MTR 2013 Final Report

ETHIOPIA HEALTH SECTOR
DEVELOPMENT PROGRAM
HSDP IV
2010/11 – 2014/15 (GC)
(2003 – 2007 EFY)
Mid-Term Review
VOLUME I
COMPREHENSIVE REPORT
By the Independent Review Team
21 April – 18th
May 2013
Final Report
Addis Ababa, 30th
August 2013

Final Report MTR; 2013.08.30. i
ETHIOPIA HEALTH SECTOR DEVELOPMENT PROGRAM
MID-TERM REVIEW OF HSDP IV
21 APRIL TO 18TH
MAY 2013
Program: Ethiopian Health Sector Development Program (HSDP IV)
Executing Agencies: Federal Ministry of Health and Regional Health Bureaus
Evaluation: Mid-Term Review (MTR) HSDP IV.
Period reviewed: July 2010-December 2012 (EFY July 2002 -Dec 2005)
Date submission: 17th
June 2013
Members of the Joint Core Coordinating Committee (JCCC):
Dr Amir Aman Hagos (FMOH, Chairperson JCCC), Mr Abduljelil Reshad Hussen (FMOH), Dr Sofonias
Getachew (WHO), Dr Muna Abdullah (UNFPA),Dr Luwei Pearson (UNICEF), Mr Eshete Yilma (USAID),
Dr Pasquale Farese (Italian Cooperation), Ms Marta Romero (Spanish Cooperation), Dr Gebresellasie
Equbagzi (World Bank), and Dr Mekdim Enkossa (FMOH coordinator).
:
Core Members of the 2013 MTR Review Team
Team members Mobile Numbers +251
Dr. Jarl Chabot 0920-244292
Ato Abebe Alebachew 0911-517122
Dr. Nejmudin Kedir 0925-415841
Dr. Humphrey Karamagi 0919-374957
Ms Fiona Duby 0924-909250
Prof Sundeep Sahay 0920-775253
Binyam Kebede 0911-224470
Asrade Asbate 0911-377096
Asheber Gaym 0911-216365
Etana Kebede 0911-246874
EyobTsegaye 0912-608183
Abonesh Hailemariam 0911-247377
Yayeh Negash 0912-609688
Solomon Emyu 0911-401551
All MTR team members were selected by the JCCC on the basis of their professional expertise and
participated in their individual capacity. There were 6 international and 8 national consultants.
The MTR was funded by DFID, the Netherlands Embassy and through the Health Pooled Fund (HPF).
(Technical Assistance component). As an independent review team, the opinions and suggestions in this
report are solely the responsibility of the authors and do not in any way commit or imply the agreement of
the FMOH or any of the other stakeholders operating in the Ethiopian health sector.
In addition to the 14 Core team members, there were 28 external team members, all participating in the
Regional visits (Annex 3 for names). The following institutions provided staff / consultancy support for the
various (core) team members in this MTR: FMOH (9), UNFPA (1), UNICEF (1), WHO (1), DFID (3),
USAID (2), JICA (1), World Bank (1), FHAPCO (1), PFSA (1), FMHACA (1), EHNRI (1), Fistula Hospital
(1), Carter Foundation (1), DKT (1), IntraHealth (1), ENGINE Project (2).

Final Report MTR; 2013.08.30. ii
TABLE OF CONTENTS
ABBREVIATIONS AND ACRONYMS ............................................................................................................... vi
KEY MILESTONES IN GREGORIAN (GC) AND ETHIOPIAN (EC) CALENDARS ................................................. xii
MAP OF ETHIOPIA ....................................................................................................................................... xvi

EXECUTIVE SUMMARY ............................................................................................................................... xvii
Objectives of the HSDP IV MTR 2013 ............................................................................................. xvii
Methodology:........................................................................................................................................ xvii
A: Achievements ................................................................................................................................ xvii
B. Challenges ........................................................................................................................................ xxi
C: Recommendations within HSDP IV ............................................................................................. xxv
D: Recommendations for HSDP V and beyond ........................................................................... xxvii

1. INTRODUCTION ......................................................................................................................................... 1
1.1. Background to the 2013 Mid Term Review (MTR) of HSDP IV .............................................. 1
1.2. Objectives of the MTR 2013 ......................................................................................................... 1
1.3. Methodology of the MTR 2013 ..................................................................................................... 2
1.4. Limitations ........................................................................................................................................ 3
1.5. Acknowledgements ........................................................................................................................ 3

2. STRATEGIC OBJECTIVES (SO) IN HSDP IV ................................................................................................... 5
2.1. Improve access to health services (C1) ...................................................................................... 5
2.1.1. Maternal, Neonatal / Child Health (C1.1.) ........................................................................... 7
2.1.2. Nutrition (C1.2) ...................................................................................................................... 37
2.1.3. Hygiene and Environmental Sanitation (WASH) (C1.3.) ................................................. 43
2.1.4. Communicable and Non-Communicable Diseases (C1.4.) ............................................ 46

2.2. Improve Community Ownership and Gender (C2) .................................................................. 58
2.2.1. The Health Extension Program (HEP) ............................................................................... 58
2.2.2. Health Development Army (HDA) ....................................................................................... 58
2.2.3. Community ownership, demand and supply side............................................................. 59

Final Report MTR; 2013.08.30. iii
2.2.4. Community ownership supply side; Boards in health facilities. ..................................... 60
2.2.4. Gender in the health sector ................................................................................................. 61

2.3. Maximize resource mobilisation and utilisation (F1) ............................................................... 63
2.3.1. Domestic Resources for Health .......................................................................................... 63
2.3.2. External Resources for Health ............................................................................................ 67

2.4. Improve Quality of health service delivery (P1) ....................................................................... 71

2.5. Improve Public Health Emergency preparedness and response (PHEM, P2) ................... 78

2.6. Improve pharmaceutical supply and services (P3) ................................................................. 82
2.6.1. Procurement, storage and distribution ............................................................................... 82
2.6.2. Local manufacturing ............................................................................................................. 84
2.6.3. Integrated Pharmaceutical Logistics System (IPLS): ...................................................... 85
2.6.4. Rational Drug Use (RDU) .................................................................................................... 85
2.6.5. Traditional Medicine .............................................................................................................. 85

2.7. Improve Regulatory Systems (P4) ............................................................................................. 89

2.8. Improve Planning and Evidence based decision-making (P5) .............................................. 94
2.8.1. Planning and Governance structures ................................................................................. 94
2.8.2 Scaling-up HMIS Formats, eHMIS, training and IT infrastructure .................................. 96
2.8.3. Software related issues ........................................................................................................ 98
2.8.4. Training and HR issues ...................................................................................................... 100
2.8.5. Information flows, use and data related practices .......................................................... 102
2.8.6. Recommendations / conclusions ...................................................................................... 104

2.9. Improve health infrastructure (CB1) ........................................................................................ 105

2.10. Improve Human Capital (CB2) ............................................................................................... 113
2.10.1. Human Resources for Health (HRH) ............................................................................. 113

Final Report MTR; 2013.08.30. iv
2.10.2. Governance and Leadership (CB2) ............................................................................... 121

3. TWO MAJOR CHALLENGES FOR HSDP IV AND HSDP V ......................................................................... 127
3.1. Reduce Maternal Mortality ........................................................................................................ 127
3.1.1. Skilled delivery ..................................................................................................................... 130
3.1.2. Increase access to family planning .................................................................................. 131
3.1.3. Increase access to Comprehensive Abortion Care (CAC) ........................................... 132
3.1.4. Adolescent Health ............................................................................................................... 132
3.1.5. Newborn Health ................................................................................................................... 132
3.1.6. Measure performance, understand behavior and count the number of deaths ........ 133
3.1.7. Advocacy for Maternal Health - act on CARMMA .......................................................... 133

3.2. Improve HMIS and M&E ............................................................................................................ 139
3.2.1. Establish robust governance and policy mechanisms ................................................... 139
3.2.2. Strengthen systems of ownership for different facets of HMIS .................................... 141
3.2.3. Strengthen scaling processes in an objective and holistic manner ............................. 142
3.2.4. Build capacity across all domains and levels .................................................................. 144
3.2.5. Build integrated software architecture .............................................................................. 147
3.2.6. Ensure data quality, Promote information use ................................................................ 150

Final Report MTR; 2013.08.30. v
ANNEXES
Annex 1: Terms of Reference for the MTR of HSDP IV
Annex 2: Work program of the MTR 2013
Annex 3: MTR team members participating in Regional Visits
Annex 4: List of people / institutions interviewed at Federal level
Annex 5: List of documents consulted
VOLUME II: REGIONAL REPORTS
1. Addis Ababa
2. Afar
3. Amhara
4. Benishangul Gumuz
5. Dire Dawa
6. Gambella
7. Harari
8. Oromia
9. Southern Nations Nationalities and Peoples (SNNP)
10. Somali
11. Tigray

Final Report MTR; 2013.08.30. vi
ABBREVIATIONS AND ACRONYMS
AAUMF Addis Ababa University Medical Faculty
ACT Artemisin-Based Combination Therapy
AFP Acute Flaccid Paralysis
AHSE Assistance to Health Systems Expansion project
AHPDPD Agrarian Health Promotion and Disease Prevention Directorate
AIDS Acquired Immune Deficiency Syndrome
ALOS Average Length Of Stay
ANC Antenatal Care
APR Annual Performance Report
ARM Annual Review Meeting
ART Anti-Retroviral Therapy
AYFRH (S) Adolescent Youth Friendly and Reproductive Health Services (Strategy)
BCC Behavioral Change Communication
BEmONC Basic Emergency Obstetric and Neonatal Care
BFHI Baby Friendly Hospital Initiative
BMI Body Mass Index
BOFED Bureau of Finance and Economic Development (Regions)
BOR Bed Occupancy Rate
BPR Business Process Re-Engineering
CAC Comprehensive Abortion Care
CAR Contraceptive Acceptance Rate
CARMMA Campaign on Accelerated Reduction of Maternal Mortality in Africa
CBHI Community-Based Health Insurance
CBN Community-Based Nutrition
CBNC Community Based Newborn Care
CDC Communicable Disease Control / Centre for Disease Control (USG)
CDR Case Detection Rate (TB)
CEO Chief Executive Officer
CEmONC Comprehensive Emergency Obstetric and Neonatal Care
CHMIS Community Health Management Information System
CJSC Central Joint Steering Committee
CLTS Community Led Total Sanitation (Strategy)
CMAM Community-based Management of Acute Malnutrition
COC Certificate Of Competence
CPR Contraceptives Prevalence Rate
C&RA Customs and Revenue Authority
CRDA Christian Relief and Development Association
CRVS Civil Registration of Vital Statistics
CSO Civil Society Organization
CSR Cataract Surgical Rate
CSRP Civil Service Reform Program
CYP Couple of Years Protection
DACA Drug Administration and Control Agency
DAG Development Assistance Group
D&C Dilatation and Curettage
DCI Development Cooperation Ireland

