Final of Final Harari HSTP-II Document For Print

የሐረሪ ህዝብ ክልላዊ መንግስት
ጤና ጥበቃ ቢሮ
Harari People`s Regional State
Health Bureau
Health Sector Transformation Plan- II
HSTP-II
2020/21-2024/25 GC
(2013 EFY – 2017 EFY)
April, 2021
Harar, Ethiopia
Health Sector Transformation Plan II
Table of Contents
Table of Contents ................................................................................................................................................... II
List of Acronyms .................................................................................................................................................... V
List of Tables and Figures ................................................................................................................................... IX
Foreword …………………………………………………………………………………………….………X
Acknowledgment ................................................................................................................................................. XII
Executive Summary ................................................................................................................................................1
Chapter 1 :Introduction .........................................................................................................................................5
Chapter 2 Regional Profile .....................................................................................................................................7
2.1.Demography…………………………………………………………………………………………. …7
2.2. Socio-Economic ................................................................................................................................. 8
2.3. Education status ................................................................................................................................. 8
2.4. Climate .............................................................................................................................................. 9
2.5. Administrative System ...................................................................................................................... 9
2.6. Health system Organization............................................................................................................... 9
Chapter 3: Performance and Situational Assessment of the first Health Sector Transformation Plan
(HSTP-I)………………………………………………………………………………………..…………11
3.1. Progress of HSTP I Transformation Agendas ................................................................................. 11
3.1.1. Woreda Transformation ............................................................................................................ 11
3.1.2. Quality and Equity in Health Care ............................................................................................ 13
3.1.3. Information Revolution ............................................................................................................. 15
3.1.4. Producing Compassionate, Respectful and Caring (CRC) Health Workforce .......................... 17
3.2. Health Service Delivery .................................................................................................................. 18
3.2.1. Improve Health Status............................................................................................................... 18
3.2.2. Health Extension and Primary Health Service .......................................................................... 23
3.2.3. Hygiene and Environmental Health .......................................................................................... 24
3.2.4. Reproductive, Maternal, Neonatal, Child, Adolescents and Youth Health (RMNCAYH) ....... 26
3.2.5. Prevention and control of major communicable Disease (HIV/AIDS, TB, Malaria) ............... 33
3.2.6. Prevention and Control of Neglected Tropical Diseases .......................................................... 40
3.2.7. Prevention and Control of Non-Communicable Diseases and Injuries..................................... 41
3.2.8. Public health emergency preparedness and response................................................................ 43
3.3. Quality Improvement and Assurance of Service Delivery ............................................................. 45
3.3.1. Implementation of Quality Improvement Initiatives................................................................. 45
3.3.2. Hospital and Health Center Reforms ........................................................................................ 47
3.3.3. Clinical services ........................................................................................................................ 49
3.3.4. Emergency and Critical Care Services...................................................................................... 49
3.3.5. Blood Bank Serviceffff ............................................................................................................. 50
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3.3.6. Laboratory Quality Improvement Program............................................................................... 51

3.4. Leadership, Management and Governance...................................................................................... 52
3.4.1. Evidence Based Decision Making ............................................................................................ 53
3.4.2. Regulatory System .................................................................................................................... 54
3.4.3. Addressing gender disparities in health .................................................................................... 58
3.5. Health System Capacity .................................................................................................................. 59
3.5.1. Health Infrastructure Development ........................................................................................... 59
3.5.2. Human Capital and Leadership ................................................................................................. 60
3.5.3. Enhance Use of Technology and Innovations........................................................................... 60
3.5.4. Pharmaceutical Supply Service ................................................................................................. 61
3.5.5. Resource Mobilization and Utilization ..................................................................................... 64
3.6. Strength, Weakness, Opportunity & Threat (SWOT) Analysis ...................................................... 66
3.7. Stakeholder analysis ........................................................................................................................ 68
Chapter 4: Health Sector Transformation Plan II: Objectives, Targets and Strategic Directions….71
4.1. Vision: ............................................................................................................................................. 71
4.2. Mission: ........................................................................................................................................... 71
4.3. Values: ............................................................................................................................................. 71
4.4. Objectives ........................................................................................................................................ 71
4.5. Targets ............................................................................................................................................. 75
4.6. Strategic Directions (Implementation Strategies)............................................................................ 78
4.7. Description of the Directions (Implementation Strategies) and Key /Major Activities .................. 79
4.7.1. Enhance provision of equitable and quality comprehensive health services ............................ 79
4.7.2. Improve public health emergency and disaster risk management............................................. 96
4.7.3. Enhance Community Engagement and Ownership................................................................... 97
4.7.4. Improve access to pharmaceuticals and medical devices with rational and proper use of it .... 99
4.7.5. Improve Regulatory Systems .................................................................................................. 100
4.7.6. Improve human resource development and management ....................................................... 102
4.7.7. Enhance informed decision making and Innovation ............................................................... 103
4.7.8. Improve Health Financing ...................................................................................................... 104
4.7.9. Enhance Leadership and governance ...................................................................................... 106
4.7.10. Improve Health Infrastructure ............................................................................................... 107
4.7.11. Enhance digital health Technology ....................................................................................... 108
4.7.12. Improve Traditional Medicine ............................................................................................... 109
4.7.13. Health in All Policies ............................................................................................................ 110
4.7.14. Enhance private sector engagement in health ....................................................................... 111
4.8. Priorities/Transformation Agendas of HSTP II ............................................................................. 112
Page III
Chapter 5: Costing and Financing……………………………………………………………………..115

5.1. Costing........................................................................................................................................... 115
5.2. HSTP-II Cost estimation ............................................................................................................... 118
5.3. Cost estimate by strategic Directions ............................................................................................ 120
5.4. Cost estimate by Funding sources and Budget Category .............................................................. 121
Chapter 6: Implementation Arrangements……………………………………………………………123
6.1. Integration Efforts ......................................................................................................................... 124
6.2. HSTP-II Governance ..................................................................................................................... 125
6.3. Planning and budgeting ................................................................................................................. 127
6.4. Health Service Delivery Arrangements ......................................................................................... 128
6.5. Optimizing Monitoring and Review Systems ............................................................................... 130
6.6. Inter-Sectoral Collaboration .......................................................................................................... 131
6.7. Public Private Partnership ............................................................................................................. 132
6.8. Fostering Innovation through Health Technology Assessment and Adaptation ........................... 132
6.9. Risks and Mitigation...................................................................................................................... 133
Chapter 7: Monitoring and Evaluation Plan ....................................................................................................135
7.1. Description of the Monitoring and Evaluation Framework ........................................................... 135
7.2. HSTP II Indicators......................................................................................................................... 135
7.3. Index measurement in HSTP II ..................................................................................................... 136
7.4. Transforming data into information and action: the data cycle ..................................................... 138
7.5. Evaluation ...................................................................................................................................... 140
7.6. Dissemination and communication ............................................................................................... 141
7.7. Coordination, Policy and Institutional Environment for Monitoring and Evaluation ................... 141
ANNEXES………………… ...............................................................................................................................143
Annex 1: Indicators and Targets of HSTP II ........................................................................................ 143
Annex 2: Equity Indicators ................................................................................................................... 148
Annex 3: Health facilities planned to be constructed and rehabilitated from 2013-2017EFY ............. 149
Page IV
List of Acronyms
AIDS Acquired Immunodeficiency Syndrome

ALOS Average Length of Stay
ANC Antenatal Care
ANC4 Antenatal Care Four visits
APR Annual Performance Report
APTS Auditable Pharmaceutical Transaction and Service
ARM Annual Review Meeting
ART Antiretroviral Therapy
ARV Antiretroviral
BCC Behavioral Change Communication
BEmOC Basic Emergency Obstetric Care
BMI Body Mass Index
BOR Bed Occupancy Rate
BP Blood Pressure
C/S Caesarean Section
CAR Contraceptive Acceptance Rate
CASH Clean and Safe Health
CBHI Community Based Health Insurance
CFR Case Fatality Rate
CHIS Community Health Information System
CPR Contraceptive Prevalence Rate
CRC Compassionate Respectful and Caring
CSA Central Statistical Agency
CVD Cardio Vascular Disease
DALYS Disability Adjusted Life Year
DBS Dry Blood Sample
DHIS2 District Health Information System
DM Diabetes Mellitus
DR TB Drug resistance Tuberculosis
eCHIS Electronic Community Health Information System
EDHS Ethiopia Demographic and Health Survey
EFY Ethiopian Fiscal Year
EHAQ Ethiopian Hospitals Alliance for Quality
EHCRIG Ethiopian Health Center Reform Implementation Guideline
EHRIG Ethiopian Hospital Reform Implementation Guideline
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EHSTG Ethiopian Hospital Services Transformation Guideline

ENBC Essential New-born Care
EOS Enhanced Outreach Strategy
EPI Expanded Program on Immunization
EPSA Ethiopia Pharmaceutical Supply Agency
EPTB Extra pulmonary Tuberculosis
ETB Ethiopian Birr
EU European Union
FHT Family Health team
FMOH Federal Ministry of Health
GMP Growth Monitoring and Promotion
GOE Government of Ethiopia
HCs Health Centers
HCT HIV Counselling and Testing
HDA Health Development Army
HEP Health Extension Program
HEW Health Extension Workers
HIT Health Information Technician
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HPV Human Papilloma Virus
HRH Human Resource for Health
HSTP Health Sector Transformation Plan
HSTQ Health Sector Transformation in Quality
ICCM Integrated Community Case Management
ICD International Classification of Disease
ICMNCI Integrated Community Case Management of New-born & Childhood Illness
ICU Intensive Care Unit
IEC Information, Education & Communication
IMNCI Integrated Management of Neonatal and Child Illness
IMR Infant Mortality Rate
IRS Insecticide Residual Spray
IRT Integrated refresher Training
ISS Integrated Supportive Supervision
IUCD Intrauterine Contraceptive Device
IR Information Revolution
JCF Joint Consultative Forum
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JSC Joint Steering Committee

KPI Key Performance Indicators
LEEP Loop Electro Excision Procedure
LLINs Long-Lasting Insecticidal Net
LQAS Lot Quality Assurance Sampling
M&E Monitoring and Evaluation
MAM Moderate Acute Malnutrition
MARPs Most-At-Risk Population
MCH Maternal and Child Health
MCP Model Community Pharmacy
MDA Mass Drug Administration
MDSR Maternal Death Surveillance and Response
MFR Master Facility Registry
MHM t Menstrual Hygiene Management
MMR Maternal Mortality Ratio
MNH Maternal & Newborn Health
MOE Ministry of education
MoF Ministry of Finance and Economic Commission
MOH Ministry Of Health
MPH Master of Public Health
MTCT Maternal To Child Transmission
NBC New Born Care
NCDI Non-Communicable Diseases and Injuries
NICU Neonatal Intensive Care Unit
NNMR Neonatal Mortality Rate
NNP National Nutrition Programme
NTD Neglected Tropical Diseases
ODF Open Defecation Free
OHT One Health Tool
OPD Out Patient Department
ORS Oral Rehydration Salt
PCR Polymerase Chain reaction
PCV Pneumococcal Conjugate Vaccine
PHCU Primary Health Care Unit
PHEM Public Health Emergency Management
PLHIV People Living with HIV
PMED Pharmaceuticals and Medical Equipments Directorate
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PMTCT Prevention of Mother to Child Transmission of HIV

