and an outcome that will take time to put in place but will exist for a period longer than one funding cycle. Generally speaking it is assumed that a strategic plan will need to be revised or redone when the context in which the service exists changes markedly. A change in context could relate to challenges to sustainability, opportunities to expand, or newly identified best practices that should be incorporated into the plan.
  • 264. • A basic guideline for planning is that a vision should be renewed every three to five years and the strategic directions emanating from that vision also re-evaluated, perhaps yearly. A strategic planning exercise will include:• Strategic goals and directions,• Specific implementation or operational planning components.• For example in establishing a new local system of children’s health services, specific budgets, service expectations, timetables and human resource models may be designed by the strategic planning group, for hand-off to providers. In particular it outlines:
  • 265. – Priority issues in the health authority – Critical challenges to population health and service delivery in the region – Goals and strategic themes that will guide service delivery – Strategic directions by sector and by geographic area.• Within any strategic planning exercise, the following activities will occur:• A visioning exercise• Creating mission and goals• Establishing objectives• Establishing strategic directions• Developing a framework to establish and monitor success – a balanced scorecard approach for instance• Creating an implementation plan/timetable
  • 266. • Although originally developed for the corporate sector, the balanced scorecard has become popular within the health sector as a tool for both planning and monitoring.• Strategic planning processes should be supported by:• Use of data, both quantitative and qualitative• Consultation with stakeholders (related to all parts of the process, from visioning to data interpretation and crafting recommendations)• Application of project management and facilitation tools, which may include activities such as SWOT (strengths, weaknesses, opportunities and threats) analysis, mind-mapping and strategic alignment models• Monitoring and evaluation protocols.
  • 267. • The best tools for strategic planning are often the ones that the person leading the planning is most familiar with and has used successfully in previous initiatives. One of the tools commonly used is SWOT analysisSWOT Analysis:• This is an outline of strengths, weaknesses, opportunities of, and threats to, the organization. It is usually done at the start of a strategic planning exercise in a group setting to identify all factors in each area.• The factors are usually organized in a table of four quadrants so participants in the planning exercise can visually (and easily) see the context for the planning.
  • 268. • Strengths: include factors like staff capabilities, effective management processes, competitive advantage and unique programs or products.• Weaknesses: include factors like gaps in staff skills, financial problems and inadequate information systems.• Opportunities: include factors like global influences, new policy developments, partnerships and research.• Threats: include factors like market demand, loss of key staff and political effects, illiteracy, poverty, weak intersectoral collaboration
  • 269. B) Operational Planning• An operational planning process starts from a point of a specific objective, for example to increase the number of clients served at the Health Posts, and focuses on the range of opportunities within that delivery framework.• Operational planning will include:• Statement of purpose/deliverables/target to be achieved/success indicators• Use of available and relevant data and information• Stakeholder engagement (who needs to fund, deliver expanded services?)• Selection of priority action approach (new program design)• Development of an implementation timetable and budget.
  • 270. • Operational planning processes may be supported by activities or tools similar to those for strategic planning but with a tighter question applied to these activities. Included in operational planning could be use of an activity hierarchy model and a program logic model. A tool commonly used is a Logic Model.• This model creates a diagram of the program and allows the effects of a proposed change to be determined. It is very helpful for program planning and implementation monitoring. A logic model depicts action by describing what the program is and what it will do – the sequence of events that links program investments to results. The model has the following six components:
  • 271. • Situation: Problem or issue that the program is to address sits within a setting or situation from which priorities are set• Inputs: resources, contributions and investments that are made in response to the situation. Inputs lead to output• Outputs: activities, services, events, and products that reach people and users. Outputs lead to outcome• Outcomes: results or changes for individuals, groups, agencies, communities or systems• Assumptions: beliefs we have about the program, the people, the environment and the way we think the program is going to work• External factors: environment in which the program exists includes a variety of external factors that interact with and influence the program action.