Final Report MTR; 2013.08.30. vii
DFID Department for International Development (UK)
DHS Demographic and Health Survey
DIC Drug Information centre
DOTS Directly Observed Treatment Short Course
DP Development Partners
DPPA (C) Disaster Prevention and Preparedness Agency (Commission)
DPT Diphtheria, Pertussis and Tetanus Vaccine
DTC Drug and Therapeutic Committee
EBF Exclusive Breast Feeding
EC Ethiopian Calendar
EFY Ethiopian Fiscal Year
EHIA Ethiopian Health Insurance Agency
EHNRI Ethiopian Health and Nutrition Research Institute
EHRIG Ethiopian Hospital Reference Implementation Guideline
EHSP Essential Health Service Package
EmONC Emergency Obstetric and Neonatal Care
EMR Electronic Medical Records
ENA Essential Nutrition Actions
ENICS Ethiopian National Immunisation Coverage Survey
EOS Enhanced Outreach Strategy
EPI Expanded Program on Immunization
EP&R Emergency preparedness and Response
ERC Ethiopian Red Cross
ETB Ethiopian Birr
EWS Early Warning System
FANC Focused Ante Natal Care
FBO Faith Based Organization
FGAE Family Guidance Association of Ethiopia
FGM Female Genital Mutilation
FHAPCO Federal HIV/AIDS Prevention and Control Office
FHI Family Health International
FIGO International Federation Obstetricians and Gynecologists
FMA Financial Management Assessment
FMHACA Food, Medicines, Healthcare Administration and Control Authority
FMIS Financial Management Information System
FMOE Federal Ministry of Education
FMOH Federal Ministry of Health
GAVI Global Alliance for Vaccines and Immunization
GBV Gender Based Violence
GC Gregorian Calendar
GFATM Global Fund against AIDS, Tuberculosis and Malaria
GHP Good Hygienic Practices
GMU Grant Management Unit
GOE Government of Ethiopia
GP General Practitioner
GTP Growth and Transformation Plan
HAPCO HIV/AIDS Prevention and Control Office
HBB Help Babies Breath
HC Health Centre
HCF (R) Health Care Financing (Reforms)

Final Report MTR; 2013.08.30. viii
HCMIS Health Commodities Management Information System
HCT HIV Counseling and Testing
HCSS Health Commodities Supply System
HCTS Health Commodities Tracking System
HCW Health Care Worker
HDA Health Development Army
HEP Health Extension Program
HEW Health Extension Workers
HF Health Facility
HH Household
HHM HSDP Harmonization Manual
HHRI Health and Health Related Indicators
HIT Health Information Technologist
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HO Health Officer
HP Health Post
HPF Health Pooled Fund (UNICEF)
HPN Health Population and Nutrition
HRD Human Resources Development
HRH Human Resources for Health
HR(M)IS Human Resource (Management) Information System
HSDP Health Sector Development Program
ICCM Integrated Community Case Management
ICT Information Communication Technology
IDA Iron Deficiency Anemia
IDD Iodine Deficiency Disorder
IDSR Integrated Disease Surveillance and Response
IEC Information, Education and Communication
IESO Integrated Emergency Surgical Officer
IDA International Development Association (World Bank)
IDSR Integrated Disease Surveillance and Response
IFA Iron Folic Acid
IFMIS Integrated Financial Management Information System
IGA Income Generating Activity
IHP International Health Partnership
IMCI Integrated Management of Childhood Illnesses
IMNCI Integrated Management of Newborn and Childhood Illnesses
I-NGO International Non Governmental Organisation
IP Implementing Partner
IPLS Integrated Pharmaceutical Logistic System
IRT Integrated Refresher Training
IRS Intermittent Residual Spraying
ISO International Standard of Organisation
IT Information Technology
ITN Insecticide Treated Nets
IUCD Intra-Uterine Contraceptive Device
JCCC Joint Core Coordinating Committee
JCF Joint Consultative Forum
JRM Joint Review Mission
JSI John Snow Incorporated / International

Final Report MTR; 2013.08.30. ix
KMC Kangaroo Mother Care
KPI Key Performance Indicators (hospital level)
LB Life Births
LLITN Long Lasting Insecticide Treated Nets
LMIS Logistics Management Information System
LOGIC Leadership in Obstetrics and Gynecology for Impact & Change (in Maternal and Newborn
Health)
LSS Life Saving Skills
MA Medical Abortion
MARP Most At Risk Population
MBB Marginal Budgeting for Bottlenecks
MDA (R) Maternal Death Audit (Review) / Multiple Drug Administration
MDG Millennium Development Goal
MDR Multiple Drug Resistance (TB)
M&E Monitoring and Evaluation
MMR Maternal Mortality Ratio
MNCH Maternal Neonatal Child Health
MNH Maternal Neonatal Health
MOCB Ministry of Capacity Building
MOE Ministry of Education
MOFED Ministry of Finance and Economic Development
MOU Memorandum of Understanding
MPI Master Patient Index
MPS Making Pregnancy Safer
MR Medical Record (room)
MSD Medical Service Directorate
MSF Médecins Sans Frontières (Doctors without Borders)
MSI Marie Stopes International
MTR Mid-Term Review
MVA Manual Vacuum Aspiration
MWH Maternity Waiting Homes
NAC National AIDS Council
NCBP National Committee for Blindness Prevention
NCD Non-Communicable Diseases
NDP National Drug Policy
NGO Non Governmental Organization
NHA National Health Accounts
NHCS National Health Communication Strategy
NICU Neonatal Intensive Care Unit
NID National Immunisation Days
NIP National Implementation Plan
NNP (S) National Nutrition Policy (Strategy)
NORAD Norwegian Agency for International Development
NTD Neglected Tropical Diseases
NTTF National Trachoma Task Force
ODF Open Defecation Free (zone)
OF Obstetric Fistula
OOP Out Of Pocket (expenditure)
OPD Out Patient Department
OTP Out Patient Therapeutic Program

Final Report MTR; 2013.08.30. x
OVC Orphans and Vulnerable Children
PAB Protection at Birth
PAC Post Abortion Care
PASDEP Plan for Accelerated and Sustained Development to End Poverty
PAV Polio Attenuated Vaccine
PBS Protection of Basic Services
PCV Pneumococcal Conjugate Vaccine
PEPFAR President's Emergency Plan for AIDS Relief
PER Public Expenditure Review
PFSA Pharmaceutical Fund and Supply Agency
PHAST Participatory Hygiene and Sanitation Transformation
PHC Primary Health Care
PHCU Primary Health Care Unit
PHEM Public Health Emergency Management
PLMP Pharmaceutical Logistics Master Plan
PLWHA People Living With HIV/AIDS
PMTCT Prevention of Mother to Child Transmission
PNC Postnatal Care
PPH Post Partum Hemorrhage
PPM&E Policy, Planning, Monitoring and Evaluation Directorate
PPM (P) Public Private Mix (Partnership)
PSI Population Services International
QA Quality Assurance
QC Quality Control
RDF Revolving Drug Fund
RDT Rapid Diagnostic Test (Malaria)
RDU Rational Drug Use
RH Reproductive Health
RHB Regional Health Bureau
RRT Rapid Response Team
RTC Regional Training Centre
RUTF Ready to Use Therapeutic Food
SAC Safe Abortion Care
SAM Severe Acute Malnutrition
SARA Service Availability and Readiness Assessment
SCMS Supply Chain Management System
SDPRP Sustainable Development and Poverty Reduction Program
SHI Social Health Insurance
SNNP Southern Nations Nationalities and Peoples Region
SOP Standard Operating Procedures
SPA Service Provision Assessment (tool)
SSAP Sanitation Strategic Action Plan
STH Soil Transmitted Helminthes
STI Sexually Transmitted Infections
SWAp Sector Wide Approach
TB Tuberculosis
TBA Traditional Birth Attendant
TFP Therapeutic Feeding Program
TFR Total Fertility Rate

Final Report MTR; 2013.08.30. xi
TOR Terms of Reference
TOT Training of Trainers
TRAC TB Research Advisory Committee
TT Tetanus Toxoid
TWG Technical Working Group
U5MR Under Five Mortality Rate
UHC Universal Health Coverage
UHEP Urban Health Extension Program (Professional)
UHEW Urban Health Extension Worker
UN United Nations
UNICEF United Nations Children’s Fund
UNDP United Nations Development Program
UNFPA United Nations Fund for Population Activities
UNHCR United Nations High Commission for Refugees
UPS Uninterrupted Power Supply
USAID United States Agency for International Development
USD United States Dollar
USI Universal Salt Iodization
VAD Vitamin A Deficiency
VCT Voluntary Counseling and Testing
WAHA Women and Health Alliance
WASH Water Sanitation and Hygiene
WBP Woreda-Based Planning
WDG Women Development Group (Tigray)
WCY Women Children and Youth
WFP World Food Program
WHO World Health Organization
WJSC Woreda Joint Steering Committee
WoHO Woreda Health Office
WOFED Woreda Office of Finance and Economic Development
ZHD Zonal Health Department
ZOFED Zonal Office of Finance and Economic Development
Conversion Rate USD and Euro to Birr, 01 June 2013:
1 USD = 18,66 Birr (June EFY 2005)
1 Euro = 24,43 Birr (June EFY 2005)

Final Report MTR; 2013.08.30. xii
KEY MILESTONES IN GREGORIAN (GC) AND ETHIOPIAN (EC) CALENDARS
The Ethiopian Calendar (EC) refers to the Ethiopian Fiscal Year (EFY), starting on 7th
July in the
Gregorian (European) Calendar (GC). Currently, April / May 2013 corresponds with the end of EFY 2005.
The overall correspondence between Ethiopian and Gregorian Calendars is given in the table below.
Twenty years HSDP and National Development Plans in Ethiopia (GC and EC)
Gregorian (GC) Ethiopian (EC) HEALTH DEVT
HSDP YEARS
NAT DEVT PLANS HEALTH
POLICY
1992/93 EFY 1985
1993/94 EFY 1986
1993
HEALTH
POLICY OF THE
TRANSITIONAL
GOVERNMENT
TILL
2013
1994/95 EFY 1987
1995/96 EFY 1988
1996/97 EFY 1989 BASELINE
1997/98 EFY 1990
HSDP I
i-PRSP
PRSP
1998/99 EFY 1991
1999/00 EFY 1992
2000/01 EFY 1993
SDPRP
2001/02 EFY 1994
2002/03 EFY 1995
HSDP II2003/04 EFY 1996
2004/05 EFY 1997
2005/06 EFY 1998
HSDP III PASDEP
2006/07 EFY 1999
2007/08 EFY 2000
2008/09 EFY 2001
2009/10 EFY 2002
2010/11 EFY 2003
2011/12 EFY2004
HSDP IV GTP
2012/13 EFY 2005
2013/14 EFY 2006
2014/15 EFY 2007
2015/16 (MDG) EFY 2008
2016/17 EFY 2009 END HSDP (20 YEARS)
2017/18 EFY 2010
EFY = Ethiopian Fiscal Year; GC = Gregorian Calendar; EC = Ethiopian Calendar