PPP Public-Private Partnership
PTB Pulmonary Tuberculosis
QI Quality Improvement
RDQA Routine Data Quality Assessment
RDT Rapid Diagnostic Test
RHBs Regional Health Bureau
RMNCAYH Reproductive, Maternal, Neonatal, Child, Adolescents and Youth Health
RMNCH Reproductive, Maternal, Neonatal and Child Health
SALTS Saving Life through Safe Surgery
SAM Severe Acute Malnutrition
SARA Service Availability and Readiness Assessment
SDGs Sustainable Development Goals
SLD Second Line Drug
STH Soil Transmitted Helminthiasis
TB Tuberculosis
TFC Treatment Follow up centers
TICs Treatment Initiating Centers
TOT Training of Trainers
TVET Technical Vocational Educational Training
TWG Technical Working Group
U5MR Under 5 Mortality Rate
UN United Nation
UNFPA United Nations Population Fund
USD United States Dollar
UVP Utrovaginal Prolapse
VAS Vitamin A Supplementation
VPN Virtual Private Network
WASH Water, Sanitation and Hygiene
WDA Women Development Army
WHO World Health Organization
WoHO Woreda Health Office
Page VIII
List of Tables and Figures

List of Table
Table 1 SWOT Analysis, opportunities and threats is a crucial step in the planning process. Prior identification ..... 66
Table 2: Stakeholder Analysis of Harari regional Health Bureau................................................................................ 69
Table 3.Harari regional health Bureau HSTP II Cost Summary for 2013-2017 E.C ................................................ 118
Table 5.Harari regional health Bureau Cost summary by Strategic Directions for 2013-2017 E.C ......................... 120
Table 6. Harari Regional Health Bureau Cost summary by Budget category for 2013-2017 E.C ............................ 121
Table 7.Harari regional health Bureau Cost Summary by funding Source for 2013-2017 E.C ................................ 121
Table 8. Risks and mitigation strategies .................................................................................................................... 134
Table 9: Harari Regional Health Bureau HSTP II indicator matrix ........................................................................... 143
Table 10. Core Equity Indicators ............................................................................................................................... 148
Table 11. facilities planned to be constructed in Harari Region from 2013-2017 .................................................... 149
Table 12.Facilities planned to be rehabilitated in Harar region from 2013-2017 ..................................................... 149
List of Figure
Figure 1 Harari Population by age and sex 2019 G.C population Distribution. ...........................................................7
Figure 2: Major Components of worda Transformation initiatives ............................................................................. 12
Figure 3: Life time expectancy at birth of Ethiopia (2007-2018) ................................................................................ 20
Figure 4:Major Cause of premature death in Ethiopia 2017 ........................................................................................ 21
Figure5:Top ten causes of disability of Ethiopia,2007-2017 ....................................................................................... 22
Figure 6: Risk factors driving the most death and disability combined of Ethiopia, 2007-2017. ................................ 23
Figure 7. National Trends of Under-five , Infant, and Neonatal mortality rate from 2005-2019, (mini EDHS 2019) 26
Figure 8: Harari Region Reproductive Health trends from routine HMIS and EDHS in the last 5 years & 20 years
respectively. ................................................................................................................................................................. 27
Figure 9: Harari Regional maternal health trend from Routine HMIS and EDHS in last 5 years and 20 years
respectively .................................................................................................................................................................. 28
Figure 10; Harari Region EPI trend from routine HMIS & EDHS of the last 5 &20 years respectively .................... 30
Figure 11: Harari Region Child nutrition trend report from 2000 – 2019 EDHS G.C. ............................................... 31
Figure 12: Trend of TB cases finding from 2007- 2012 EFY Harari Region. ............................................................ 36
Figure 13: Trend of successful TB Treatment out come from 2007 - 2012EFY of Harari region............................... 37
Figure 14: Trend of HIV screening among TB Patient and Positivity rate from 2007 - 2012 EFY of Harari Region. 38
Figure 15: Trend in the number of malaria cases in Harari region from 2008 - 2012 EFY ......................................... 39
Figure 16: Trend of EHCRIG from 2009EFY to 2012 EFY of Harari Region. .......................................................... 48
Figure 17: Trend of Blood units collected from 2002 to 2011EC in Harari Region. ................................................... 51
Figure 18 Status of Food facilities inspection coverage and internal quality management system from 2008-2011
EFY (2015/16 – 2018/19 G.C) in Harari Region. ........................................................................................................ 56
Figure 19: Plan and achievement of Tobacco free public places of Harari Region from 2015/16 to 2018/19 G.C.... 57
Figure 20: Trends of Total Harari regional Health Budget Allocation from 2008-2012 E.C. .................................... 64
Figure 21: Health Budget as share of Woreda Budget of Harari region from 2008-2012 E.C. ................................. 65
Figure 22: One Health tool framework ...................................................................................................................... 115
Figure 23: Maternal Mortality Ratio targets (per 100,000 live births) of Ethiopia from 2019 to 2024 .................... 117
Figure 24: Neonatal mortality rate (per 1000 live births) targets of Harari Region from 2019 to 2024 .................... 117
Figure 25: Under five mortality rate (per1000 live births) targets of Harari region from 2019 to 2024 ................... 117
Figure 26. Harari Regional Health Bureau HSTP II Cost Share................................................................................ 119
Figure 27. Ethiopian Health Tier System .................................................................................................................. 128
Figure 28. HSTP II Monitoring and Evaluation Framework ..................................................................................... 135
Page IX
Foreword
Harari Regional Health Bureau has implemented
the first Health Sector Transformation Plan
(HSTP-I) from 2015/16 to 2019/20, during which
significant achievements were registered in
improving the health status of the people of our
region. Health outcome indicators have shown an
improvement with a remarkable reduction in
Maternal and Neonatal mortality, decreased
MTCT of HIV, increased immunization coverage
and skilled delivery, reduced morbidity and
mortality from communicable diseases. To
address the risk of financial barriers in accessing
essential health services, the government has
implemented several strategies in the last five
years.
Mr. Ibssa Ibrahim (BSc., MSc.)
Head of Harari Regional Health Bureau
These strategies include provision of high impact interventions free of charge through an
exemptions program; subsidization of more than 80% of the cost of care in government health
facilities; implementation of CBHI schemes; and full subsidization of the very poor through fee
waivers both for health services and for CBHI premiums.
Despite significant improvements, the prevalence of non-communicable diseases (NCDs) and

injuries are on the rise creating a triple burden of diseases for the health system. There is disparity
in service utilization at primary health care level. The quality of health care is still sub-optimal.
The health system is also challenged by emerging pandemics such as COVID-19.
The Second Health Sector Transformation Plan (HSTP-II) which will cover the period between
2013-2017 Ethiopian fiscal years (July 2020 – June 2025 GC) is developed as the first part of a
ten-year health sector strategic plan. It aims at improving the health of our population through the
realization of accelerating progress towards Universal Health Coverage (UHC), protecting people
from emergencies, creating Woreda transformation and making the health system responsive to
people’s needs and expectations. To measure the progress of its objectives, the HSTP-II has set
targets by considering the baseline, national and international targets and anticipated resources.
The plan has identified 14 key strategic directions that define the major strategic areas and
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initiatives of the strategic period. These strategic directions include enhancing provision of
equitable and quality comprehensive health service, improving health emergency and disaster risk
management, ensuring community engagement and ownership, improving access to
pharmaceuticals and medical devices and their rational and proper use, improving regulatory
systems, improving human resource development and management, enhancing informed decision
making and innovations; improving health financing; strengthening governance and leadership,
improving health infrastructure, enhancing digital health technology, improving traditional
medicine, ensuring integration of health in all policies and strategies, and enhancing private
engagement in the heath sector.
From the 14 strategic directions, five priority areas of transformation agendas have been identified, which will be
the top priority issues of the sector. These include Quality and Equity of health Services, Information Revolution,
Motivated, Competent and Compassionate Health workforce (MCC), Health Financing and Leadership.
Harari Regional Health Bureau recognizes that the objectives of HSTP-II can only be successful
through the dedicated and concerted efforts of all categories of health workers, the continued
political commitment, community engagement, the private sector, government sectors, woredas,
development partners, civil society organizations and other relevant stakeholders.
I am grateful for what has been achieved over the past five years during HSTP-I period and hope
we will keep the momentum for the successful implementation of HSTP-II. We will look forward
to continue our collaborative efforts to provide the highest possible quality of care for our people
by achieving the ambitious targets set in the plan.
Ibssa Ibrahim (BSC, MSC)
Head of Harari RHB
Page XI
Acknowledgment
Harari Regional Health Bureau would like to acknowledge the Planning Core Technical Team
(CTT) members for their unreserved devotion during the whole process of developing the health
sector strategic plan (HSTP-II) of Harari region which will be implemented in the next five year
period.
Planning Core Technical Team

• Mr. Abdulsemed Ali
• Ms. Rania Mohamed
• Mr. Engida Gizaw
• Mrs. Bethelhem Sime
• Mr. Nesredin Ishak
• Mr. Seyfudin Amin
• Mr. Mohamed Muhedin
• Mr. Solomon Mezgebu
• Mr. Ketema Mehari
The Regional Health Bureau also extends its appreciation to the Technical Working Group
members for their strong commitment and technical support to the Core Technical Team during
the planning process.
Planning Technical Working Group

