LMG in Devolved Health Systems: Learning from International Experience

1. Health System Decentralization
the Case of Ethiopia
Kenya National Health Leadership
Management and Governance Conference
Nejmudin Kedir Bilal, P. Health Economist, AfDB
January 29, 2013

2. Outline
1. Background
2. How was decentralization conducted?
3. Why decentralization in Ethiopian health
system?
4. Key health systems aspects of
decentralization
5. Lessons learnt

3. Background
• A coalition of rebel forces under the Ethiopian
Peoples’ Revolutionary Democratic Front
defeated the socialist government of Mengistu
Haile Mariam in May 1991
• Ethiopia’s first popularly chosen national
parliament and regional legislatures were
convened in May and June 1995
• The current government of Ethiopia was
established in August of 1995
• Since then the government has promoted a policy
of ethnic federalism, devolving significant powers
to subnational authorities.

4. THE PROCESS OF
DECENTRALIZATION
Part of broader government
decentralization 9 regional state
governments,
Phased approach
2 city adminis
• 1996 to Regional States
• 2002 to Woredas (and Zones) Zones,
Not one size fits all More than 850
approach districts
• Some with strong zones 15,000 Kebeles
• Some with lessor role for zones
• Some with no zones

5. Health Systems Decentralization was one of the
key reforms triggered by multiple challenges
High burden of
disease of
preventable
causes
Poor access and
quality of health
care
Low Biased
level of towards
Health service
financin Health PlanningGovernance and
curative
Decentralization Delivery reform Shortage HIS reforms Financing Reform
g & care
and
Pharmaceuticals
poorly Poor governance of
Centralized motivated
reform health health institutions

6. Health System Decentralization
• 4 tier health system Specialized
organization Hospital(5
million)
– PHCU (health center + 5
health posts) (25,000)
General
– District hospital (250,000) Hospital
(1million)
– Zonal hospital (1 million)
– Specialized hospital (5
million people) Rural Hospital
(100.000)
• Health Extension
Programme 2003/2004
PHC unit=1HC+5 Satellite HP
(25 million)

7. Roles of different levels of the health system
was defined
• MOH –policy direction, setting standards and resource
mobilization
• RHBs, ZHDs and WorHOs set health priorities, deliver
services, and determine budget allocations
• WorHOs manage personnel issues, health facility
reconstruction, and procurement at PHCU
• Regions and woredas get block grants

8. Health Human resources management was one
of the key decentralized functions
• Major universities under MoEducation
• Regional collages midlevel and low level
health workers
• RHBs, ZHDs and WorHOs can hire and fire
• WorHOs are charged with HCs and HPs
• Challenge: inter regional transfer

9. Health Planning Challenges in early phase of
decentralization
– Global and national commitments vs
decentralized decision
– Challenge of getting priorities across
– Multiple plan documents
– Historical budgeting not relevant to the
local contexts

10. The “One plan” initiative
• Priorities are set every 5 years and every year
• The main Principe is ensuring vertical and
horizontal linkage of priorities and targets
• Led by government via steering committees at all
levels
• Combination of top down and bottom up process
• Sharing and consulting with stakeholders
• Endorsing the strategic and annual plans at joint
sector meeting
• Joint monitoring on annual basis

11. Centralized and fragmented information
system required reform
• Data collection
– Too much data items 400 at
HCs, 500 at WorHo.
– Irrelevant
• Reporting problems
– Incomplete, Untimely
– Redundancy, parallel=
administrative burden
• Data analysis
– Not done at point of
collection
• Uncoordinated initiatives
• Poor institutionalization
11

12. Key principles were set to reform and
decentralize health information system
1. Standardize
Indicators by Category
Indicators & definitions
Disease list for reporting & case definitions
Client / patient flow & data elements 0 5 10 15 20 25
Recording & Reporting forms
Procedure manual Reproductive Health
Information use guidelines
Child Health and EPI
2. Simplify Malaria
Reduce data burden
Streamline data management procedures TB/Leprosy
HIV/AIDS
3. Integrate
Data channel Assets
Client / patient information at facility
(integrated folder) Finance
Human Resources
4. Institutionalize
Coverage and Utilization

13. Not only collection but use information at all
levels
FMOH
Compiled and used
RHB
WoHO
Compiled and used/reported
HF
Compiled and used/reported
Service delivery report

14. Health Service challenges: Preventable health problems
as major causes of morbidity and mortality (60%-80%)
 Only 1% of households had ITNs (<18% insecticide treated)
 Only 40% of the population within 10 KM of health institution
 Poor utilization = 30%
 Children < 6 months, exclusively breastfed: 32%
 Children with diarrhea given ORT: 37%
 Delivery attended: 6%
 Children with fever/cough brought to a health facility: 17%
 Low immunization coverage
Due to
 Limited knowledge of optimal care practices at the family level
 Limited physical access to health services in rural communities
 Poor institutionalization of PHC

15. HEP: Innovative approach to deliver Preventive and
Promotive Health Services
Hygiene and Disease
Environmental Prevention
Sanitation and Control
HEP
MNCH
Health
Education

16. HEP: Process & Roles defined for Training, Deployment &
Support on Implementation
2 trainees per village recruited by local government and community
MOH and MOE collaborate to provide a 1 year training
Community builds health post as a hub of operation for HEWs
HEWs assigned back to the village, train and graduate households
Local government pays salary
Village council involves the HEWs and provides leadership
Supervisors assigned
1 HC/5 HPs for technical and logistic support
FMOH and DPs provide equipment and supplies
Customized HMIS to track progress

17. Capacity building: Accelerated scaling up of HRH
and infrastructure to support HEP

18. Decentralized Governance and Health Care
Financing Reform-Five Components
1. Health facility governing boards
2. HFs user fee revenue retention and utilization.
3. Systematizing the fee waiver system and
exemption scheme
4. Outsourcing of non-clinical services.
5. Establishment of private Clinics/wings in public
hospitals

19. Key Lessons
1. Part of broader government decentralization
2. Sequencing decentralization makes it more
effective
3. Continuous and demand based capacity building
4. Some things are better kept at higher levels
5. Devolution does not mean no accountability!
6. Be ware of interrupting ongoing programmes