Final Report MTR; 2013.08.30. xiii
NATIONAL INDICATOR MATRIX1
(HMIS / HHRI, EDHS)
No(1) Indicators Baseline Target
Yr1
Result
Yr1
Target
Yr2
Result
Yr2
Target
Yr3
Result
Yr3 (1/2)
Overall
Perform
Gregorian Calendar (GC) 2009/10 2010/11 2010/11 2011/12 2011/12 2012/13 2012/13
Ethiopian Fiscal Year (EFY) 2002 2003 2003 2004 2004 2005 2005
C1. IMPROVE ACCESS TO HEALTH SERVICES
C1.1 MNCH HEALTH
13 ANC Coverage 1 visit 68 76 82.2 83 89.1 88 41.6 HMIS
14 ANC Coverage 4 visits 31 53 NA 70 NA 81 19.1% EDHS in
HMIS
15 Births attended by skilled personnel 18 36 16.6 49 20.4 58 7.9 HMIS
16 Births attended by HEW 11 22 14.7 30 13.2 35 5.1
18 Early Post Natal Care 34 52 42.1 65 44.5 74 21.6
40 Availability of BEmOC2 5 43 72 NA 91 NA HMIS
41 Availability of CEmOC 51 71 85 95 NA HMIS
23 PMTCT Prophylaxis 8 36 9.5 56 25.5 70 13.3 HMIS
10 Contraceptive Acceptance Rate 56 66 61.7 74 60.4 79 29.3 HMIS
Contraceptive Prevalence Rate 8 27 EDHS
TOR Unmet need for FP 36 25 EDHS
TOR Adolescent Fertility Rate 79 EDHS
42 HF with Post Abortion Care services 4 30 NA 45 NA 55 NA NA in HMIS
CHILD HEALTH
43 ICCM coverage at HP levels NA NA 9 55 61 75 86
44 IMNCI coverage at HC level 52 67 67 84 68 95
44 IMNCI coverage at Hospital level 62 100 100 100 100 100
25 Pentavalent (DPT3) Coverage 82 88 84.5 92 84.9 95 36.7
31 Full Immunisation Coverage 66 75 74.5 83 71.4 88 30.9
32 Neonates protected against Tetanus 42 60 66.4 73 63.8 82 29.0
45 Adolescent Youth Friendly Coverage 10 45 8 65 NA 80 NA
C1.2 NUTRITION
6 Children <5 yrs underweight 38 35 NA 33 NA 30 HMIS track
for<3yrs
7 U5 Treated for severe Malnutr (HF) 23 51 71 85 Survey
7 U5 treated for severe Malnutr (HEW) 5 11 15 18 Survey
10 Exclusive breastfeeding < 6 ms 49 NA NA NA DHS
12 Children 6-59 ms with 2 doses Vit A 95 96 110 97 91.7 98 29.5
14 Children 2-5 yrs de-wormed 86 88 112 90 19.8 92 29.6
C1.3 HYGIENE & ENVIR HEALTH
1 Population with improved latrines 20 NA 86 NA 84 76 DHS
3 HH using safe water storage 7 NA 73 NA 68.5 70 Survey

1. Selection based on the list of key indicators for the Results Framework at national level (pages 88-89) and indicators listed in
the TOR. Target Numbers refer to Annex 8 of HSDP IV (Detailed indicators pp 109-119). Baseline refers to Year 2009/10 (EC
2002); Annual Result figures provided by HMIS Department of the FMOH and/or HHI. Indicator values (figures or %%) are
defined in HSDP IV.
2. EmONC functions need to be looked at to verify whether a facility provides Basic or Comprehensive EmONC. Mapping will be
done shortly as part of the upcoming Service Provision Assessment study.

Final Report MTR; 2013.08.30. xiv
Yr1
Result
Yr1
Target
Yr2
Result
Yr2
Target
Yr3
Result
Yr3 (1/2)
Overall
Perform
C1.4 PREVENTION AND CONTROL
OF MAJOR COMMUN DISEASES
8 Pregnant women currently on ART NA 26 35 44 NA in HMIS
8 Children currently on ART NA 54 57 59 HMIS track
by line
regimen
8 Adults currently on ART
(male/female)
53 61 70 78 HMIS track
by line
regimen
1 TB Case Detection rate 34 50 37 63 71.8 71 27.6* 2004&2005
all TB form
2 TB Treatment Success Rate 84 86 88 90.6 89 74.6
5 # Confirmed MDR-TB on treatment NA 116 289 340 Survey
8 Proportion HP with community DOTS 6 15 23 32
5 HH with ITN coverage (utilisation?) 65 NA NA 88 MIS
8 HH with IRS 55 64 50 70 73 74 34.5
4 HF with mental services 10 26 NA 34 NA 42 NA NA
5 # Cataract surgical cases 460 676 N/A 784 568 892 N/A
C2. COMMUNITY OWNERSHIP
1 Model HH graduated 25 50 69.9** 67 68.6** 79 NA **cumul.13,
195, 845
2 Number of HDA networks NA 100 0 100 55 100 100 1,674,971
3 HF with Boards / community
representation)
20 22 NA 50 NA 100 NA WoHO
F1. RESOURCE MOBILISATION
1 Proportion HF using their revenue 20 22 50 50
TOR GOE budget allocation to health
TOR Total per capita health expenditure
6 Proportion of people in CBHI scheme 1 -- -- 11
7 Health Budget utilization 70 78 82 85
TOR Ratio Health Budget allocation to
utilisation
P1. QUALITY OF CARE
TOR In-patient case fatality rate
TOR Proportion standardized Labs/level
1 Bed Occupancy Rate 51 74 22 78 27 82 23
2 Average Length of Stay (days) 6.7 6.7 3.7 6.4 4.9 5.7 3.8
3 OPD attendance per person / yr 0.2 0.4 0.3 0.5 0.29 0.6 0.17
4 Customer satisfaction index 50 NA NA 90 Survey
5 Hospitals with Emergency Unit 50 70 80 90 MSD
TOR Primary Health Service Coverage 92.1 92.9

Final Report MTR; 2013.08.30. xv
Yr1
Result
Yr1
Target
Yr2
Result
Yr2
Target
Yr3
Result
Yr3 (1/2)
Overall
Perform
P2. EMERGENCY PREPAREDNESS& RESPONSE
1 Proportion epidemics with zero
mortality
NA 50 NA 50 NA 50 NA Data not
available
TOR Proportion epidemics averted NA NA NA Data not
available
P3. PHARMACEUTICAL SUPPLY No National
figures
2 HF with stock-out for ED 35 NA NA 5
3 Procurement lead time (days) 240 190 170 150
7 % stock wasted due to expiry 8 5 4.5 3.5
TOR Cold Chain management index
P4. REGULATORY SYSTEMS No National
Figures
2. HF Inspection coverage NA 100 100 100
4 No Accredited Hospitals 0 -- -- 1
TOR Proportion HF complying standards
P5. EVIDENCE BASED DECISION MAKING
1 Report completeness and accuracy 57 70 90 77 80 83 93
2 Report timeliness 57 70 36 77 52 83 52
4 No Woredas with annual plans 100 100 100 100 100 100 -
5 DPs implementing One Plan NA 100 100 100 Only in
survey
7 DPs providing funds in MDG/PF NA 75 75 75 Only in
survey
TOR % DPs using HMIS for reporting Only in
survey
TOR % DPs providing long-term
commitments
Only in
survey
CB1. HEALTH INFRASTRUCTURE
1 Functional HP to pop ratio 1/5,630 NS 1:5426 NS 1:5382 NS
1 Functional HC to pop ratio 1/37,300 NS 1:30794 NS 1:28108 NS
1 Functional Prim Hospitals(/pop ratio) 1/690.000 NS NA NS NA NS
2 General Hosp constructed upgraded NA NS NS NS
2 Referral Hosp constructed/upgraded NA NS NS NS
5 No HF with functional infrastructure NA NS NS NS
TOR % HF fully equipped and furnished
7 Hospitals implementing EMR NA NS NS NS
CB2. HUMAN CAPITAL AND LEADERSHIP
1 No trained and deployed midwives 2000 NA 2404 NA 3186 NA
2 Health staff to population ratio 0.7/1000 NA 1:1162 NA 0.7/1000 NA
3 Physicians to population ration 1/38,000 NA NA NA 1:38,256 NA
TOR % HF staffed as per standard NA NA NA NA NA NA

Final Report MTR; 2013.08.30. xvi
MAP OF ETHIOPIA

Final Report MTR; 2013.08.30. xvii
EXECUTIVE SUMMARY
Objectives of the HSDP IV MTR 2013
The general objective of the MTR is to measure and document the extent to which the targets set for the
HSDP IV are being achieved, assess constraints and/or challenges, draw lessons learned and
experiences gained, and provide recommendations to improve future governance, management and
implementation of activities to attain the HSDP goals. The specific objectives are:
• Assess the progress made in achieving all the targets set in HSDP IV
• Show the trend in the performance for key MNCH indicators from HSDP I to HSDP IV
• Document the major policy, strategy, institutional input and other implementation challenges
• Provide feasible and actionable recommendations to improve performance within the HSDP IV period
and new interventions that need attention in the formulation of post HSDP IV period
• Document best practices and areas to replicate across the nation; and
• Assess the governance and leadership structure of the Health Sector
In addition to addressing all 10 Strategic Objectives of the HSDP IV, the TOR also asks for two focused
studies: first on ways to address Maternal and Neonatal Mortality reduction in the country and second on
the implementation and reliability of the Health Management Information System (HMIS).
Methodology:
The MTR used three major instruments for this assessment: (i) document review, (ii) key informant
interview and (iii) direct facility and community observation. All regions and federal level were visited. In
the three larger regions (Amhara, Oromia, SNNP) two zones (one well performing and another less well
performing) were selected by the respective RHBs and within these zones, one well performing Woreda
and one less performing Woreda was selected. The teams also visited well performing and less
performing facilities and communities within each Woreda. In the other regions - without Zones - the
sampling frame remained the same. This MTR did not have adequate time to undertake a representative
sampling of all Woredas. Performance indicators of HSDP IV provided by FMOH was the basis for much
of the quantitative analysis. Quantitative and qualitative information obtained were used to provide
strategic and programmatic recommendations. The main findings for each of the 10 SO are summarised
below, followed by challenges, and short- and long term recommendations.