• Mr. Elias Yonis • Mr. Fozi Salih
• Mr. Meseret Zerihun • Mr. Mohammed Adem
• Mr. Remedan Ibrahim • Mr. Hafiz Mohammed
• Mr. Assefa Tufa • Mr. Tekalign Morka
• Mrs. Iftu Hassan • Mr. Restem Umer
• Mr. Damena Abdeta • Mrs. Munira Mehadi
• Mr. Berhane Mesfin • Mr.Redwan Mohammed
• Mr. Belsti Tassew
• Mrs. Tsehay workalemahu
Page XII
Executive Summary
This is the second Health Sector Transformation Plan (HSTP-II) covering the period between
2013-2017 Ethiopian fiscal years (July 2020 – June 2025). HSTP-II is developed as the first part
of a ten-year health sector plan. The preparation of HSTP-II is based on an in-depth situational
analysis and performance evaluation of HSTP-I and considering the region’s and country’s
commitment at global level and aligned with its overall macro-economic development framework.
Encouraging improvements in life expectancy at birth are among the achievements recorded in
HSTP-I period, even though pre-mature death and suboptimal quality of life still constitute major
development challenges. The reduction in maternal mortality is also notable, as it went down from
676 deaths per 100,000 in EDHS 2011 to 401 in 2017. Under 5 , Infant and Neonatal mortality per
100,000 live birth decreased from 192, 188.3 and 54 in (2000 EDHS) to 72, 57 and 34 in (2016
EDHS) respectively. Similarly, morbidity and mortality from common communicable diseases
including malaria, HIV, and vaccine preventable diseases declined dramatically.
The performance of major health programs has substantially improved as shown in the increased
utilization of health services. Accordingly in 2019 EDHS, 30.3% of married women in the region
were using contraception compared to just 19% in 2000. The unmet need in family planning was
gradually declining from 30.1% in 2000 EDHS to 21.3% in 2016 EDHS the performance of ANC,
SBA, and PNC services of maternal health showed progress for the last five years. ANC service
has improved from 75.9% in 2016 EDHS to 80.7% in 2019 EDHS, SBA improved from 51.2% in
2016 EDHS to 64.9% in 2019 EDHS, and PNC improved from 37.4% in 2016 EDHS to 45.2% in
to 2019 EDHS. The 2019 mini-EDHS report has also indicated that the region’s proportion of
children receiving three doses of pentavalent vaccine and all basic vaccines reached 52.8% and
45.8%, respectively.
Prevention and control of major disease burdens also seems to be impressive. The region is on
track for achieving one of the three targets of the Global End TB strategy by meeting its milestone
of reducing incidence by 21% from the 2015 estimate (as compared to a 20% target). TB case
notification has been improving, with a detection rate of >100%; TB treatment success and cure
Page 1
rates also reached 99% and 95%, respectively in 2019. There was also progress towards achieving
all the three 90s HIV targets of 2020 in that 99% of HIV infected individuals knew themselves and
95% of them were on ART with 97% viral supersession. Furthermore, 70% of eligible mothers in
2019 have received ART. Similarly, malaria control is on track for a 85% reduction in the number
of new malaria cases, and zero death due to malaria by 2020.
To address the risk of financial barriers in accessing essential health services, the government has
implemented several strategies. These strategies include provision of high impact interventions
free of charge through an exemptions program; subsidization of more than 80% of the cost of care
in government health facilities; implementation of CBHI schemes; and full subsidization of the
very poor through fee waivers both for health services and for CBHI premiums. A revised health
care financing strategy was developed within the framework of the goal of achieving universal
health coverage (UHC).
Among the measures that have been in place to address the social determinants of health through
multi-sectoral engagement with local and international stakeholders include nutrition and WASH
programs. Multi-sectoral collaborative efforts & interventions have been implemented to improve
the status of food security and nutrition in the country, including a multi-sectoral and high-level
government commitment platform - the “Seqota” Declaration to end child under-nutrition by 2030.
The delivery of health services continued to be structured into a three-tier system - primary,
secondary and tertiary level health care. The primary health care infrastructure has made huge
expansion in terms of potential coverage reaching 100% in 2019. Similarly, outpatient attendance
rate also reached 1.2 per capita per year. Being the main platform for delivery within the primary
care level, the HEP has continued to significantly contribute to improvements in health indicators.
At the second and third tier levels, pre-hospital and hospital clinical care has been strengthened
through the implementation of strategic initiatives and reforms.
In HSTP I, the health sector identified and implemented four transformation agenda. During this
period, the agenda reached the attention of all actors and were closely monitored by the leadership
at all levels. These transformation agenda played pivotal role in mobilizing resources, gearing and
catalysing the health sector efforts which resulted in tremendous achievements.
The regional HSTP-II was developed building upon the successes and challenges as well as
Page 2
making an in-depth situational analysis and performance evaluation of HSTP-I, and in

consideration of the region’s and the country’s commitment to global situations. It is also aligned
with the region’s overall macro-economic development framework through a consultation with
the Regional Plan and Development Commission and by employing Strategic Planning and
Management (SPM) tool. Led by the health sector, the plan development process was participatory
with the inclusion of representatives from various health sector stakeholders. The process has also
been iterative through the development and release of a series of versions of the plan for comments
and inputs by partners, health bureaus, professional and civil services organizations, as well as
members of the academia.
The overall objective of HSTP II is to improve the health status of the population through
realization of - accelerating progress towards Universal Health Coverage; protecting people from
health emergencies; woreda transformation; and improving health system responsiveness.
The plan has set targets to measure its objectives and target setting was done using One Health
tool and by considering baseline, national and international standards and anticipated resources.
HSTP-II sets ambitious targets to reduce MMR per 100,000 live births, under 5 and neonatal
mortalities per 1000 live births to 279, 43 and 21 respectively. In terms of service uptake some of
the targets but not limited to increasing skilled delivery attendance to 100%, ANC 4 coverage to
85%, Pentavalent three coverage to 100%, TB detection rate to 100%, ART coverage to 98%. The
list of all indicators with the corresponding targets is presented in the “Targets” section.
To achieve the targets, a list of 14 strategic directions are identified and each is described along
with their major activities:
• Enhance provision of equitable and quality comprehensive health service;
• Improve health emergency and disaster risk management;
• Ensure community engagement and ownership;
• Improve access to pharmaceuticals and medical devices and their rational and proper use;
• Improve regulatory systems;
• Improve human resource development and management;
• Enhance informed decision making and innovations;
• Improve health financing;
Page 3
• Strengthen governance and leadership;

• Improve health infrastructure;
• Enhance digital health technology;
• Improve traditional medicine;
• Ensure integration of health in all policies and strategies; and
• Enhance private engagement in the heath sector
HSTP-II has also identified five transformation agenda with their respective interventions that will
help the sector to transform and result in better health for all. The transformation agenda identified
within HSTP-II include:
1. Quality and Equity: Ensuring equity in delivery of quality health services by creating
high-performing primary health care units, ensuring active engagement of the community
in service delivery, and continually improving clinical care outcomes.
2. Information revolution: Significantly improving methods and practices for collecting,
analyzing, presenting, using, and disseminating information that can influence decisions.
3. Motivated, competent, and compassionate health workforce: Ensuring equitable
distribution and availability of an adequate number and skill mix of health workers who
are motivated, competent, and compassionate to provide quality health services.
4. Health financing: Reforming public financial management and health financing to
improve efficiency and accountability, while pursuing the agenda of sustainable domestic
resource mobilization for health.
5. Leadership: Enhancing leadership and governance mechanisms at all levels of the health
system to drive.
The overall costing for HSTP-II implementation is computed using One Health Tool (OHT), a tool
that is built on the WHO’s six health system building blocks framework. The overall cost
estimation for the first five years (2020/21 – 2024/25) is 3.89 Billion ETB. The average yearly
total estimated cost is 779 million ETB. The highest cost estimation share is for Medicines,
commodities, and supplies which is 38% of the total cost estimate for the next 5years.
The plan will be cascaded to all levels and will be translated into annual operational plans using
the Woreda-based health sector annual plan. Its implementation will be regularly monitored using
the agreed monitoring framework in a coordinated manner.
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Chapter 1 :Introduction
The Harari people regional state health sector has successfully concluded the first Health sector
transformation plan (HSTP I) which was the health chapter of the second Growth and
transformation plan of the region that spanned from June 2015- July 2020. HSTP-I, as part of the
second growth and transformation plan (GTP-II), was the first phase of the ‘Envisioning Ethiopia’s
Path towards Universal Health Coverage through Strengthening Primary Health Care by 2035”. It
followed the 20 years Health Sector Development Program(HSDP) which commenced in 1997.
The performance of HSTP I has been reviewed critically using its annual performance reviews and
relevant reports, including Health Information Management System (HMIS), the Mid-Term
Reviews (MTR), and different population and facility-based surveys. The review findings showed
that the Region has made tremendous achievements from implementing high impact interventions
mainly through its flagship community focused program known as the Health Extension Program.
The health sector has been successful in stirring momentum in the health sector through the
implementation of the four transformation agendas. The four transformation agendas namely
Woreda Transformation, Information Revolution, Transformation in Quality & Equity and
Compassionate, Respectful and Caring health workers engendered momentum with the health
sector to transform critical barriers of the health system. The health sector has also rigorously
advocated the need for multi-sectoral collaboration to address social determinants of health and
thereby to realize socio-economic development in the region. Nonetheless, challenges such as
conflicts leading to internal displacement of people and the COVID-19 pandemic that occurred at
the fifth year of the strategic period has to some extent caused certain setbacks in health gains and
has somewhat swayed implementation of some of the programs.
The Health Sector Transformation Plan II (HSTP II) is the next five-year regional health sector
strategic plan, which covers the period between 2013-2017 (July 2020–June 2025). It has been
prepared by conducting in-depth situational analysis and performance evaluation of HSTP I;
considering the global situation, the country’s and the region’s commitment; and most importantly,
the goals of the national and the regional long-term vision and Growth and Transformation Plan
(GTP).
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The development of the Health Sector Transformation Plan II was guided by a roadmap prepared
jointly with all relevant stakeholders under the leadership of the Regional Health Bureau. The
roadmap clearly stipulated the major steps of the development process, planning approach and
methodology and communication strategy. It also clearly indicated the roles and responsibilities
of all actors giving due emphasis for the involvement of all relevant stakeholders, including the
private sector to ensure commitment by all for the implementation of the strategic plan by having
a shared vision. A series of consultations were conducted with the private sector, university,
professional associations and other government sectors. The feedback received from these
consultative workshops were carefully documented, reviewed and incorporated accordingly.
The objectives and strategic directions were developed based on the situational analysis of the
HSTP-I and baselines and targets were set based on the recent survey findings and in consultations
with experts from the programs. The costing and target setting was developed using one health
tool—a software tool designed to inform national strategic health planning in low- and middle-
income countries by linking strategic objectives and targets of health programs to the required
investments in health systems
The HSTP II document is organized in to seven chapters: Chapter one is introduction; chapter two
covers the regional profile; chapter three describes the situation analysis; chapter four deals with
the HSTP II objectives, targets and strategic directions; chapter five details the costing and
financial gap analysis, Chapter six describes implementation arrangements and chapter seven
cover frame work of monitoring and evaluation.
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Chapter 2 Regional Profile