  • 272. 7.2: Resource Identification1. At the end of this lesson the learners should be able to identify information systems to be used for resource identification7.2.1. Introduction to Classification (and Identification) of Resource• In the planning process resource identification is one of the critical success factors. Resources can be classified as:• Facilities• Equipment• Human resource• Finance/funds
  • 273. • The commonly cited resources are the three Ms and a T, that is,• Money• Materials• Manpower (human power)• Time• When assessing and identify resources the use of information systems becomes crucial. The commonly used information systems are: – Human Resource Information System (HRIS) – Logistics Management Information System (LMIS) – Financial Management Information System (FMIS)
  • 274. A) HRIS (Human Resources Information Systems)• Human Resources Management (HRM) is the attraction, selection, retention, development, and utilization of labor resource in order to achieve both individual and organizational objectives. HRIS is an integration of HRM and Information Systems (IS). HRIS helps HR managers perform HR functions in a more effective and systematic way using technology. It is the system used to acquire, store, manipulate, analyze, retrieve, and distribute pertinent information regarding an organization’s human resources.• A strong human resources information system gives health care leaders the data they need to quickly answer the key policy and management questions affecting healthcare service delivery. HRIS strengthening process includes:
  • 275. • Building local HRIS leadership• Strengthening infrastructure• Developing HRIS software solutions• Effectively using and analyzing data• Ensuring that users can support and improve the system themselves.Benefits of HRIS:• HRIS has showed many benefits to the HR operations. A few of them can be detailed as:• Faster information process,• Greater information accuracy,• Improved planning and program development• Enhanced employee communications
  • 276. B) LMIS (Logistics Management Information System)• Designing an effective and sustainable supply chain system for drugs and other commodities is important and can be complex. A correctly run distribution system should also keep drugs in good condition, rationalize drug storage points, use transport as efficiently as possible, reduce theft and fraud and provide information for forecasting needs. This requires a good management of the system along with a simple but well- designed information system in place.
  • 277. C) FMIS (Finance and Materials Management Information Systems)• Finance and Materials Management Information Systems (FMIS) comprises of applications that support core health agency financial management, including general ledger, assets and materials management.• FMIS will modernize and standardize business processes and reporting associated with finance and materials management. FMIS will provide health agencies with robust and capable, industry standard tools that will appropriately support the management of complex health agency settings
  • 278. The core functionality of FMIS includes:• General ledger• Budgeting• Accounts payable• Accounts receivable• Trust accounting• Assets management• Equipment hire• Materials management• Procurement• Cash receipting• On-line invoice submission• Expenses
  • 279. The benefits of FMIS are:• Additional control over expenditure - enforce financial delegations• Substantial cleanup of supplier data• Online procurement - timely, increased control• Move to EFT payment and cheque printing• Flexibility of reporting• Stock management• Workflow support and controls.
  • 280. • A) Glossary• Accreditation: to certify that an individual, organization, educational institution, etc., meets and maintains suitable standards.• Allied health professional: a person who is not a physician, nurse, or pharmacist, and who works in the health field. An allied health professional may, for example, be a dietitian, an emergency medical technician, or an aide• Ambulatory care: medical services that may include diagnosis, treatment, and rehabilitation, that are provided on an outpatient (nonhospitalized) basis.
  • 281. • Ancillary services: Hospital services other than room and board• Business Process Reengineering (BPR): a fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical contemporary measures of performance such as cost, quality service, and speed. Also known as Business Process Improvement• Catchments area: the geographical area from which a school takes its students, or the area from which a hospital services its patients• Elective Surgery: surgery that is subject to choice (election). The patient or doctor may make the choice.• Emergency room: a part of a hospital that takes care of sick or injured people who need immediate attention
  • 282. • Equity in health: is the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/disadvantage—that is, different positions in a social hierarchy.• Goal: a broad statement describing a desired future condition or achievement without being specific about how much and when.• Health education: education that increases the awareness and favorably influences the attitudes and knowledge relating to the improvement of health on a personal or community basis• Health Policy: is a legal document which contains decisions usually developed by government policy makers for determining present and future objectives pertaining to the healthcare system.• Health post: one of the satellite facilities in the Primary Health Care Unit
  • 283. Health stations: the smallest health units in the conventional Health Service structure and are staffed with 1-3 health assistants.Health: is a state of physical, mental and social well- being. It involves more than just the absence of disease or infirmity. This definition was ratified during the first World Health Assembly and has not been modified since 1948.Healthcare delivery system: a term without specific definition, referring to all the facilities and services, along with methods for financing them, through which health care is provided to the population.Healthcare: the prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical and allied health professions.
  • 284. • According to the World Health Organization, health care embraces all the goods and services designed to promote health, including “preventive, curative and palliative interventions, whether directed to individuals or to populations”• Higher clinic: staffed at least by a general medical practitioner, a specialist and assisted by various specialists serve for general outpatient clinics. For emergency and delivery this clinic has up to 5 beds.• Hospital: an establishment with at least 25 beds that provides general medical care round the clock. It is at least equipped with basic laboratory, X-ray and basic treatment facilities. It is staffed with at least one medical practitioner.
  • 285. • Household: a single person living alone or a group voluntarily living together, having common housekeeping arrangements for supplying basic living needs, such as principal meals. The group may consist of related or unrelated persons.• Indicators: established measures used to determine how well an organization is meeting its customers’ needs as well as other operational and financial performance expectations.• Infant mortality rate (IMR): the ratio of the number of deaths under one year of age occurring in a given year to the number of births in the same year. Also used in a more rigorous sense to mean the number of deaths that would occur under one year of age in a life table with a radix of 1,000.• Infant mortality: the probability of dying between birth and age one per 1000 live births in a given year.