A: Achievements
1. Access to MNCH, Nutrition and Disease control (C1)
Mother, Neonatal and Child Health
There are gains in maternal and child health over the last two years. Addis Ababa and Harari regions
have both surpassed the HSDP target for skilled delivery (66% and 67%). In Tigray, a remarkable
increase from 18.2% to 32.2% was seen in one year. By comparison, Benishangul Gumuz (8.4%), Afar
(12.3%) and Amhara (12.4%) have low rates of skilled delivery. Both DHS (10%) and HMIS (20.4%) show
little change in uptake for skilled delivery at national level. Both HMIS (contraceptive acceptance rate
60%) and DHS (contraceptive prevalence rate 27%) show positive trends in FP over the past ten years
but equally, significant regional and urban/rural variation, with the lowest rate (6.9%) being reported from
Somali Region, and the highest (84.7%) from Amhara Region. There was an increase in Afar, SNNP and
Harar and a decrease in the other eight regions. The Safe Abortion Technical and Procedural Guideline in
2006 in Ethiopia is one of the most progressive in Africa. The joint implementation of IMNCI and ICCM
have contributed substantially to the reduction of child mortality in the country
Nutrition
The NNP has been revised with a special focus on key actions using the lifecycle approach to (i)
accelerate stunting reduction, (ii) to provide more focus on maternal nutrition, together with (iii) more
emphasis on inter-sectoral actions on nutrition. There is increased access to CMAM services over the last
2.5 years.

Final Report MTR; 2013.08.30. xviii
Hygiene and Environmental Sanitation
The WASH strategy and WASH/SWAp have helped to harmonize interventions with partners; There is a
national task force led by FMOH. Reducing the contamination of household water supply has led to a
reduction in diarrhea prevalence for children under 5 years from 23.6% in 2000 to 13% in 2011.
Disease Control (HIV, TB, Malaria and NTD / NCD)
HIV incidence in adults is reduced, from 0.28% to 0.03%, lower than the HSDP IV target of 0.14%.ARV
drug availability was significantly strengthened, with wide availability of adult HIV drugs. TB output targets
show a consistent and positive picture with regard to improvement in TB outputs, including the increase in
enrolment of MDR/TB cases, while TB Case Detection Rate has improved from 36 – 72%, against an
HSDP IV target of 75%. Looking at early diagnosis and treatment of Malaria, community and facility
capacity for early diagnosis has been increased. HEW’s have been trained on how to diagnose and treat
malaria. RDT’s are provided to them and to the staff in health centres. Recently there was a national
symposium on Neglected Tropical Diseases (NTD) and the launching of the national master plan for
NTDs, which has brought the NTD high on the policy agenda. The importance of Non-Communicable
Diseases and injuries (NCD) is rapidly increasing.
2. Improve Community Ownership (HEW / HDA) (C2)
The Health Extension Workers (HEW), supported by the Health Development Army (HDA) at community
level, have significantly increased both demand and access to MNCH services. HEWs have records on
the population in their catchment area in the form of family folders; they conduct household visits to
deliver the 16 different packages of healthcare prevention and promotion messages. They also started
providing some curative services like ICCM. A total of 34,382 HEWs have been trained and are deployed
paid by the GOE in the past 6-7 years. Acceptability by the community has improved with their growing
scope of work and confidence, especially after the introduction of ICCM. The tasks of HEW have grown
through skills improvement and Integrated Refresher Training (IRT).
A well developed draft guideline for Gender mainstreaming in Health has been developed and awaits
endorsement by FMOH.
3. Maximise Resource Mobilisation (F1)
Health financing (domestic and external resources)
HSDP IV aimed to increase the share of government health budget as a proportion of total government
budget from 5.6% to 15%. Although allocation of domestic resource allocation for health showed an
increment over the last decade in absolute terms, with an increment of around 2 billion Birr per year, its
share from the GOE budget stagnated at 8.5%. HSDP IV sets to increase the proportion of Development
Partners (DPs) providing funds through MDG/PF to 75%. The number of partners contributing to the
MDG/PF has increased from 6 to 10 over the last three years. The amount of resources coming through
the MDG/PF has also increased from around 33 million to around 133 million USD/year i.e. an increment
of 300% during the same period. This shows improvement in channeling of funds through the preferred
channel from 35% to 42% over the three-year period. Areas financed by the MDG/PF align well with the
priorities of the health sector: Maternal health, equipping of health facilities, child health and prevention
and control of diseases are the top ranking areas of resource allocation.
The implementation of health financing reform is going on well. The number of health institutions
implementing the Health Care Financing (HCF) Reform has reached 2,241 health facilities. On average,
health centers generate 30% of their total budget from retained revenue, while hospitals generate 23%.
The retained revenue has improved availability of essential medicines, diagnostic equipment and medical
supplies. The number of fee waiver beneficiaries has reached 2 million, and total subsidy for the poor has
reached more than 20 million Birr. While this progress is encouraging, it constitutes less than 10% of the
total population that lives below the poverty line in the country. All hospitals and 93.3% of HCs have
established governing bodies to enhance efficient decision-making and the responsiveness of the health
institutions to the local communities. 97% of hospitals and 75% of the health centers confirmed that their
respective governing board/bodies approved their expenditure items in 2010/11 EFY

Final Report MTR; 2013.08.30. xix
Health Insurance
HSDP IV sets a target of increasing the proportion of people enrolled in Social Health Insurance (SHI)
from 1% to 50% and start and finalize a pilot test of Community Based Health Insurance (CBHI) in
selected districts. The Ethiopian Health Insurance Agency (EHIA) has already been established and
staffed. The agency is undertaking the necessary preconditions to kick-start SHI to be launched in July
2013. CBHI schemes have been piloted in 13 districts in Amhara, Oromia, SNNP, and Tigray. Regions
have put in place the necessary administrative and coordination structures and provided trainings. The
scheme so far registered 141,656 House Holds (HH) (119,426 HHs paying and 22,230 HHs non-paying).
It also generated Birr 20,671525.07.Health service utilization by CBHI pilot scheme members has
substantially increased in the pilot districts. The average coverage of CBHI in the pilot Woredas stands at
47% indicating that about half of the eligible population is yet to be enrolled.
4. Improve Quality of service delivery (P1)
The HSDP IV proposed six outcome targets relating to quality of care. The most recent data suggest
there is progress against three of these. Customer satisfaction Index is at 73, from a baseline of 50, with
average length of stay at 4.3 days, against an HSDP IV target of 5 days, and 88.4% of emergency room
clients are triaged within 5 minutes of arrival, against a baseline of 50%. However, there is no progress
with bed occupancy rate and OPD attendances, which are still within their baseline value range (50% and
0.29 respectively). There was no information available on back-referral rates.
5. Public Health Emergency Management (PHEM) (P2)
The Ethiopian Health and Nutrition Institute (EHNRI) has established a Public Health Emergency
Management center (PHEM) since 2009 that is the responsible body for PHEM activities in the country.
The PHEM centre has responded to 994 disease outbreaks, rumors and events in 2004 EFY. It has also
established an emergency coordination center, which provides laboratory support to public health
emergencies in the identification of diseases or other emergency conditions. Integrated disease
surveillance and response (IDSR) is being implemented at all levels. Implementation of the International
Health Regulations (IHR) is well underway based on the recommendations of WHO. All regions have a
unit for PHEM in their structure with adequate human resources. Most regions also have multi-sectoral
Emergency Preparedness and Response (EPR) committees for coordination of emergency responses.
At Woreda level there are focal persons for PHEM and disease surveillance and Woreda multi-sectoral
committees.
6. Improve Pharmaceutical supply and services (P3)
The value of the procured pharmaceuticals, medical supplies and equipment through the Revolving Drug
Fund (RDF) and the various programs, is increasing over time, reaching commodities worth of ETB 3.59
and 4.97 Billion in the last two fiscal years, which is more than 95% of the planned procurement.
The RDF commodities supply is largely based on a pull system. Anecdotal evidence during MTR visits
show that the capacity of health facilities to carry out the quantification of their requirements is
inadequate. The supply of program commodities (EPI, Malaria, MDR/TB and FP) largely remained a push
system mainly due to the fact that the commodities are financed through programs that are managed at
the federal level. Anecdotal evidence of MTR regional reports show that more stock-outs are reported for
program commodities as compared to RDF. The frequently reported stock-outs included TB drugs, FP
commodities, test kits and de-worming medications.
Currently below 20% of the value of procured commodities is supplied through domestic producers.
However, there is concerted effort to encourage domestic production of health commodities through
provision of different incentives, including (i) 25% protective price margins, (ii) 30% advance payment
from the PFSA upon signing of an agreement and (iii) a tripartite agreement between the PFSA,
Development Bank of Ethiopia and local producers to allow local producers get 70% of their contract cost
as a loan from the Ethiopian Development Bank.
To strengthen and expand modern storage and distribution networks throughout the country, PFSA is
constructing 17 modern warehouses of 320,000 meter cube volume. Of these, ten are very modern and
four are found in emerging regions. In the meantime, until these warehouses are ready, the Agency is
using 17 leased warehouses to keep up with the expanded distribution operations. In addition to the