2.1. Demography
Harari People`s National Regional State is one of the 10 regions in the country, which is located
in the eastern part Ethiopia at 526 Km distance from the capital city of Addis Ababa with a total
area of 343.2 square kilometers. The region is surrounded by different Woredas of Eastern zone
of Oromia Regional state, namely Kombolcha and Jarso in the north, Gursum and Babile in the
east, Fedis in the south and Aweday in the west.
Based on the 2007 G.C CSA data, the projected population of the region was 270,031 for year
2020 G.C and this makes Harari Region the least populous region in the country. Nearly 55.7%
the population lives in the urban area. With regard to Male to Female sex ratio is 101.97 % of the
population. The population density of the region is the most densely populated in the country next
to Addis Ababa with the density of 713 people in a square km. The population density is high in
urban area than rural area.
The following figure shows the predicted population pyramid of Harar for 2019 G.C. Children
under age 15 accounted for 39% of the population and the age group of 15 and 65 years accounted
for 57%, and individuals aged 65 and older accounted for only 4% of the total population. While
the sex ratio between males and females is almost equal, women of reproductive age constitute
about 50% of the population. Source; One Health Tool 2019 population (CSA)
Figure 1 Harari Population by age and sex 2019 G.C population Distribution.
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2.2. Socio-Economic
Harari, with its ancient capital Harar is characterized by having service sector, as its main
economic sector followed by agriculture. This is one of the typical features of the region, especially
the Harar town. The unique characteristic of the regional state and especially the town is its
UNESCO heritage-fortification-defensive Jugel wall. The wall separates the old Jugel from the
new town. It is estimated that in Jugel the density could be one of the highest even compared to
the data of Harar itself.
The economy has grown in real GDP at a rate of 11 percent per annum in the past five years. With
an average population growth rate of 2.6 percent, the GDP growth rate translates to an 8.4 percent
growth in average annual per capita income.
The residents of the region are composed of different ethnic groups, living in Harmony. Oromo
and Amhara are the main ethnic compositions followed by Harari. In terms of religious
composition, majority of the inhabitants are Muslims and followed by follower of Orthodox
Christianity.
2.3. Education status
It is a well-established fact that education plays the central role in economic and social
development and hence considered as one of the basic human rights. According to several studies,
people are observed to have differences in health status, exposure to health risks, access to health
services and health seeking behavior because of their differences in educational status. Ethiopia
has given due emphasis to improving the educational status of its citizens evidenced by massive
expansion of primary, secondary and tertiary level educational institutions.
In Harari people regional state, there were 89 Primary and 14 Secondary Schools in the EFY 2011.
In the same year, 39, 917 students were attending the primary school education while 16,285
students were attending the secondary school education. The Gross Enrollment Ratio (GER) of
primary school (Grades 1-8) has reached 121 per cent while that of the secondary school (Grades
9-10) is 62.7 per cent. The Net Enrollment Ratio (NER) at primary level (grades 1-8) has reached
105.2 percent and the Net Enrollment Ratio at Secondary level (9-10) 28.7 percent. The gender
gap has also narrowed accordingly from the total students at First Cycle (1-4) a Net Enrollment
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Ratio of Girls 0.83, Primary School (1-8) 0.82, Secondary School (9-10) 0.78 and preparatory
education has reached 0.98% in 2011EFY. This shows an increasing trend in girls education which
is expected to contribute a lot to improve health status and socioeconomic development.
2.4. Climate
The region is found at 1,639 meters above sea level with mainly ‘’weina dega’’ climate varying
across seasons of the year. Generally, the mean maximum temperature is highest from April to
May and the mean minimum temperature is lowest from October to December. The Mean annual
daily temperature of the region is 19.20C.
The regional mean annual distribution of rainfall is influenced by the south-easterly winds. The
general distribution of annual rainfall is seasonal. The precipitation of the region is recorded as a
mean monthly rain fall of 67.1mm and mean annual rain fall of 804.7mm.
2.5. Administrative System
Harari People Regional State is one of the 10 regional states in the Federal Democratic Republic
of Ethiopia under the 1995 constitution. It has a regional parliament with the executive branch
includes the president and Council of cabinet of the region. According to the administrative
structure, Harari Region is divided in to six urban and three rural local Woreda administrative.
These local Woreda administrative are further divided in to 19 sub-kebeles (in urban area) and 17-
sub-kebele peasant association (in rural areas.)
2.6. Health system Organization
The health system priorities are mainly focusing on health service delivery at household,
community and facility level mainly 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. This have been
implemented through the four strategic transformation agenda of the health sectors which includes
Woreda transformation, Compassionate, Care and respectful and Quality and Equity of health
service and Information revolution (HSTP I).
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According to the currently Revised BPR, the regional Health Bureau is organized in five core and
5 supporting directorates led by the regional Health Bureau Head. The health bureau management
is the highest in decision making for the health system in the region. The RHB focus more on
capacity building, technical support and regulatory activities; while local Woreda administrative
Health office coordinators have basic roles of managing and coordinating the operation of a district
health system under their jurisdiction.
With regard to the number of facilities, the region has relatively a higher degree of Health Service
with potential coverage of 100 % as per the national Standard. However, taking the regional
population as denominator is a tricky thing to do and should not be done to calculate coverage for
Harari region as the service is also shared by neighboring regions.
Having adequate numbers and mix of motivated and skilled human resource are essential at all
level of the health system. In the 2012 EFY The region health work force ratio shows, one medical
doctor for 4084 people, one nurse for 476, one midwifery for 2709, one pharmacy for 2891, one
laboratory for 1878 and one health officer for 3959 people are giving services. Also in the region
there are around 144 health extensions worker/ profession giving services in both rural and urban
areas. This shows in the household level one health extension worker services on average for 469
house holder.
During HSTP-I implementation Period Under the RHB there are one health science college, one
Regional public Health Laboratory & Research Center, One blood bank, two public hospitals (One
general and One specialized university hospital), one Federal police hospital, two private general
hospitals, one fistula hospital, Nine Health Centers, 45 private clinic ,1 Family Guidance
Association Model Clinic and 28 community Health posts providing health care services for the
population.
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Chapter 3: Performance and Situational Assessment of the first

Health Sector Transformation Plan (HSTP I)
The first Health Sector Transformation Plan (HSTP I) 2008-2012EFY, provided a clear guidance
on where the Region plans to reach by 2012 EFY. Hence, critical review of lesson learned from
HSTP I is paramount important as a basis for the next year strategic plan
3.1. Progress of HSTP I Transformation Agendas
3.1.1. Woreda Transformation

In Health sector transformation Plan I (HSTP I 2008-2012 EFY), Harari RHB has tried a more
integrated approach to woreda transformation by bringing together planning and implementation
of the four transformation agendas of the HSTP I at the regional and woreda level. The integration
strategy includes: advocacy and awareness raising, integrated baseline assessments and situation
analysis, an integrated implementation of tailored intervention including provision of trainings,
supportive supervision, mentorship, and review meeting in an integrated manner at different levels.
Since the end 2010 EFY Comprehensive dashboard for monitoring of HSTP I transformation
agendas has also been designed and implemented.
During the HSTP I, a steering committee and technical working groups (TWGs) were established
to lead the woreda transformation integration process. Guiding manual was also prepared to guide
the integration process. In addition, training on the integrated transformation agendas was provided
to all RHB and woreda level leadership.
The overall goal of the Woreda Transformation agenda of the Health Sector Transformation Plan
(HSTP I) was to achieve universal health coverage by providing quality health care in an equitable
manner. To achieve this overarching goal, the RHB had identified the following objectives during
the implementation of woreda transformation:
 Building resilient health system.
 Creating high performing primary health care units (PHCUs), and model kebeles.
 Ensuring community participation and ownership.
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 Ensuring transparency and accountability at primary health care unit level.

 Ensuring financial protection of peoples while accessing health services.
 Creating effective data utilization for decision making at woreda level.
•Model Houshold
•Improved latrine •Model Kebele
•Skilled birth attendant •Key performance
•Model School Health Indicators
•Model Youth Center High •Health Center
Model Riform
(Urban) Performi
Kebele Implementation
ng PHCU guideline
(EHCRIG)
Woreda
Manage
CBHI
ment
Standard
• Community • Woreda
Based Health management
Insurance standard
Coverage
Figure 2: Major Components of worda Transformation initiatives
At the National level MOH had planned a total 155 woreda to be transformed at the end HSTP I.
The Harari RHB had also planned to transform a total three woreda up to the end 2012 EFY even
though could not achieve its target due to different reason and hindering factors.
With regard to creating high performing PHCUs, during the first HSTP, out of a total of 8 PHCUs
self-assessed in the 7 woredas, none of woredas PHCUs were reported as “high
performing”/Model, 5 reported medium performing and 3 PHCU reported low performing PHCU.
All 9 woredas were also planned to be covered by Community Based Health Insurance (CBHI) at
the end of HSTP I. However, the implementation of CBHI was lastly launched in five woreda at
the end of 2012 EFY, but still needs strong community mobilization to increase the households
participation in the premium both in the currently launched woredas and the remaining woredas to
launch CBHI.
Challenges
The implementation of woreda transformation has been lagging behind compared to the HSTP I
targets. So many challenges have contributed to this. The major challenges that need particular
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attention include; weak inter-sectoral collaboration, lack of ownership and commitment at woreda
level, low performance of the community engagement platform (WDA), inadequate support to the
health extension program, limited capacity of woreda health offices in terms of structure and
staffing, lack of basic amenities at health posts and health centers (rooms, water, electricity,
transport and computer), interruption of supply of essential medicines and equipment, weak
accountability framework at different levels of the health system, shortage of budget and
inefficient budget utilization at woreda level to implement planned woreda transformation
activities, security problem limiting community mobilization efforts, unable to launch of CBHI as
planed due to different reasons, frequent change of leadership at woreda and Kebeles level and
suboptimal quality of care services have also contributed to the slow implementation of the woreda
transformation initiative.
Way forward;
To overcome the above mentioned challenges the following key recommendation were considered
as way forward which include; strengthening multi-sectoral engagement and integration of all of
the transformational agendas and establishing functional coordination platforms at all levels are
necessary, improving community participation and engagement approaches, optimization of the
health extension program, building capacity at PHCU and woreda levels, improving infrastructure
particularly at health post and health center levels, implementing an integrated monitoring and
evaluation framework encompassing all of the transformation agenda will be necessary to
accelerate implementation. With regard to CBHI, all the necessary effort need to be made to
increase enrolment in the CBHI to reach 80% or more in all woredas in the region. Covering all
health facilities through clinical and claim audit is also necessary.
3.1.2. Quality and Equity in Health Care
Quality and equity of care is one of the four transformation agendas of the HSTPI which aspires
to build a high performing health system. The aim of quality and equity transformation agenda is
to consistently improve the outcomes of clinical care, patient safety, and patient centeredness,
while increasing access and equity for all segments of the region’s population.
In order to achieve the equity and quality transformation agenda, the region have taken a lot of
endeavors in the past five years. Different quality structures including technical working groups
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and learning platforms were established at all levels. Several guidelines on quality of care , that
have been developed by MOH, were distributed to users at facility levels by the RHB. The RHB
in collaboration with the MOH and development partners has facilitated several quality
improvement trainings, supportive supervision and mentorships in order to improve the capacity
of health workers and managers in the area of health care quality. Various quality improvement
projects were also developed and implemented in different areas of the health service delivery.
Moreover, collaborative platforms such as Ethiopian hospital alliance for quality (EHAQ) and
Ethiopian primary health care alliance for quality (EPAQ) were implemented to facilitate learning
and support among member facilities.
Equity is also one of the major areas of focus under this transformation agenda. The Heath
extension program continued to respond to the health needs of women and children in particular
who resided in rural places. Implementation of the health care financing strategies such as the
community-based health insurance, fee waiver, services exempted from user fee has played critical
role alleviating financial barrier to access health care for the poor.
Challenges
Some of the challenges that affected the effective implementation of ensuring equity and quality
agenda include; lack of shared vision and understanding about quality, slow responsiveness of
Hospitals regarding establishing quality structures at different levels, inadequate action taken to
achieving regulatory standards, inadequate number of skill labs, and lack of implementation
researches that can be used to improve quality of care and poor data management practices have
been limiting factors in designing innovative approaches. In most places community endorsement
groups are not established, demanding for quality care and reporting of poor quality care is not
practiced, and lack of trust in quality of services at lower level of the health system is resulted in
poor patient flow and in low utilization of care by the community.
Way Forward
The following way forward is important to consider which include: Quality improvement
structures need to be strengthened at all levels, a shared vision for quality need to be set-up and
necessary inputs for health facilities and health workers need to be availed. In addition standards
need to be developed for service areas that are not addressed in the existing standards and services
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packages like the integration of operation theatre units within health centers to maximize health
outcomes, new services like non communicable disease corners, mental health, etc should be
strengthened at the lower levels. Most importantly accountability framework for quality of care
including but not limited to professional and institutional licensure and inspection and external
evaluation need to be strengthened. Engagement of patient, family, community, private sectors,
civil societies and professional associations, and allocation of budget from internal revenue to
support QI activities should also be strengthened.
3.1.3. Information Revolution
The Harari RHB has made a steady progress in the implementation of the Information Revolution
(IR) agenda of the HSTP I. It has designed, developed and implemented several key digital systems
including Smart care to manage health facility service delivery ,DHIS-2 to manage regional
reporting system, e-CHIS to support community health information system, and MFR to manage
and uniquely identify health facilities.
Regional DHIS-2 Rollout