  • 286. • Informatics: an emerging term that is used to cover information along with its management, particularly by computer. Usually the field involved is used along with “informatics”, e.g., “medical informatics.”• Inpatient admission: admission to an institution that provides lodging and continuous nursing services.• In-patient: a patient who is admitted and occupies bed in a health institution for diagnosis and/or treatment.
  • 287. • Leprosarium: leprosy hospital, a hospital for the treatment of patients with leprosy• Licensure: the state or condition of having a license granted by official or legal authority to perform medical acts and procedures not permitted by persons without such a license. It is also the approval of a drug or medical procedure by official or legal authority for use in the practice of medicine.• Life Expectancy at Birth: the average number of years a newborn infant can expect to live under current mortality levels.
  • 288. • Live birth: the complete expulsion or extraction from its mother of conception, irrespective of the duration of pregnancy, which after such separation shows any evidence of life.• Lower clinic: Staffed at least by a health assistant or a nurse and serve for general outpatient clinic.• Maternal mortality rate (MMR): a measure of a woman’s risk of dying from causes associated with pregnancy.• Medium Clinic: staffed at least by health officer or general medical practitioner and serve for general medical services.
  • 289. • Morbidity: the extent of illness, injury or disability in a population.• Organization: a collection of people working together in a planned deliberate social structure to achieve a common goal.• Organizational Structure: the structure and/or hierarchy of an organization and how its component parts work together to achieve common goals.• Out-patient: a patient who receive ambulatory care (examination and treatment) without being admitted or occupying a bed.• Postnatal visits: women attended, at least once during postpartum (42 days after delivery), by health professional including HEW’s for reasons relating to post partum.
  • 290. • Potential health service coverage : the population covered in percentage based on the existing health centers and health stations in catchments’ area.• Process: what happens between the start and end points. It includes all the activities performed by each department, group, or person who are involved in the process. Activities are the major “works” that transform an input into an output
  • 291. • Public health: is the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals. It is concerned with threats to the overall health of a community based on population health analysis. The population in question can be as small as a handful of people or as large as all the inhabitants of several continents. Public health is also a branch of preventive medicine, a medical specialty. Specialization in public health also occurs in nursing, nutrition, law, and other disciplines.• Rate of national increase: the difference between the births and deaths occurring during a given period divided by the number person-year lived by the population during
  • 292. • Risk Behavior: engaging in behavior that is harmful or dangerous to oneself• Strategic Planning: the process by which an organizations, public health or otherwise, envisions its future and develops strategies, goals, objectives, and action plans to achieve that future.• System: a completely functioning process dependent upon many parts to create results where each part has a central purpose that is linked to the global goal of the entire system and achievement of that goal is contingent upon the interaction of the parts.• Total fertility rate (TFR): the average number of children that would be born per woman of all women lived to end of their childbearing years and born children according to a given set of age specific fertility rates.
  • 293. • Under-five mortality: the probability of dying between birth and age five per 1000 live births in a given year.• Vital events: births, deaths, marriages and divorces• B) Business Process Reengineering (BPR) CORNER PAGE• BPR – about FMOH• The Government of Federal Democratic Republic of Ethiopia has embarked country wide reform initiative aimed at bringing effectiveness and efficiency in the execution of business practices to achieve dramatic improvement in critical, contemporary measures of performance such as cost, quality, service and speed.
  • 294. In line with this, the Federal Ministry of Health (FMoH) and agencies under the Ministry have made strong commitment to fundamentally rethink, radically redesign and fully decentralize the health care, health professionals, health facilities and health related products regulatory systems with the intension of satisfying customers/stakeholders needs and expectations and to fulfil sectoral visions/missions.
  • 295. The BPR principles are:• Organize around outcome not function and departments• Provide a single point of contact for customers and suppliers• Bring downstream information upstream• Capture information once at the source and share it widely• Substitute parallel for sequential process• Maintain a continuous flow of the main sequence• Identify and eliminate non-value adding steps• Use triage, not a one-size-fits-all strategy
  • 296. Based on these principles, the FMoH has made extensive analysis of the current work activities, health care practices and overall organizational structure in order to identify its strengths, weaknesses, opportunities, and threats. Consequently, various departmental functions have been merged and/or categorized under 8 core processes and 4 support processes.
  • 297. • The core processes are: • Health Care Delivery • Policy, Planning & Monitoring and Evaluation • Health Infrastructure Expansion and Rehabilitation • Financial Resource Mobilization and Health Insurance • Research and Technology Transfer • Public Health Emergency Management • Pharmaceutical Fund and Supply Management • Health and Health Related Regulatory Services
  • 298. The support processes are: • Human Resource Management • Finance and Procurement • Legal Office • Public Relation