Final Report MTR; 2013.08.30. xx
already existing 85 vehicles, 50 new vehicles have been procured this year; procurement of another 25
vehicles is in process. The agency has 17 refrigerator fixed trucks. Cold rooms (400 mt. sq. each) are
under construction in the ten hubs. Expansion of cold chain facility is being carried out in line with the
introduction of new antigens.
7. Improve Regulatory systems (P4)
A comprehensive food regulation guideline was developed and submitted to the `Council of Ministers for
review and approval. New guidelines for food producers, food importers, and pharmaceutical
manufacturers, revised guidelines for distribution of medicines are in place. A salt iodization law was
passed and about 93% of distributed salt is now iodized, although non-iodized salt is still sold in many
markets. Health facility (both private and public) standards are now approved by the Ethiopian Standards
Authority (FMHACA) and launched with 39 categories. This will remove the ‘double standards’ that exist
in enforcing regulation. The establishment of the health insurance agency (HIA) as a purchaser and the
need for accreditation to provide services for health insurance is expected to accelerate the licensing of
public facilities. Regional regulatory bodies developed their own region specific regulations and guidelines
that have been reviewed and approved by their regional cabinets (e.g. are Benishangul, Dire Dawa and
some other regions). In light of the possibility of achieving comprehensive medical coverage and the
increasing demand of the population for quality health care and complexity of health care provision,
Ethiopia should consider the introduction of a Comprehensive Medical Bill (Act).
8. Improve Planning and evidence based decision-making (P5)
Most RHBs reported significant achievements in planning, budgeting and in the role of HMIS in
supporting these processes. Woreda Based Planning (WBP) is now the formal planning process in most
regions. It has become more-participatory involving more stakeholders, such as the head of health
centres, community representatives, NGOs, community leaders, administrative leaders and development
partners. Increased ownership, growing participation and collaboration at different levels, better alignment
and harmonization of the planning, budgeting, resource allocation, prioritization, tracking and reporting
systems are observed. The use of Marginal Budgeting for Bottlenecks (MBB) contributed to an increase
in budget allocations. There is better adherence to processes of one plan/one budget. Various
institutional processes are in place for review and supervision involving varying frequencies (bi-monthly,
bi-annually, monthly etc).
The country has made significant progress in HMIS scaling process. 85% of the health facilities have
been scaled with respect to HMIS, with regional variations ranging from 100% in Tigray to and 43% in
Somali. These numbers indicate primarily the distribution of the standardized formats, but there is a much
lower coverage in relation to the spread of the eHMIS software, internet, training, power back-ups and
other elements. While hospitals and health centres were using similar patient folders, in hospitals the
process was automated while in health centres it was still largely manual. Standardization of formats has
contributed to improvements in data quality, timeliness and enabling comparisons.
9. Improve Health Infrastructure and access to services (CB1)
There is a transformation of the health system when it comes to creating access to care. The health
facility construction has created access to care to many people who were never reached with any type of
service before. Health services have been able to reach the planned 15,000 health posts. Regions whose
population density is low, are still constructing additional health posts either through regular and
government MDG funds. The health centre expansion has enabled the sector to enhance access to
services for programs like HIV/AIDS (ART and PMTCT services). 94% (3056 of 3546) of health centres
are now available throughout the country. Tigray, Dire Dawa, Harari have fully completed the construction
process while region with the lowest performance is Addis Ababa, but delays are seen Oromia, Somali,
SNNP and Benishangul. New HCs have received the required standard equipment. Ethiopia planned to
have another 800 primary hospitals, and there are currently 185 hospitals being built Furthermore, 740
health centres are being upgraded to primary hospitals.

Final Report MTR; 2013.08.30. xxi
10. Improve Human Capital (CB2)
Human Resources for Health
In 2003 and 2004 EFY a total of 2,463 health care providers have been deployed by the health system to
serve at health facilities. The number of midwives in 2005 has increased to 3,186, although it is still below
the expected number at the midpoint of the plan period. Although physician to population ratio has
remained at 1 physician to 38,256 populations with the remarkable expansion of medical education in the
country, this figure is likely to improve significantly in the coming years. The medical education volume in
terms of training capacity has greatly expanded in the last three years of HSDP IV through the
introduction of an innovative medical education curriculum under the new medical education initiative.
The number of medical schools has increased to 10 from the previous 5 universities. The annual entry
capacity has expanded from less than 300 a few years ago to 2,317 in 2004.
Various initiatives to meet the needs of mid level human resources started during HSDP IV. The first
batch of 40 Integrated Emergency Surgical Officers (IESO) has graduated in 2004 of which 29 have been
deployed by the FMOH. Sub-specialty level training on Emergency Medicine has been initiated.
Upgrading of HEWs from Level III to Level IV has been initiated with the training of 1,367 HEW, of which
208 have graduated and were awaiting the results of a Certificate of Competence (COC) for deployment.
A paramedical professionals Level IV (diploma) training for first aid and emergency services at the first
level of care has also been initiated. A three week competency based BEmONC training was provided to
1,788 health care providers working in maternity services in 2003-2005. 15 BEmONC training sites across
the country are established. Up to 30 rural hospitals access services of experienced obstetricians and
gynecologists who can also provide in-service training on CEmONC for Health Officers (HO) and General
Practitioners (GP). A draft guideline for motivation of health workers and retention mechanisms has been
prepared and is currently under review
Governance and Leadership
The Governance structures and functions of the various institutions Federal and Regional levels have
been clearly defined at national level and function well. JCF started to meet regularly. JCCC’s continued
to play its role of management of the operations of the HSDP IV implementation. However, there is room
to review its composition (some members have asked to be replaced) and its relation with the various
Technical Working Groups (TWGs). The annual evidence based planning process is improving overtime
and continue to help allocate resources for high impact interventions.
At health facility level, over 95% of health facilities established a governing body or board. 52% of
hospitals governing boards and 49% of HC governing bodies meet every month. These organs decide on
plans, budget allocation, monitoring of progress as well as following up on the responsiveness of the
health facilities to the needs of the communities. Their performance still varies.
B. Challenges
Mother, Neonatal and Child Health
About 90% of deliveries continue to be in the home and by unskilled birth attendants. The 2011 DHS
found the main reasons for women not attending a health facility for delivery were because they believed
it to be ‘not necessary’ or not customary. In the past year (2003-2004), safe and clean deliveries
by HEWs have reduced from 14.7%-13.2%. There seems no clear policy on HEW deliveries as
there are targets within the annual plans for both ‘clean and safe deliveries’ by HEW and for
'skilled deliveries' by professional staff. Both demand and supply side issues need to be
addressed simultaneously.
There has been limited investment in hospital services, which has skewed improvements in
service delivery. Some critical Maternal Health interventions (e.g. CEmONC), requiring primary
hospital facilities are not yet possible as the improved access has benefitted mainly the lower
levels (HC / HP) of the health system. While 4 ANC visits is norm, in reality, most women
undertake only one ANC visit, often late in pregnancy, thus not benefitting from its potential

Final Report MTR; 2013.08.30. xxii
advantages. HMIS does not record the number of ANC visits. Maternal Death Audits have not
yet been rolled out nation-wide.
Use of Post Natal Care is low and stands out as a serious gap in the continuum of care in
maternal health. There is little information available on newborn health and an inadequate set of
activities for newborn care in the Roadmap. For child health, there is insufficient ownership of
the IMNCI program by FMOH and RHBs, jeopardizing future funding. Immunisation coverage
has shown stagnation, unreliable data, serious cold chain and maintenance problems and
overall poor management at several levels. Finally, there is a lack of clear direction on the
adolescent health strategy at FMOH level.
Nutrition and Hygiene and Environmental Sanitation
While there is a slight decline in the proportion of children stunted, the figures for stunting
remain very high with serious consequences for the physical and intellectual development of the
new generation.
Coordination among sectors working on environmental health is still limited. There is low coverage of full
WASH facilities (latrines, water) in half of all of health facilities.
Disease Control (HIV, TB, Malaria and NTD, NCD)
There is weak stewardship capacity at the FMOH (only one focal point) and at the Regional and
Woreda levels. Case teams spread the responsibility for regional support across a diverse
reporting structure, making coordination difficult. The work culture is focused more on planning
and meetings, with limited follow up of what is agreed – leading to initiatives started, but their
implementation not attained.
There is inadequate stewardship at the FMOH across the different TB case teams, as these are
not working in a harmonized manner to take advantage of their existing expertise. Malaria
vector control initiatives (LLITN/IRS use and environmental management) have progressed
slowly. Availability of LLITN’s has been inadequate, with many households having LLITN’s for more
than 3 years, making them ineffective. Challenges for the NCD include amongst others integration of
services, development of program management and guidelines, cancer management, NCD’s advocacy
and social mobilization and partnership for integrated NCD’s
2. Improve Community Ownership (C2)
HEWs are reportedly overburdened with several responsibilities at HP and home visits, support for HDA,
too many reports; distances to households and between households; lack of transport. HEWs have high
attrition rates (10-20%), partly due to absence of housing, limited / no annual salary growth plan, their
wish for change and expansion of their horizon). Sometimes work is de-motivating, as HEWs have to
travel longs distances on foot and/or pay (high amounts) for transport to the HC.
The capacity and budget for Gender at Federal and RHB levels is limited. There are no guidelines or
teaching materials for capacity building on gender mainstreaming activities.
Insurance
Readiness of the system to launch SHI still needs to be assessed. This includes capacity of the EHIA to
manage the system, capacity to collect revenue, verify and reimburse health facilities, ensure quality of
health service, and monitor and mitigate risks associated with health insurance (fraud, misuse, and
financial sustainability). EHIA is also under-resourced to conduct further TOTs, hire technical experts and
undertake critical studies to set baseline and define key health insurance parameters. The introduction of
CBHI and SHI is seen as an appropriate vehicle for progressing toward Universal Health Coverage
(UHC). However, the HCF Strategy has not been revised in light of the recent developments in the health
financing landscape (both within and outside the country) and an evolving concept of UHC.
Significant improvements have been observed in utilization of resources, but more capacity needs to be
built at sub-national levels. Engagement of the leadership at all levels of the health system to track