In early 2009 EFY, the MOH has made the decision to transit existing eHMIS software
applications to a standardized and customized District Health Information Software-2 (DHIS2).
The DHIS 2 system helped to advance capturing, processing and presenting of health data based
on the national core indicators that are embarked to measure the provision of health services, and
ultimately improve the health conditions of the population. In addition, the RHB has cascaded and
trained over 69 health workers on DHIS 2 at all levels of the health system. The online and offline
version of DHIS2 is deployed all over the region. Almost all public and private health facilities
are reporting through this system.
The reporting rate is also improving over time. Currently, service reporting rate has reached more
than 95%; with 80% of the reports being submitted timely as per the national standard. In the last
5 years, the average disease reporting rate has also reached 90%. The focus has now shifted
towards development of thematic and program specific dashboards for all levels of the health
system. So far, national level dashboards have been created for HSTP core indicators. Program
specific dashboards have also been prepared for MCH, TB, and tracking of woreda transformation.
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The regional rollout of DHIS2 enabled the health system to conduct regional analysis of
performance using data captured and reported using single platform. It also helped to avoid paper-
based reporting, offline data aggregation and analysis, and improved data visualization for
program monitoring. Program managers are also able to track and monitor progress of their
program by looking at live data coming from the lower level in the health system.
Cultivating an Information Use Culture

As part of the Woreda Transformation, the RHB started to implement IR model woreda
interventions in three woredas in the region. The interventions included creating shared
understanding of the Connected Woreda strategy, developing data quality and data use training
manuals, building data capabilities at woreda and health facility level, and measuring system
performance improvement using Connected Woreda (IR-Model Woreda) criteria. Accordingly,
the nine health facilities assessed in the 9 Capacity Building and Mentorship Program (CBMP)
woredas that also supported by Haramaya University are classified as Emerging (89%), Candidate
(11%) and Model (0%) and performance improvement interventions are developed based on
identified need. Tailored interventions are being implemented to support health facilities and
woredas to advance in connected woreda pathway and to become models in IR.
Improving Health Data Quality

Data quality has been one of the major challenges of the regional health information system. A
recent assessment by the RHB in collaboration with Haramaya University in six woredas revealed
that all data quality indicators are well below the regional targets across WorHo, health facility
and health post levels. Data quality improvement, specifically around content completeness, data
accuracy and report timeliness, is needed at all levels.
Challenges
Some of the challenges that hindered the full implementation of the Information Revolution
initiative are weak support, maintenance structure and capacity at different levels, budget
constraint to fully implement planned IR interventions, decreasing partner support for HIS
implementation and Infrastructure and connectivity related challenges. Moreover there was poor
information utilization for decision making at lower level.
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Way Forward
Strengthening the implementation of Connected Woreda strategy for the creation of Model
Woredas in Information Revolution should get a particular attention which need strengthen
information use practice at all levels, strengthening of DHIS2 data visualization and dashboard
and the use of routine health information for decision making by strengthening performance
monitoring teams at all levels of the health care system. Finalization, launching and use of the
Master Facility Registry (MFR), strengthening the implementation of DHIS2 as the main platform
of the regional HIS and implementation of eCHIS in 100% of rural and urban need to be
strengthened under the Regional eHealth architecture and interoperability standard.
3.1.4. Producing Compassionate, Respectful and Caring (CRC) Health Workforce
The main objective of producing Compassionate, Respectful and Caring (CRC) health workforce
is to have an adequate number of well qualified, compassionate, respectful and caring health
workers contributing to the health sector vision of the region. Training health and non-health
workers in the health sector is one of the approaches followed to introduce and institute CRC
principles in the health sector.
In this regard, the HSTP I plan included intensive training of health and non-health worker,
establishing CRC regional council, establishing CRC incubation centers, coordinate volunteer
services, Selecting CRC ambassador, conducting consultative workshops with honorable senior
staff, and conduct CRC sub-task force meetings.
In the last five years, a total of 511 health worker were trained on CRC as compared to 518 the
total planned for the HSTP I plan which was possible to achieve 98.6%.
Challenges
During the implementation CRC agenda the following major hindering factors were identified
which includes: implementation progresses were hampered with challenges stemmed from lack of
better awareness, insufficient financial and logistic provisions, impeding leadership and
governance, and lack of technical skills, a decline in culture of team spirit and collaboration among
health professional and lack of understanding on how CRC contributes to quality healthcare
remained a bottleneck. Lack of ownership of the transformational agendas in general, and CRC in
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particular, by the leadership of the sector at different levels and lack of experience and skills
coupled with unyielding working environment have been additional challenges.
Way Forward
Ensuring institutionalization of CRC at all levels of the health care system is one area that needs
due attention. Strengthening efforts to ensure integration of the implementation of the agendas,
preparing motivational packages to help the health workforce to become respectful and
compassionate health care workers, and continuing the support to strengthen professional
associations consortiums are main focus areas. Underscoring the fact that CRC is very much to
nature desires, priorities will be given to making recruitments based on passions and interests than
on grades and marks. Beside this, expanding the implementation of CRC principles to other sectors
through multi-sector woreda transformation platform, performing embedded implementation
research, creating structures at all levels that support implementation of CRC, benchmarking CRC
experiences, and engaging stakeholders at optimum level are other priority areas to be considered
in HSTP II.
3.2. Health Service Delivery
3.2.1. Improve Health Status
The state of health and wellbeing of Ethiopians is analyzed based on the three dimensions of health
status as described in the WHO African Region framework for situational analysis: the state of
healthy life, the burden of disease, and risk factors driving ill-health and death. Evidences from
different sources indicated that the health of Ethiopians, as measured by average life expectancy
and health adjusted life expectancy at birth, has been improved over the last two decades with
some change in the causes and risk factors for ill health and pre-mature mortality.
The state of healthy life
Ethiopia achieved remarkable improvement in health indicators during the last two decades. Life
expectancy at birth, the average number of years that a newborn is expected to live if current
mortality rates continue to apply1, increased from 58 years in 2007 to 66 years in 2018 with an
annual rates of increase ranging from 1.98% in 2007 to 0.56% in 2018. Life expectancy at birth is
1 https://www.who.int/whosis/whostat2006DefinitionsAndMetadata.pdf
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currently higher for females (67.3 years) compared to that of males (64.7 years)2, 3.
Ethiopia Demographic and Health Surveys also revealed remarkable progress in several markers
of health status including maternal mortality, child mortality, and mortality from major
communicable diseases. Between 2000 and 2016, pregnancy-related mortality declined from 871
to 401 per 100,000 live births; the probability of children dying before their fifth birthday (under-
5 mortality rate declined from 166 to 67 per 1000 live births4. According to mini DHS 2019, this
figure reduced further to 55 per 1000 live births. The region specific report shows that the Under
5 Child, Infant and Neonatal mortality improved from 192, 188.3 and 54 in (2000 EDHS) to 72,
57 and 34 in (2016 EDHS) respectively. Similarly, morbidity and mortality from common
communicable diseases including malaria, HIV, and vaccine preventable diseases declined
dramatically.5
Despite encouraging improvements in life expectancy at birth, the occurrence of pre-mature death
and compromised quality of life among Ethiopians still constitutes a major development challenge.
Estimates from the World Health Organization indicate that disability from poor health conditions
in the country is equivalent to loss of 8.5 years per person resulting in healthy life expectancy at
birth, a form of life expectancy that adjusts for years spent due to disability, of 57.5 years (58.9 for
females and 56.1 years for males).6
2 https://knoema.com/atlas/Ethiopia/topics/Demographics/Age/Life-expectancy-at-birth
3 World Health Statistics, 2019.
https://www.who.int/gho/mortality_burden_disease/life_tables/hale_text/en/
4 EDHS 2016
5
Burden of Disease Analyses for Ethiopia. http://www.healthdata.org/ETHIOPIA
6
World Health Statistics, 2019. https://www.who.int/gho/mortality_burden_disease/life_tables/hale_text/en/
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68.0
66.2
65.9
65.5
66.0 65.1
64.6
Life Expectancy at Birth (in years)
64.0
64.0 63.3
62.5
61.6
62.0
60.7
59.6
60.0
58.5
58.0
56.0
54.0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
LE at Birth
Figure 3: Life time expectancy at birth of Ethiopia (2007-2018)
Ethiopia’s health adjusted life expectancy at birth is above average for the region of Africa (54
years) and that of low-income countries (55 years); however, it is lower than the global average of
63 years and that of middle-income countries, 59 years.
Major causes of morbidity and mortality

The Ethiopian population is currently dying and suffering from both communicable and non-
communicable diseases affecting all age groups but with disproportionate burden on children and
women of reproductive age group. The major causes of morbidity and mortality in Ethiopia have
remained to be predominantly related to communicable, maternal, neonatal, and nutritional
diseases (CMNND). The increasing incidence and prevalence of non-communicable diseases
(NCD) including mental health problems, that followed increasing urbanization and changes in
lifestyle, in recent years has resulted in a double burden. Analyses of burden of disease in 2017
showed that the major causes of premature mortality are CMNNDs with neonatal disorders,
diarrheal diseases, and lower respiratory tract infection constituting the top three. The contribution
of NCDs has also increased during the last decade with congenital defects and ischemic heart
disease ranking 6th and 10th in their contribution for pre-mature mortality in 2017, respectively.
Between 2007 and 2017, the relative contribution of communicable diseases, including measles,
HIV/AIDS, and lower respiratory tract infections, for premature mortality has shown substantial
decline. Death due to measles has significantly reduced (by 78.4%) over a decade and is no more
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in the list of the top 10 killers. Neonatal disorders, diarrheal diseases, and lower respiratory tract
infections, constituting the top three causes of causes of premature death, coupled with
malnutrition are among the common causes of under-five mortality in Ethiopia. Communicable
diseases such as Tuberculosis, HIV, Meningitis, even though they are declining in their magnitude,
they are still among top ten killers in the country. Non communicable diseases are also among top
ten killers in Ethiopia with Ischemic Heart Disease and Cirrhosis showing increasing trends over
a decade by about 6.4% and 17.2%, respectively.
Figure 4:Major Cause of premature death in Ethiopia 2017

In addition to the increasing contribution of NCDs for pre-mature mortality, NCDs have become
major causes of disability among Ethiopians; six of the ten top causes of disability were NCDs in
2017. Low back pain and depressive disorders are currently the first and second ranking causes of
disability with 37.5% and 34.2% increases in their contribution, respectively, between 2007 and
2017. (Figure5)
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Figure5:Top ten causes of disability of Ethiopia,2007-2017
Risk factors driving morbidity and mortality

Behavioral and environmental risk factors drive the large majority of morbidity and mortality
among Ethiopians. Common behavioral risks include malnutrition, dietary risk, unsafe sex, alcohol
and tobacco use while environmental risks include inadequate WaSH conditions, air pollution, and
occupational risks. Metabolic risks identified among ten top drivers of morbidity and mortality
includes high blood glucose and high blood pressure levels. Between 2007 and 2017, a relatively
high level of reduction has been observed in unsafe sex behavior with about 73% reduction while
the risk from WaSH, alcohol use, dietary risk, and blood glucose level showed a lower rate of
reduction ranging from 16 % to 1%. Occupational risk and high blood pressure showed increasing
rates over the past decade.7As depicted in figure 5 below, Malnutrition, WaSH, Air pollution,
Dietary risk and high fasting blood glucose level were considered as the top five risks that drove
the most deaths and disabilities combined.
7 Burden of Disease Analyses for Ethiopia. http://www.healthdata.org/ETHIOPIA
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Figure 6: Risk factors driving the most death and disability combined of Ethiopia, 2007-2017.
3.2.2. Health Extension and Primary Health Service
Harari region has achieved substantial progress in improving health outcomes during the past two
decades. These achievements were realized after the expansion of primary health care services to
households and communities through the implementation of the Health Extension Program (HEP).
The HEP is an institutionalized community health system designed as the main vehicle to achieve
universal coverage of primary health care .The establishment of the HEP led to the training and
deployment of 144 (74 urban and 70 rural ) Health Extension Workers (HEWs). To further
strengthen the HEP and sustain the gains made due to the rollout of HEP, the Government has
launched the Health Development Army (HDA) strategy in 2010/2011, which is also referred to
as Women Development Army (WDA) strategy. The formation of networks is facilitated by health
centers, HEWs and Kebeles administrations. Through the HEP, more than 13,168 WDA Network
have been created and mobilized regionally.
To improve the capacity of the WDA team, a competency-based training scheme was developed
by the MoH to train 1:5 leaders with a technical guidance from Technical, Vocational and
Education and Training Center (TVET). At the end of 2012 EFY, 5052 WDA leaders completed
the training. Out of these, 2595 (51%) of them were found to be competent. For the last five years,
a total of 49855(77%) were graduated as model household.
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Recently, the MOH has revised the HEP and has been providing a one-year additional training to
the HEWs. The aim is to upgrade the former HEWs to level IV to improve their skills and
competency as part of transforming the quality and equity of health services. In addition, integrated
refresher in-service training has been designed and implemented for the HEWs. To date, 34 level
three Health Extension Workers (HEWs) have been graduated as level 4 Health Extension-
Professionals (HE-Ps) and redeployed to their Kebeles.
In urban areas, a Family Health Team approach has been scaled-up along with the urban HEP. The
aim of the reform is developing and introducing a well-functioning system which provides high
quality and equitable services to the community at the PHCU level. As a result, the Family Health
Team (FHT) has been adopted to ensure that every household has an easy access to all spectrums
of health care services. The region first started the implementation of FHT approach at Jinela
Health center in 2010EFY. After piloting in Jinela health center, the urban primary health care
reform implementation has expanded to other 3 urban health centers.
Challenges that faced during implementation of HSTP1 were weak technical and capacity gap of
supervisor at PHCU level, poor infrastructure facilities like water, electricity, internet and
telephone, poor supportive supervision at woreda level to the Health extension worker , high
turnover health extension worker, poor commitment and motivation of HEW, weak WDA
structure and functionalities at it is expected, and lack of motivational, retention and incentive
strategy.
3.2.3. Hygiene and Environmental Health
The Country’s first National Hygiene and Sanitation Strategic Action Plan forms a key element of
Ethiopia’s Universal Access Plan for water and sanitation and highlights the importance of
achieving the GTP and Health Sector Development Program. The National WASH Program has a
multi-sectoral approach involving four Ministries (Ministry of Water & Energy, Ministry of
Health, Ministry of Education & Ministry of Finance and Economic Development) who have
pledged, through a Memorandum of Understanding to support an integrated WASH program that
addresses the needs of individuals, communities, schools and health posts more holistically and
reduces bureaucratic compartmentalization of services.
Page 24
The objectives of the National WASH Program are to increase latrine coverage and ensure
facilities are properly handled, sustained and utilized; to promote communal solid waste disposal
sites; to improve medical and other waste management system in public and private health
institutions; to increase drinking water quality monitoring; and monitor food safety and food
processing industries.
The Health Extension Program is one of the government’s primary vehicles for driving sanitation
improvement at the kebele level. Of the 18 packages, 7 of these cover hygiene and environmental
sanitation: excreta disposal, solid and liquid waste disposal, water quality control, food hygiene,
proper housing, vector control (arthropods and rodent control), personal hygiene, health education
and promotion.
In 2012 EFY, the proportion of households with access to any type of latrine was 78.7% while
access to improved latrine was 30.6% which was short of meeting the target of 100% by the end
of HSTP I. The proportion of Kebeles declared Open Defecation Free (ODF) was also 64.7% (11
kebeles) which was again much lower than the 90% target set in HSTP I.
Institutional WASH
Institutional Hygiene and Environmental health service is one of the key intervention area to
address infection preventions and control, promote hygienic behavior and make institutions safe
for the clients and the public at large.
Since 2008EFY, a total of 14 water facilities were constructed for health centers and health posts.
Besides, 6 improved latrine facilities and 7 waste disposal facilities such as incinerator and
placenta pit were constructed. Integrated supportive supervision and field visit was carried out in
one WASH national programs implementing Woredas and technical support was provided on
hygiene and sanitation program.
Hygiene Promotion
To enhance public awareness on proper hand washing practice, regional level hand washing day
were celebrated through different events. Various information, education and communication
materials were distributed. Regarding safe menstrual hygiene management (MHM),
implementation guideline and training manuals were adopted and distributed to all health facility
Page 25
3.2.4. Reproductive, Maternal, Neonatal, Child, Adolescents and Youth Health

(RMNCAYH)
Improving the health status of women, neonates, children and young people is one of the main
strategic objectives of the heath sector transformation plan 2008-2012 EFY, for which different
strategic initiatives on RMNCAYH is developed and on implementation at different levels of the
health system. Some of the RMNCAYH strategies that are developed and currently on
implementation are: National Reproductive Health Strategy (2016-2020), National Adolescent and
Youth Health Strategy (2016-2020), National Nutrition Program and others.
Building upon achievements during the MDG period, Ethiopia continued to improve key maternal
and child health indicators during the period of the Health Sector Transformation Plan. According
to United Nations Inter-agency estimates, maternal mortality ratio declined from 1030 in 2000 to
446 in 2015 and 401 in 20178. The 2019 mini Ethiopian Demographic and Health Survey also
showed that the coverage of maternal and child health services continued to rise leading to
sustainable reduction in under five and infant mortality rates. Between 2005 and 2019, under-5
mortality rate declined from 123 to 55 deaths per 1000 live births and infant mortality rate declined
from 77 to 43 per 1000 live births. Neonatal mortality has also decreased from 39 to 29 between
the 2005 and 2016 EDHS, but has remained stable since the 2016 EDHS.
Figure 7. National Trends of Under-five , Infant, and Neonatal mortality rate from 2005-2019, (Source:-
mini EDHS 2019)
Currently, the risk of mortality during the neonatal period contributes 54.5% of the total risk of
8 UN inter-agency estimates on maternal mortality
Page 26
death during the first five years of life among Ethiopian children. In this section, the trend and
annual performance of RMNCAYH-N indicators, major activities conducted and performance in
HSTP I are discussed. The major challenges and way forward for the Next HSTP II are also
discussed for each program area.
Family Planning
Bearing many children are among the factors which affect maternal health status. The trend in the
last two decades for Harari region women to give birth to an average of 5 children in their lifetime
(Total fertility rate). According to the EDHS 2016, the average total fertility among the region
women has reduced to 4.1 in 2016 EDHS which was even higher than the 3.8 total fertility rate
report of EDHS 2005 and 2011. Nonetheless, the objective of the family planning National
commitment 2020 was reducing TFR to 3 by the end of 2012 EFY.
Figure 8: Harari Region Reproductive Health trends from Routine HMIS and EDHS in the last 5 years &
20 years respectively.
The region’s routine HMIS report indicated that contraceptive acceptance rate was very gradually
improving from the baseline 51% in 2007 EFY to 63% but declined to 54% in 2012 EFY; Which
is still far from the regional GTP target to reach 90% by the end of HSTP I. The unmet need in
family planning was gradually declining from 30.1% in 2000 EDHS to 21.3% in 2016 EDHS. The
discrepancy of the family planning service between HMIS and EDHS was still very high that
30.3% in 2019 EDHS is lower than the 56% HMIS routine report.
Page 27
Maternal health services
With the aim of reducing maternal mortality to 199 per 100,000 live births, a set of high impact
interventions were being implemented, including antenatal care (ANC), skilled birth services and
postnatal (PNC). According to the region HMIS reports, the proportion of pregnant women who
received ANC services at least once exceeded 100%. However, continuity of service and quality
of care is not optimal as evidenced by low coverage showed by EDHS of skilled delivery, tetanus
toxoid (TT) vaccine uptake, and screening for syphilis, utilization of ITN as well as suboptimal
uptake of prevention of mother-to-child transmission of HIV (PMTCT) services by pregnant
women.
Access to safe abortion services and post-abortion care has been expanded during the period of
HSTPI. This effort has led to reduction in the contribution of abortion as a cause of maternal
deaths. Analyses of data from MDSR reports showed that maternal death due to unsafe abortion
decreased from 32% in 2006 to 4% in 2018. Obstetric fistula (OF) and Pelvic organ prolapse (POP)
are still problems in Ethiopia. The 2016 EDHS revealed that 0.4% of women had obstetric fistula.
Though there is paucity of data on public organ prolapse, it is expected that Ethiopia could be one
of the countries with high burden of POP, due to child marriage, high fertility and high proportion
of home delivery.
HMIS Report
120% 107%
100%
94% 95% 91% 95% 95%
100% 85%
90% 90%
84% 84%
76% 74%
80% 66% 70%
63% 61% 60%
54% 50% 61%
60%
46%
40% 37% 39% 40%
20% 24%
0% 5%
2007 2008 EFY 2009 EFY 2010 EFY 2011 EFY 2012 EFY Target
EFY(Base 2012 by
Line) HSTP
ANC-4 Skilled Delivery PNC