Final Report MTR; 2013.08.30. xxiii
resources and ensure liquidation has played a significant role. The establishment of the Grant
Management Unit (GMU) under the Finance Directorate in FMOH will help resolve some of the
outstanding issues of resource utilization if adequately capacitated at federal and regional levels.
There is an imbalance between increasing access, and providing quality of service delivery, which limits
the utilization of potentially available services. The issue around quality is attributed to many factors
including lack of knowledge and skills, absence of HIV test kits which stops HCT services prevention,
absence of microscopes at health centres. Inputs that have been made available are not always used as
they are supposed to (e.g. ambulances, RDTs/Microscopes, etc.). In situations where all the knowledge /
skills and inputs are available, a number of facilities are not ready to provide services (lack of water,
inability to provide maternity services), power sources (inability to run a lot of equipment, including
refrigerators), and other soft investments. The lack of comprehensive information on the burden of ill
health and risk factors is limiting appropriate targeting of investments and services. As a result, some
interventions that could address major causes of illness or death are not being implemented,
Quality of care outcomes remain low in the country. Emergency management scale-up is still rather low
and built around existing standards. The changes in the management of blood transfusion services have
created a gap in capacity to mobilize blood donors. There is still limited regulation and support of the non-
public service providers on improving quality of care. Progress with the hospital reform agenda, while
commendable, still faces many risks mainly due to its use of separate planning and reporting
mechanisms and inadequate management capacity. There is lack of comprehensive and independent
monitoring of the improvement in quality of care in the country.
At Federal level the multi-sectoral coordination is not very active in its response to outbreaks and
emergencies. At Regional level multi-sectoral coordination for PHEM is functioning well in Tigray,
Amhara, Oromia, SNNP, but it has limited or no functionality in Gambella, Benishangul Gumuz and
Somalia. However, at Woreda level most regions have a coordination mechanism, which can be activated
during emergencies. At Woreda level the capacity for preparedness is limited due to lack of budget
allocated for emergencies. The involvement of HEW in PHEM activities is limited to routine weekly
reporting due to lack of communication.
6. Improve pharmaceutical supply and services (P3)
The challenge of commodity storage and distribution is seen at Zonal and Woreda, but mainly at facility
levels. There is inadequate pharmaceutical storage (including in the newly constructed Health centres)
and shortage of warehouse equipment like shelves, ladders, and trolleys. There is also shortage of
transport and budget at Woreda levels to use the vehicles for movement of commodities. There are also
weaknesses in the capacity of the health sector to properly quantify and order supplies and commodities -
the capacity for accurate quantification is far from adequate. There are weak and fragmented pharmacy
units in facilities with limited capacity in selection, quantification, inventory management and inadequate
reporting. Despite the growing capacity of PFSA, it is unable to fully meet the increased demand for
health commodities from the expanding health facilities. The capacity of the hubs to analyze and use the
data from health facilities is also not adequate. There are still delays in procuring and distributing
commodities. This is further hampered by inadequate communication and work arrangement between
PFSA and RHBs.
No pharmacy unit exists to oversee or coordinate the pharmaceutical services. Most health facilities have
a weak pharmacy unit (mostly structured as a case team under the medical service directorate or as a
focal person). RHBs, Zonal HDs, and WoHO do not provide leadership in the distribution, consumption
and use of drugs and pharmaceutical supplies in the supply chain (drug supply and rational drug use).
While there are standards and norms both at federal and regional levels, there is very weak enforcement
capacity at all levels. There is overall shortage and turnover of professionals at all levels as retaining staff
is difficult in the absence of a special salary scale and the fact that staff of the regulatory sector is

Final Report MTR; 2013.08.30. xxiv
prohibited to work (part-time) in private practice. The regulatory sector has not been operating as a fully
independent entity in some regions. Most of the private sector and some teaching facilities are not
reporting on their services and achievements.
8. Improve Evidence based decision-making (P5)
There is inadequate infrastructure (electricity, UPS, Rural to access internet) to support eHMIS
expansion. The distribution of the family folders has been relatively slow and variable. Delay in delivery of
shelves, inadequate budgets, weak availability of training material, all adversely affect CHMIS roll-out and
use. MPI, which can help reduce patient waiting time and track patient records is not working effectively.
Private facilities are currently not included in the HMIS. There are also software related issues: there exist
two “eHMIS” software packages that are non-open source and non-web based, posing serious
constraints for future expansion. Various other software developments including HRIS, IFMIS, LMIS,
HCMIS are in process. There are some fundamental design challenges related to the absence of data
warehouse approach, and stand-alone deployment. These systems will involve a cumbersome process of
updating changes as well as challenges in coordinating their merging every month to develop
consolidated reports and in providing support to distributed installations. They also potentially include
possible license liabilities.
There is evidence of congestion with the patient registration in facilities - the MR room and triage room
being all in one place. The current “EMRs” in the hospitals are primarily patient registration systems, and
are not connected with other administrative and clinical systems in the health facility.
Progress in ICT and new technologies is limited due to lack of champions for ICT, lack of costed and
comprehensive ICT strategy (bringing together, HMIS, HCMIS, IPLS and HRIS) that will link all these
systems through a master facility list for possible interface. Partners’ support is mainly focused on
supporting different information systems rather the building overall ICT capacity.
While access to services has improved, because of the issues around functionality, health facilities are
not able to provide some of the basic priority services such as deliveries in a manner that attracts mothers
and which meets standards for safe clinical practice. Out of 2,508 health centres assessed, about 55% of
health centres are yet to have access to any source of electricity or water. The effort to include HC water
sources in the institutional WASH component has not taken off. There were some efforts to install solar
panels by GIZ, and Ministry of Water and Energy, but very limited compared to the demand. The poor
cleanliness and limited functionality of these facilities might well be one of the major contributing factors to
these low utilization rates.
Systematic and planned inspection and maintenance have not been adopted by the HCs. No
standardized system exists for the maintenance and first-look repairs of medical equipment. Equipment
occupies space needed for clinical services). The effort to establish a strong maintenance structure at all
levels of the health systems remains fragmented. Investment on biomedical engineers’ training and other
human resources related to infrastructure maintenance is inadequate. Ethiopia will lose the capital
investments that are incurred in the HCs, IF priority is not given for maintenance in the coming years.
With the increasing number of health facilities constructed and the fact that there are also concerns on
the quality of construction, the cost of not focusing on maintenance would increase.
Despite significant progress during HSDP IV, the increase in the number of key human resource
categories is still lagging behind demands of the public sector, especially for anesthesia and CEmONC
(emergency caesarean sections). The low number of IESO graduates annually and the few gynecologists
graduating every year will not be sufficient to increase providers in time for the MDGs or the immediate
post MDG period. The IESO deployment has been challenged by the lack of preparation of primary
hospitals as well as the shortage of anesthetists.
Midwifery training colleges (now 46) continue to face a shortage of trainers especially those with
adequate qualifications and experience. This, and the low number of institutional deliveries affects the
practical training and subsequent quality of the graduating midwives. There is also inadequate focus on
training support staff including health management at all levels.

Final Report MTR; 2013.08.30. xxv
Assuring quality of education during a rapid medical education program expansion is a daunting task with
the risk of compromised quality of training. Detailed career structures are not available for most
professions and those available are not often clearly communicated to health care providers.
Annual attrition of HEWs is estimated at 10-15% in the larger regions and is much higher in the
developing regional states. Remuneration and incentive mechanisms within the health system are based
on academic training (year of training, certification profile etc.) rather than workload and stress profile of a
specific job. This has resulted in similar remuneration profiles for jobs such as midwifery, nursing and
nurse anesthesia despite the very different stress, workload and other profiles of these professions (all of
them are diploma level certification).
One of the weaknesses in the governance of health sector is the fact that insufficient emphasis is given to
the transparency and accountability of health service delivery, and the communities’ voice. Furthermore,
various priority programs of the sector (Malaria, TB, HIV etc.) are scattered across 3-4 directorates by
geography and level of health system, making it very difficult to see how the programs are streamlined
and coordinated within the sector. This adds to the challenge of working with development partners
supporting these areas. Challenges in planning include late sharing of the Core and Comprehensive Plan
with DPs, poor involvement of the Regions in decision making for allocation of centrally mobilized
resources, including the MDG/PF resources; shallow policy dialogue with DPs during planning and
budgeting; need-based planning making the targets too ambitious and unmatched with available
resources. The mutual accountability framework of the IHP+ Compact has never been put to use. The
framework should be put to use in consultation with all partners to further the agenda of harmonization
and alignment in the health sector.
C: Recommendations within HSDP IV
Maternal, Neonatal and Child health and Nutrition
• To increase skilled delivery, make MNCH services women friendly and respectful. Reduce delays in
accessing care by promoting Maternity Waiting Homes in all primary hospitals.
• Expand access, referral and quality of EmONC in order to reduce both maternal and newborn lives.
• Institute Maternal Death Audits as a matter of urgency
• Reduce the unmet need for family planning especially for the 15-19 age group; increase the number
and type of service outlets for FP through collaboration with non-state providers
• Ensure continuity of supplies and resources for child health related services (cold chain, vaccines,
essential medicines).
• Intensify the promotion of exclusive breastfeeding and appropriate complementary food at six
months;. In addition, access and process locally available, nutritious foods where needed
therapeutically.
Disease Control
• A clear and well capacitated unit managing HIV health response should be established in the FMOH,
and respective regions. This should be executed in the context of overall institutional restructuring of
the health sector institutions.
• Prioritize the scale-up of the management of MDR-TB across the Country
• For Malaria, the country needs to start laying the framework for a move towards elimination by scaling
up vector control and improve the database to better understand the details of the epidemic
• Undertake a comprehensive NCD / Burden of Disease study, together with a nationally representative
STEPS survey to map the burden of risk factors to the NCD’s.
2. Improve Community Ownership (C2)
Increase number of trainees together with upgrading in function with 3 HEWs at HP
Consider provision of bicycles for HEWs and strengthen their supervision

Final Report MTR; 2013.08.30. xxvi
Provide tools and funds to allow RHB to strengthen the gender mainstreaming capacity of their staff
• Improve resource-mapping capacity at sub-national levels, improve policy dialogue during planning
and budgeting at national level, including the inclusiveness of regions in decision-making for
allocation of centrally mobilized resources, including the MDG/Fund resources;
• Revisit Health Financing Strategy within the context of the changing health financing landscape (both
within and outside the country) should precede the development of HSDP V.
• Build capacity of the Health Insurance Agency, refine key preconditions before take-off.
• Enhancing community mobilization for blood donations, through use of the HDA and the HEW teams,
• Expand the hospital reforms agenda into comprehensive medical care reforms, involving health
centres, and non-public hospitals,
• Ensure all staff are involved in the quality improvement initiatives,
• Address management capacity weaknesses in quality assurance at FMOH, RHBs, and Woreda levels
through orientations in quality assurance for all managers.
• Update the Essential Package of Health, to ensure there is a defined, clear and comprehensive
package of health services to be provided at each level of care. This should be supported by mapping
of the current state of provision of health services across all the interventions of the Essential Health
Package;
• Carry out an inventory of health inputs (physical infrastructure, equipment, ICT, transport, human
resources) available and functional, and develop investment strategies to fill the investment gaps,
• Assess the readiness of existing health facilities to provide care, and carrying out a comprehensive
burden of disease and risk factors in Ethiopia.
• Strengthen capacity for Emergency Preparedness and Response at Regional, Zonal and Woreda
levels and ensure availability of Rapid Response Team at Regional, Zonal and Woreda Levels.
• Enhance the implementation of the PHEM guideline provide training for RRT teams at Regional and
Woreda levels giving priority for vulnerable Woredas is required.
• Consider strengthening capacity of Regional Laboratories, continuing implementation of International
Health Regulation (IHR) recommendations; improve risk assessment in SRH and safe motherhood.
6. Improve pharmaceutical supply and services (P3)
• Revisit the structure of the sector at all levels and consider establishing a unit that coordinates
pharmaceutical services.
• Continue and enhance the efforts to strengthen PFSA and its hubs in terms of the number and skill
mix of the staff, raising the RDF capital and strengthening the logistic systems with technology (IPLS
and HCMIS).
• Review the potential of the HDA to promote RDU and control illegal drug marketing and develop
appropriate actions.
• Strengthen the enforcement of the regulatory environment, such as strengthening the joint planning,
consultation and review with regional regulatory bodies, developing an annual national regulatory
enforcement plan;
• Strengthen the capacity of regulatory authorities in terms of number and composition of human
resources, increase resource allocation for non-salary recurrent costs (DSA and transport); enable
them to do their inspection work without going through lengthy administrative processes;
• Accelerate the implementation of the licensing and inspection of public facilities;
• Develop strategies for patient center accountability and enhance the role of communities and HDA in
illegal drug control