ANC-1 DOR ANC 1st- 4th Linear (ANC-4)
Figure 9: Harari Regional maternal health trend from Routine HMIS and EDHS in last 5 years
and 20 years respectively
Page 28
According to 2019EDHS, the performance of ANC, SBA, and PNC services of maternal health
showed progress for the last five years. ANC service improved from 75.9% in 2016 EDHS to
80.7% in 2019 EDHS, SBA improved from 51.2% in 2016 EDHS to 64.9% in 2019 EDHS, and
PNC improved from 37.4% in 2016EDHS to 45.2% in to 2019 EDHS. However, the routine HMIS
report indicated a slight decline in SBA and PNC from the baseline. Although it is narrowing from
time to time, there is discrepancy between HMIS report and EDHS in the performance of maternal
health services. The main challenge of the HSTPI was high dropout rate of ANC due to poor
quality of maternal health service and problem of early initiation of ANC service.
Child health
Between 2016 and 2019, Ethiopia’s under-five and infant mortality rates declined from 67 to 55
and 48 to 43, respectively. However, neonatal mortality has been stagnant with a rate of 30 per
1,000 live births in 2019. Despite the encouraging reduction in under-5 mortality rate, it is still
estimated that 189,000 under-five children die from preventable childhood diseases every year.
Many more children suffer illnesses and face long term disabilities due to complications of
neonatal and childhood diseases. Pneumonia and diarrhea remain the major killers of under-five
children contributing for 16.4% and 8% of deaths, respectively, followed by injury, measles, and
malaria each contributing to 7.1%, 4.6%, and 0.8% of deaths. Malnutrition remains to be a major
contributor to child mortality contributing for nearly half of under-5 deaths.
Ethiopia has been implementing several high impact neonatal and child health interventions
including basic disease prevention, health promotion and treatment services. These interventions
have been provided through national initiatives such as Community Based Newborn Care (CBNC),
ICCM at community level and essential newborn care (ENC), integrated management of newborn
and childhood illness (IMNCI) and neonatal intensive care unit (NICU) services at health facility
level. The health extension program (HEP) served as the main platform to reach rural populations.
Despite increasing accessibility of services, uneven distribution of health resources, sub-optimal
quality of care, low child health care seeking behavior of communities, low coverage of KMC
services, and shortage of essential health commodities and equipment at service delivery points
remain to be key challenges contributing to high rates of neonatal mortality. Ensuring sustainable
9
Mini DHS 2019, Ethiopia
Page 29
domestic financing for child health program commodities remains to be a challenge for the health
sector. There is lack of uniformity in implementing fee exemptions for newborn and child health
services at all levels. The private sector plays an increasing role in improving access to care of
newborn and child health care; however, its role is mostly limited to urban centers.
Expanded Program Immunization

The expanded program on immunization (EPI) has been one of the major investments in the
prevention of childhood morbidity and mortality in Ethiopia. Over the last two decades, the
coverage of child vaccination increased substantially. The 2019 min-EDHS indicated that the
region’s proportion of children receiving three doses of pentavalent vaccine and all basic vaccines
reached 52.8% and 45.8%, respectively. Current coverage levels, even though it can protect
millions of children from a number of vaccine preventable diseases, lack the required levels to stop
transmission. As a result, unacceptably large number of children still die from preventable
communicable diseases. Low immunization coverage in the region is the result of limitations in
the components of EPI in the areas of 1) vaccine supplies and quality, 2) service delivery
(coverage, equity and quality), 3) advocacy and behavioral change communication, and 4) EPI
management, human capacity, and financial.
Harari Region EPI Trend from 2007 to 2012 HMIS Harai Region EPI Trend from 2000 to 2019 EDHS
report
34.1% 42.2% 45.8%

103% 35.9%
100% 88% 90% 90%
34.9% 64.7%
58.6% 53.6% 58.7%
93% 108%
100% 97% 98% 39.9%
57%
51.8% 58.7% 52.8%
50.7% 45.8%
125% 61% 116%
100% 108% 103%
63%
2000 2005 2011 2016 2019
2007EFY 2008EFY 2009EFY 2010EFY 2011EFY 2012EFY EDHS EDHS EDHS EDHS EDHS
Penta3 Measel Fully Immunized Penta3 Measel Fully Immunized
Figure 10; Harari Region EPI trend from routine HMIS & EDHS of the last 5 &20 years
respectively
The achievements of the Penta3, Measles and Fully immunization were remained successfully
Page 30
improved in the last five years. However, there is still high EPI dropout rate in Routine HMIS. The
discrepancy of EPI service between HMIS and EDHS in HSTP I was high as about 40-50 % which
could be due missed opportunities of unimmunized children and data quality of the services.
Nutrition
Nutrition is a cross-cutting issue that contributes to achievement or acceleration of progress
towards several SDG. Ethiopia has one of the highest rates of malnutrition in Sub-Saharan Africa,
and faces acute and chronic malnutrition and micronutrient deficiencies. Nutrition deficiencies
during the first critical 1,000 days (pregnancy to 2 years) put a child at risk of being stunted.
According to mini EDHS 2019, the region specific report indicated that the percentage of women
who took iron tablets during pregnancy for their most recent live birth was 66.2%, while
percentage of children 6-35 months who received vitamin A supplements was 48.8%. These
achievements are very far behind the 100% target set for both to reach at the end of HSTP-I.
45%
39%
40% 37%
34.70%
35%
30%
29%
30% 27.10% 26.70%
25%
21.50%
20%
18.90%
20%
15%
10% 10.70%
9.10% 9.10%
6.30%
5%
4.20%
0%
2000 EDHS 2005 EDHS 2011 EDHS 2016 EDHS 2019 EDHS
Stunting Under Weight Children Wasting
Figure 11: Harari Region Child nutrition trend report from 2000 – 2019 EDHS G.C.
The region’s prevalence of stunting has decreased from 37% in 2000 to 34.7% in 2019 EDHS,
even though there was an increment from 29% in EDHS 2016 to 34.7% in EDHS 2019. That is
why stunting rate of 34.7% remains a great concern with the subsequent life course impact of
malnutrition on the long-term health of individuals and the socioeconomic development of the
nation. The rate of wasting in Harari has increased, from 9% in 2011 to 11% in 2016 then declined
significantly to 4.2% in 2019. While the rate of underweight in children under 5 years has slightly
Page 31
decreased, from 21.5% in 2011 to 18.9% in 2019. In HSTP-I, the target was to decrease the
prevalence of stunting to 20%, wasting to 3% and underweight to 8.5%. However, the 2019 mini
EDHS report indicated that stunting and underweight were far from the target set to achieve by the
end of HSTP I.
PMTCT
The proportion of pregnant women counseled and tested for the prevention of maternal to child
transmission (PMTCT) of HIV since 2008EFY was >100% (67,453). The percentage of HIV-
positive pregnant women who received ART to prevent Maternal to Child Transmission (MTCT)
of HIV has planned to reach 100% (750) by the end of HSTP-I, and the performance for the last
five years was 70% (522). From the total 449 HIV positive pregnant and lactating women who
were receiving ART, 39% were newly identified and linked to PMTCT while 61% are known HIV
positives who were linked to PMTCT. Further efforts on PMTCT services’ delivery as an integral
component of MNCH care packages with focus on areas with high unmet needs (hotspots), is being
implemented in order to achieve the goals of eliminating MTCT of HIV. Moreover, an integrated
register to follow the mother and baby as a paired cohort is in place. Currently option B+ is being
implemented in our region. However, the PMTCT coverage is challenged with factors such as low
level of poor referral linkage in some areas, stock interruption of diagnostic kits and suboptimal
community awareness.
Adolescent and Youth Health
Adolescents and youth (10-29 years age) in Ethiopia constitute 42% of the population10. This group
is an opportunity for the country when it enters into productive activities but poses a challenge
when it is not healthy and out of the productive activities. Adolescents face various health
problems. However, Access to and utilization of health services is limited; and health education
and life skills trainings are given in a fragmented approach. Only 51% facilities offer adolescent
friendly health service, and only 32% of them have staff trained in adolescent sexual and
reproductive health (SARA 2018). Service data is not age/sex disaggregated to show discrepancies
for a better planning and budgeting. Increasing skills and knowledge on health risks, recognizing
the meaningful participation of adolescents and youth, reinforcing the implementation of existing
10
Central Statistical Agency (CSA). Population Projections for Ethiopia 2007–2037. Addis Ababa: CSA, 2013.
Page 32
strategies and strengthening the continuum of sexual and reproductive health care is vital for the
health and wellbeing of young people so that they will be able to contribute to the country’s
development agenda.
Although Ethiopia has made significant progress on access to basic health facilities, young people
still face several health challenges; including communicable diseases, nutritional problems,
substance abuse, non-communicable diseases and gender-based violence. About 20% and 23% of
adolescent girls aged 15 to 19 are anemic and underweight, respectively. Most young people in
Ethiopia lack comprehensive knowledge on SRH and engage in risky behaviour. Rural young
people and girls are disproportionately affected. Only 16% of rural young females had
comprehensive knowledge about HIV compared to 38% rural young males. Similarly, only 36%
of the rural young females had ever been tested for HIV, compared to 65% urban young females,
and 59% urban young males. About 37% of girls and 43% of boys aged 15-19 year consume
alcohol. About 57% of boys also chew Khat11.
The current family law (revised in 2000) raised girls’ minimum age of marriage to 18 years, while
the Penal Code (revised in 2005) criminalizes acts of violence against women, including child
marriage and abduction. However, the practice of child, early, forced marriage continues to be a
common practice. According to the EDHS 2016, the median age at first marriage was 17.1 years
among women and 23.8 years among men; 58% of women and 9% of men were married before
their 18th birthday. About 13% of women, aged 15 to 19 have already begun childbearing. Despite
the significant increase in contraceptive use among youth over the past years, unmet need remains
high at 20% in 2016.
3.2.5. Prevention and control of major communicable Disease (HIV/AIDS, TB, Malaria)
Prevention and control of HIV/AIDS
In the last five years different activities were conducted to prevent and control HIV/ AIDS.
Behavioral change activities, HIV testing and counseling, adult and pediatric treatment, care and
support, STI, KP, TB/HIV, PMTCT and GBV care were among the program areas implemented
during HSTPI period. Since the region is located along a high HIV risk transport corridor, prevent
11 Ibid. 6.
Page 33
and control of HIV/ AIDS is one of the priority areas of the region. The region’s HIV prevalence
is 2.4% which is significantly higher than the national HIV prevalence which is of 0.9%12.. At the
end of 2012EFY, 4774 PLHIV are currently on ART, which is 99 % of PLHIV the estimate.
The provision of comprehensive HIV/AIDS services is one of the major activities under regional
health to reduce new HIV infections and bring about epidemic control. The region, currently
working to achieve nationally and international set targets of comprehensive HIV/AIDS
prevention, treatment, and care and support programs. HIV testing and counselling services,
PMTCT, and Antiretroviral Therapy (ART) are being provided in 12 health facilities of the region.
HIV testing is the critical first step in identifying and linking and PLHIV to the treatment cascade
and also provides an important opportunity to reinforce the HIV prevention. Up to 2012 EFY, a
total 233,431 people were tested for HIV and received their test results which account 100% of
the target in each annual years. From the total tests in the last five years, 1480 (0.6%) of them were
tested positive.
The region is in good progress in achieving the three 90’s targets set for 2020 with the aim of
ending HIV/AIDS by 2030 G.C.
First 90: The total number of estimated PLHIV who know their HIV status during reporting period
was 4810. During 2012EFY a total of 4774 were on ART and 1st 90 performances were 99%
which is in line with the target.
Second 90: The second regional-90 performance currently stands at 95% which is in line with
HSTP one target set for 2019. This might be due to the urban nature of the region as well as its
proximity to other surrounding regions that attracts large number of patients from other areas to
get better services and to avoid stigma. This may need further data segregation.
Third 90: A total of 3556 have viral load suppressed out of the total 3672 samples tested. And if
we calculate the third-90 target from the existing current on ART, the viral load suppression rate
will be 97% and the region is achieving the third-90 target of HSTP I.
12 EDHS 2016
Page 34
Despite all the above achievements, there were challenges that need due attention in the coming
HSTP II implementation period. Some of the major challenges are inadequate targeting of HIV
testing service and low yield, suboptimal HIV case finding especially in paediatric and adolescent
age groups, key and priority populations , high turnover of trained health care professionals, low
viral load test coverage, suboptimal data quality, data use at various level, delay in dissemination
of generated evidences, and most importantly overall budget cut to HIV program specifically from
donors.
Prevention and control TBL, TB/HIV and MDR TB Disease