Final Report MTR; 2013.08.30. xxvii
8. Improve Evidence based decision-making (P5)
• Undertake an external critical design review of eHMIS software with respect to functionality, future
needs, integration requirements etc. This could be supported by making a global and regional review
of best practice software being used for HMIS based on open source models.
• Build and use the potential of 22 regional Health Science Colleges (HSC) for both in-service and pre-
service training will enhance sustainability of the scaling up process.
• With the Service Provision Assessment being undertaken it is necessary to strengthen the shift of
investment from HC to primary hospitals, by linking service with service readiness criteria.
• Enhance the implementation, dissemination and enforcement of the use of ambulance guidelines
(use, operation financing, replacement).
• Accelerate the efforts being made to ensure health facilities are fully functional with water and
electricity through the development and implementation of a costed plan and resource mobilization
strategy. Priority should be given to renewable energy supply and water harvesting.
• Consider lobbying the Ministry of Works and Urban Development to establish a National
Infrastructure Maintenance Policy and guideline supported by standards and resource allocation
criteria. Such a national guideline (beyond the health sector) is required for nationwide Federal,
Regional and Woreda level maintenance of (health) infrastructure entities.
• Assess and generate evidence on the strength and weaknesses of the current health infrastructure
maintenance program and the alternative options available in the local market with the aim of
developing and implementing a health sector asset (building, equipment, transport and cold chain)
maintenance strategy and investment plan. This strategy and investment plan should focus on
preventive and corrective maintenance.
• Sustain and enhance the pace of change in increasing critical human resource such as anesthetists,
midwives and emergency surgical officers.
• Enable MD graduates to perform caesarean and selected emergency surgical procedures through
intensified training in pre-service and internship periods; this will increase the human potential to
perform life-saving emergency surgery by a significant margin.
• Augment the capacity of midwifery training schools in terms of number and caliber of tutors and
clinical trainers in order to provide better competency-based training.
• Coordinate and collaborate with the education sector at federal as well as regional levels.
• Support RHBs in acquiring human resources in critical shortage areas.
• Encourage retention mechanisms such as housing and hardship allowances for working in difficult
and remote rural postings..
• Restructure FMOH, bringing together the various priority programs to improve coordination.
• Improve the linkages between the TWGs, the JCCC and the JCF.
• Translate and share timely the Core and the Comprehensive plan with DPs (in English).
• Develop an accountability framework of the IHP+ Compact together with DPs.
D: Recommendations for HSDP V and beyond
Ethiopia has an implicit movement towards ensuring Universal Health Coverage (UHC) of the population
to health services. This needs to become more explicit in its overall strategic focus in health. For
improvements in access to lead to significant cross-country impact on illness and death, it is important to
address the following issues in the long term:
1. Define explicit universal access and coverage goals as a policy direction, with targets towards
improving populations covered, services to be provided, and reductions in out of pocket payments by
the populations.
2. Scale up investments at the hospital level, to ensure a comprehensive primary health care approach

Final Report MTR; 2013.08.30. xxviii
is being implemented that provides community based services primary care services in Health
Centres, and comprehensive hospital care services.
3. Integrate quality of care as a key element of services, not as a project. This would involve agreeing
on a core set of quality improvement interventions patient client experience, assuring patient/client
safety and assuring effectiveness of care) for each level of care that MUST be included in any service
delivery intervention. These should be supported by description of a core set of quality of care
indicators that are integrated into existing data generation systems (HMIS or surveys). The country
should also work towards having an independently verified system for monitoring and assuring quality
of care which includes user perception of care and possible introduction of an ‘ombudsman’ system at
all levels.
4. Consider the fiscal space considerations and readiness of health facilities for scaling up
CBHI in other woredas. Scaling up and maintaining GMU at sub-national levels will help
efficient utilization of resources. To enhance effectiveness and efficiency, it is essential to
consider conducting Public Expenditure Tracking Surveys, Public Expenditure Reviews;
assessment of drug wastages; assessment of productivity of HRH on regular basis. A Health
Bill (Act) could provide the appropriate (legal) framework for all these elements to be clearly
defined and with mechanisms for monitoring and evaluation.
5. Build IT capacity of the pharmaceutical sector at all levels to enable all actors including users and
distributing hubs to know in real time what is consumed and required.
6. Provide the regulatory authorities with the capacity and strategy to self-finance their operations. This
should be accompanied by the development of a database that will help regulatory authorities at
federal, regional and Woreda levels to have access to lists of all providers, professionals, products
and their performance in real time. The capacity of professional associations should be built and
enabled to undertake professional licensing and registration for their members.
7. Consider developing an alternative HMIS scaling model based on a top-down approach rather than
bottom-up to speed up the process. There is need to move toward data warehouse thinking based on
a web-based architecture. FMOH should also consider establishing a national level “centre of
excellence” for guiding overall training strategy on technical and public health aspects of HMIS.
8. Revisit the physical structure of all health facilities, making them more (women) client friendly. This is
specifically true for HPs constructed using community contributions. Future expansion of health
facilities should be based on a revision of service standards and norms to meet the growing and
dynamic health situation in the country taking into account the specific needs of different regions and
populations e.g. pastoralists. It is necessary to lobby for the establishment of national asset
maintenance regulation that will allow better resource allocation from MOFED and BOFEDs.
9. Establish HR standards based on expected (and acceptable levels of workload per work hours; per
staff category rather than the current uniform facility based allocation of human resources. In
consultation with the Civil Service, the HR management should consider remuneration and incentive
mechanisms that are based on workload and work stress levels of different health care providers
rather than limited to specific academic standards. Considering expanding the national examinations
to all professional categories will help assure quality of graduates prior to accreditation and licensing.
Enhancing the capacity of health professional associations will enable them to play a more proactive
role in assuring standards of training, accreditation, licensing and ethical practices. Planned
expansion and modification of post graduate training programs should use the potential of the
increased number of MDs and training institutions for increasing the types and numbers of specialists
in the country. Twinning arrangements with internationally renowned training institutions overseas can
help with this process.
Addis Ababa, 30 August 2013.
Dr. Jarl Chabot (Team Leader MTR 2013)
Ato Abebe Alebachew (Dept Team Leader MTR 2013)

Final Report MTR 2013; 2013.08.30. 1
1. INTRODUCTION
1.1. Background to the 2013 Mid Term Review (MTR) of HSDP IV
Health Policy
In September 1993 (EFY 1986), the Transitional Government of Ethiopia published its “Health Policy of
the Transitional Government”, a visionary and lucid document, containing general policy priorities and 17
general strategies. The document defines the overall principles to realize a fair and equitable health
system, based on popular participation and social justice. A few years later, in 1997/98 (EFY 1990), the
Ethiopian Government initiated its Health Sector Development Program (HSDP), a 20-year health sector
program, covering 1997/98 till 2017/18 (EFY 1990 – 2010).
HSDP I, II and III
The first and second phases of HSDP were completed in 2002 (EFY 1994) and in 2005 (EFY 1997)
respectively. The third phase, HSDP III, covered the period July 2005 to June 2010 (EFY 1998 – 2003).
In June 2008, a MTR was conducted on the HSDP III, providing the GOE and the DPs with in depth
analysis of its achievements, its challenges and a wealth of recommendations. No final evaluation of the
HSDP III was undertaken, as the annual Joint Review Missions (JRM) provided sufficient feedback to
assess the performance of the sector.
In November 2010, the fourth HSDP (HSDP IV, 2010/11 till 2014/15) was launched, defining 10 Strategic
Objectives (SO), each with their specific initiatives, that the GOE is committed to achieve.
According to the HSDP Harmonization Manual (HHM), a Mid-Term Review has to take place halfway in
the third year of the plan period. It is to be conducted by teams of national and international experts
working according to a TOR prepared at the level of the JCCC (Annex 1) and approved by the Joint
Consultative Forum (JCF). The draft MTR report will be submitted for endorsement to the JCCC and
eventually to the JCF and presented at the Annual Review Meeting (ARM 2013).
HSDP IV
HSDP IV comprises ten Strategic Objectives (SO). For each SO, targets /indicators have been set and
relevant strategic initiatives / activities have been defined. A total of 108 indicators (of which some 42
core indicators) have been defined. These provide the result matrix to annually monitor progress in
achieving the HSDP IV targets. Indicators together with their results (where available) have been
summarised in the table at the top of this report. The costs to implement HSDP IV are given on the basis
of two scenarios: the base-case scenario that would allow the country to achieve the health MDGs (for an
additional USD 12/pp/year), or the best-case scenario that would result in much higher reductions in
under-five and maternal mortality for an additional USD 14/pp/year.
1.2. Objectives of the MTR 2013
According to the TOR (Annex 1), the MTR has the following general and specific objectives:
General objective:
To measure and document the extent to which the targets set for the HSDP IV are achieved or on track,
assess constraints and/or challenges encountered and solutions provided, draw best lessons learned and
experiences gained, and forward recommendations to improve future governance, management and
implementation of activities to attain the HSDP goals.
Specific objectives:
1. Assess the progress made in achieving all the targets set in HSDP IV with geographic and
income breakdowns
2. Show the trend in the performance for key MNCH indicators from HSDP I to HSDP IV.

Final Report MTR 2013; 2013.08.30. 2
3. Document the major challenges (policy, strategy, institutional input and other implementation
constraints) that these priority areas are facing
4. Provide feasible and actionable recommendations to improve performance within the HSDP IV
period
5. Provide recommendations for the new interventions that need attention and formulate post-HSDP
IV recommendations for issues that require long-term implementation.
6. Document best practices areas to replicate across the nation.
7. Assess the governance and leadership structure of the Health Sector
1.3. Methodology of the MTR 2013
During the preparatory phase (February), with guidance from the JCCC and its TWG sub-committee, an
Inception report was drafted that provided the detailed preparations for the actual MTR: (i) a work
program (Annex 2); (ii) a list of informants / institutions to be interviewed at Federal level (Annex 4); (iii)
detailed Questionnaires for each of the 10 Strategic Objectives and for each level of the sector (Federal,
Regional, Zone, hospitals, Woreda, Health Centre, Health Post, Community / Health Development Army);
(iv) agreement on the sampling frame (Regions and Woredas) to be visited by the MTR team; (v) the
quantitative Result Matrix with the relevant indicators for each of the 10 SOs; (vi) relevant documentation
and background studies (Annex 5). These were circulated to all 14 core team members in advance.
The sampling frame has been addressed as follows: in the three bigger regions (Amhara, Oromia, SNNP)
two zones (one well performing and another less performing) were selected by the respective RHBs.
Again, within these zones, one well performing Woreda and one less performing Woreda was selected.
The teams also visited well performing and less performing facilities and communities within each
Woreda. In the other regions - without Zones - the sampling frame remained the same. This MTR did not
have adequate time to undertake a representative sampling of all Woredas. The main focus is to
understand the various strategic initiatives and see what is working and not working to inform the
implementation of the HSDP IV in the remaining period and beyond. Consequently purposive sampling
has been the preferred chosen methodology. The findings generated during the regional visits are used
as anecdotal evidence to single out best practice and lessons learnt and were not the main basis for
conclusions and recommendation of this report.
An overview of HSDP IV performance indicators provided by the M&E Unit of FMOH during the inception
phase was the basis for much of the quantitative analysis. Where possible (mainly in the MNCH chapter)
these data were linked with the figures from the evaluations of HSDP I, II and III, and DHS 2000, 2005
and 2011, allowing for an analysis over the full period of HSDP I - IV at the national level as per the
TORs. It should be noted that results for the HMIS and population-based DHS are significantly different.
Quantitative and qualitative information obtained during the many interviews in the Regions and with
federal agencies were used to fill the gaps in information that HMIS does not capture. This completed the
picture of the achievements and challenges of the HSDP IV.
The actual MTR took place over a period of four weeks (20 April to 18 May 2013). A multidisciplinary
team, composed of 8 national and 6 international consultants (being the core team) together with a total
of 28 external consultants conducted the assignment. The list of all MTR team members and which
Regions they visited is provided in Annex 3.There were two weeks of field visits to regions. Six teams
visited the first six regions / city administrations during the first week (including a debriefing to the RHBs
at the end of their stay and the writing of the Regional Report) and then proceeded to the other five
regions during the second week (which was shorter due to the Easter Holidays). All the eleven Regional
reports were brought together in Volume II of this MTR. Unfortunately, due to time constraints no
separate report on the Federal level interviews was made, but the outcome of the many interviews has
been fully captured in this main MTR report.
In the third week, the core team members continued with interviews at the Federal level (FMOH
departments, Agencies, DPs, NGOs and IPs). Findings from the Regional and Federal interviews were
shared among all core team members during a one day meeting, after which the writing of a draft of the
comprehensive MTR report (Volume I) started.

Final Report MTR 2013; 2013.08.30. 3
In the last (fourth) week of the assignment, presentation of the preliminary findings was made to the
FMOH, the JCCC and stakeholders with the aim of seeking feedback and comments on our initial
findings. These forums provided very valuable feedback that was included in the report. Back home, a
draft was produced and shared with the MTR team in order to reach consensus about content and
wording. This consensus version (the first draft) was then submitted to the FMOH, the JCCC and later to
all HPN donors for comments. The feedback from all these stakeholders was then reviewed by the core
team, thus supporting the finalisation of this final version of the MTR report.
1.4. Limitations
This MTR acknowledges various limitations, the most important ones being:
• The methodology used for this MTR is extensive and demanding. In addition it is quite ‘external’ in
nature, as little ‘self-evaluation’ from the regions and Woredas is requested. This limitation was
already highlighted during the evaluation of HSDP II and III. While more self-evaluation was originally
the intention in this MTR, unfortunately, it could not be realised due to other competing work in all the
Regions (developing the Woreda Based Plans and other reviews).
• The relative short duration of the field visits, especially during the second week forced the teams to
meet only a limited number of HEWs in each region, making a detailed assessment of the HEP and
the HDA and other interventions less complete than desired.
• National and Regional figures, as available from the Health and Health Related Indicators (HHRI)
were not always consistent, due to incomplete reporting at the lower levels and inaccuracies in the
upward reporting on quantitative targets and achievements. This issue is discussed in more detail in
the chapters on HMIS (chapters 2.8 and 3.2).
• There was only limited information available on the private and NGO sector. Representatives from
MOFED, MOE and RHBs did not formally participate in the team, nor did traditional health
practitioners. These institutions are essential to the performance of the whole sector and their missing
contributions are an indication of the limitations in our findings and suggestions.
• One of the assigned team members - responsible for the important section on Governance and
Leadership - had to withdraw her participation at the last moment, due to unforeseen circumstances.
Thanks to the flexibility of the other team members, this constraint could be overcome.
• The team was not always able to visit the more remote and poorer areas, due to distance and
security constraints (Somali, Afar). Such a limitation might have biased our findings.
• Many staff in the RHB / WoHO had only recently been appointed. The high staff turnover limited the
gathering of information on the experiences, the constraints and best practices of HSDP IV.
These limitations should be taken into account when reading the various chapters of the main report.
1.5. Acknowledgements
The MTR team would like to express its gratitude to the Minister of Health, His Excellency, Dr. Kessete
Birhan for his support to this MTR. His comments and advice during our debriefing in Hawassa on the
16th of May have been appreciated. Gratitude goes also to the two State Ministers, His Excellency Dr.
Amir Amane and Dr. Kebede Worku for their time and their vision on the performance and future of
HSDP. The team was impressed with the detailed level of their information and their commitment to
continue moving the sector forward towards improved health of the Ethiopian people. The senior
management of the FMOH showed us leadership and a vision for the way forward, despite the many
challenges ahead. They have also inspired us with hope that HSDP IV will achieve most of its objectives
in the remaining years.
The MTR team would also like to express its sincere gratitude to all members of the JCCC, headed by His
Excellency Dr. Amir Amane. JCCC members and its Sub-committee, chaired by Ato Noah Elias (Director
PPM&E) provided active support during the MTR preparations and during the interviews and visits.
Through the elaboration of the TOR, the selection and provision of the team members, review and
approval of the inception report, arranging the individual interviews and the various meetings, the JCCC
and TWG members showed interest and commitment to guide and steer this MTR. The PPM&E office (in

Final Report MTR 2013; 2013.08.30. 4
particular Dr Mekdim Enkossa and W/ro Hanna Dessalegne) provided timely support for the many content
and logistic related challenges in preparing this MTR.
Many thanks are due to the heads and staff working at the 11 RHBs, the various heads of departments
with their collaborators at federal level, the staff in health, training and finance departments, working at
Zonal and Woreda levels that the team has visited. We are very grateful for their time and effort in sharing
ideas and suggestions with us. The feedback given by RHBs during the debriefing also improved the
quality of the regional reports. We hope that the draft regional reports submitted to them will be reviewed
by the respective regions and used for their future planning exercises.
The Co-Chairs of the HPN Donor Group (Mrs Angela Spilsbury and Dr Peter Salama) and the technical
staff of the various DPs have been instrumental in providing us with the required information and new
developments in HSDP IV. We are also grateful to the staff working in CSOs, the NGOs, the
Implementing Partners (IPs) and other non public sector organizations for their inputs and their patience
to respond to our questions.
We hope that this MTR report will help to improve the implementation of the HSDP IV at Regional and
Woreda levels and will allow for a further commitment of the FMOH to make HSDP IV deliver on its stated
outputs. We expect this report not only to provide concrete inputs in the implementation of HSDP IV till
2015, but also to contribute ideas for the next five year health sector development program (2015-2020).

Final Report MTR 2013; 2013.08.30. 5
2. STRATEGIC OBJECTIVES (SO) IN HSDP IV
2.1. Improve access to health services (C1)
Improving access is critical in assuring utilization of provided health services. It ensures that required
services are made available to the populations, close enough to be used, in an affordable and acceptable
manner. The HSDP IV effort to improve access to health services was premised on need to support
communities to practice and produce good health, protected from emergency health hazards and having
access to quality health care at all levels and at all times. The plan provides guidance for the provision
and management of preventive, curative, rehabilitative and emergency health services, and the promotion
of good health practices (personal hygiene, nutrition, environmental health) at individual, family and
society level. These concepts aim to improve maternal, neonatal, child, adolescent and youth health,
nutrition, hygiene and environmental health (WASH) and to reduce/combat HIV/AIDS, TB and Malaria
and other communicable and non-communicable diseases.
All aspects of the health system are to be strengthened to facilitate attainment of the Strategic Objectives
- At the Community Level, the Health Extension Program is to serve as a primary vehicle for
prevention, health promotion and basic curative care at Health Post (HP) level, through effective
implementation of the well defined 16 essential packages.
- Health Centers (HC) are to serve as a first curative referral level for HPs. HCs will provide health care
that is not be available at the HPs through ambulatory and in-patient admissions, including Basic
Emergency Obstetric and Neo Natal Care (BEmONC).
- Primary hospitals and General hospitals are to be the main hubs for the reduction of maternal
mortality by providing amongst others Comprehensive Emergency Obstetric and Neo Natal Care
(CEmONC).
- Referral and specialised hospitals are meant for the handling of more complicated and sophisticated
health care, including the clinical management of non-communicable diseases.
There have been clear positive trends during HSDP IV of physical improvements in access to services, in
particular at the level of Health Posts and Health Centres. Similarly, significant investments in human
resources and equipment / commodities have been made, also focusing at the Community (health posts)
and Health Centre levels. These many achievements in expanding access to care have been well
presented in chapter 2.9 (infrastructure) and chapter 2.10.1 (Human Resources for Health /HRH) and will
not be repeated here.
Nevertheless, in terms of access, there remain a number of challenges worth noting:
The improvements in access are focusing at the primary care levels, with limited investments in
hospital services. As these are an integral part of the Primary Health Care (PHC) system, absence of
investments in this part of the health system means service improvements will be skewed, jeopardizing
access to the continuum of care.
Some critical Maternal Health interventions (e.g. CEmONC), Non-Communicable Disease (NCD)
interventions and other forms of care defined as critical in HSDP IV are not optimally benefitting from
the documented improvements in access.
Some of the current services being provided at the different levels of care are not in line with the
Essential Package of Health for the country. While there are service standards for the various levels of
care, the level and quality of their implementation varies
There is an imbalance between increasing access and providing quality service. This imbalance is
limiting the utilization of potentially available services.
o Some health facilities are not providing the interventions they are expected to provide, due to lack
of knowledge and skills.
o Where required knowledge and skills exist, critical investments needed to provide the services
are not always available. For example, absence of HIV test kits stops HCT services prevention,
absence of midwives hampers skilled deliveries, absence of microscopes at health centres limits

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