The burden of tuberculosis in Ethiopia is high with an annual estimated incidence of 2012 EFY
was 151 TB cases per 100,000 populations. In addition, the emergence of drug resistance TB in
Ethiopia is adding a burden to the health of the population and to the health system. Regarding
leprosy, the incidence and prevalence has been decreasing over the past years but still the disease
is affecting many in the region. As a result, the RHB has given due attention and implemented a
TBL, TB/HIV and MDR-TB prevention and control strategy. In this section, the performance of
key indicators, major activities undertaken on TB and leprosy control program in HSTP I and
challenges are discussed below.
TB Case Detection: Between 2008-2012EFY, 2493 all forms of TB cases (New plus Relapse)
were detected and put on treatment. The RHB HSTP-I was to increase the case detection rate for
all forms of TB from 85% in 2007EFY to 100% at the end of 2012EFY with the aim to detect 2416
TB cases and achieved the target, which was higher than the WHO estimate during the entire
period. Figure 11 depicts percentage of the reported TB cases in the Harari Regional State from
2007EFY to 2012EFY.
Page 35
120%
100%
80%
60%
40%
20%
0%
2008EFY 2009EFY 2010EFY 2011EFY 2012EFY
Case Detection 97% 94% 103% 113% 112%
CTBC 34% 14% 18% 30% 19%
PPM 5% 8% 12% 15% 28%
Figure 12: Trend of TB cases finding from 2007- 2012 EFY Harari Region.
While looking the trend in TB incidence rates over time in the Region, there has been a steady
decline in TB incidence rates from 230.6 per 100,000 in 2007EFY to 183.2 per 100,000 in
2012EFY. According to WHO estimate, the global average and Ethiopia incidence rate is 142 and
177 per 100,000 populations, respectively. Despite a decline in TB incidence rate by 21% from
2007EFY to 2012EFY, the burden of TB in the region remain higher than both the global average
(142/100000) and national average (177/100000).
Tuberculosis Treatment Outcome
TB Treatment success rate and cure rate
The overall TB treatment success rate for bacteriologically confirmed TB cases and clinically
diagnosed TB cases were shown an increment from the baseline. Although the cure rate and the
TSR are slightly lower than the 100% target for both by the end of HSTP-I, they are still in line
with the WHO standard.
Page 36
105%
100%
95%
90%
85%
80%
75%
2007EFY 2008EFY 2009EFY 2010EFY 2011EFY 2012EFY
Cure rate 84% 93% 96% 93% 96% 95%
TSR for bacteriologicaly confirmd 90% 95% 98% 96% 96% 99%
TSR for Clinicaly Diagnosed 94% 98% 98% 95% 97% 98%
Figure 13: Trend of successful TB Treatment out come from 2007 - 2012EFY of Harari region.
For all forms of TB cases, the report showed that there were a decline in unsuccessful TB treatment
outcomes from 7% in 2007 EFY to 1% in 2012 EFY. The TB mortality rate in the region has
decreased by 72% from the period of 2007–2012EFY.
MDR-TB Case Finding

The plan for MDR-TB case finding was 55 from 2008-2012 during this period a total of 34(62%)
MDR-TB cases were identified and put on second line treatment. Of 34 MDR-TB cases identified
75% were enrolled in to second line drug treatment.
TB/HIV Services
The HIV screening has shown an improvement from the baseline. The positivity rate was also
shown an increment from the base line, this might be under reporting during 2007.
Page 37
120%
100% 100% 99% 100%

94% 91%
80% 82%
60%
40%
20%
12% 12% 12% 15% 11%
5%
0%
2007EFY 2008EFY 2009EFY 2010EFY 2011EFY 2012EFY
HIV Screening for TB Pts HIV Positivity Rtae
Figure 14: Trend of HIV screening among TB Patient and Positivity rate from 2007 - 2012 EFY
of Harari Region.
Leprosy prevention and control

Leprosy Case Detection Rate
Leprosy is a disabling disease causing permanent physical disability. Over the past several years,
leprosy prevention and control program has achieved notable results in reducing the prevalence of
leprosy. It is a disease targeted for elimination in Ethiopia. In 2012 EFY, a total of 15 case of
leprosy cases were detected with detection rate of more than 100% against the regional plan. In
HSTP-I the plan was to detect 51 leprosy cases and 47 (92.2%) of these were detected and put on
treatment.
Grade II disability rate among new cases of leprosy and Treatment out come
Grade II disability rate among new cases of leprosy is an indicator that measures the quality and
effectiveness of leprosy case-finding activities. A high disability rate among new cases signals that
cases are detected late during the course of the disease. If the rate is high, it is essential to strengthen
case-finding activities and develop health education in order to encourage the population to seek
treatment before disabilities appear. For the last five years, there was no Grade II Disability
reported cases. The treatment success rate for leprosy cases has increased from 70% in 2007EFY
to 100% in 2012EFY.
Prevention and Control of Malaria

Malaria has been one of the major causes of morbidity and mortality in Ethiopia. To reduce
Page 38
morbidity and mortality from malaria, nationally designed malaria prevention and control program
has been implemented in the region. The prevention and control program mainly focuses on
expansion and strengthening of vector control and malaria case detection and treatment. Increasing
the availability and utilization of long-lasting Insecticidal Nets (LLINs), as well as implementing
indoor residual spraying (IRS) are powerful vector control tools that are being implemented to
reduce malaria transmission. Furthermore, access to care for suspected malaria cases and
appropriate diagnostic testing and therapeutic management at all places of care have been
implemented to ensure that all patients with malaria receive prompt and effective treatment.
12000 11151
10000
7645
8000 6741
6000
4000
1562 1659
2000
0
2008EFY 2009EFY 2010EFY 2011EFY 2012EFY
Figure 15: Trend in the number of malaria cases in Harari region from 2008 - 2012 EFY
The region has made significant progress in its efforts to control malaria. In 2012 EFY, a total of
1659 malaria cases were reported which was lowered by 85% (9,492) when compared with 11151
malaria cases in 2008 EFY. From the total malaria cases, clinically treated cases were 0.2% which
indicates there was significant reduction in clinical case management of malaria and high
improvement of parasitological confirmation of malaria diagnosis. There was no death reported
due to malaria cases in the region. This is among the success of the regional malaria program goal
that aims to achieve zero malaria death.
Long-Lasting Insecticide Net Distribution

As indicated in malaria elimination roadmap, during the optimization phase the distribution of
LLINs was aimed to reach universal coverage of the population at risk of malaria transmission.
Accordingly, in 2011 EFY, LLINs distribution took place successfully in all targeted districts in
the region with House Hold served, Population served and LLINs distributed were 96.6%, 97%
and 93.6%, respectively. During the phase of optimization, ownership and utilization of nets were
Page 39
monitored at village and household level by using HEWs. Moreover, awareness creation activity
also conducted in order to improve utilization and decrease the misuses of ITNs.
Indoor Residual Spraying of Unit structures

For the last five years, in each year, IRS Campaign was conducted following the end of the rainy
season in all kebeles which are identified as epidemic prone areas with high risk of malaria and
sprayed using insecticides supported from MOH.
Malaria Elimination Program

Several malaria elimination activities were carried out in all woredas that are targeted for
elimination in the region. A total of 140 malaria vector breeding sites from 36 kebeles were
identified for different elimination activities. Malaria elimination specific supportive supervision
was conducted in all woredas with high malaria incidence. Capacity building activities were also
conducted to health workers on integrated vector control and Case management. Some of the
challenges that hindered the full implementation of Malaria prevention & control that needs due
attention in HSTP II are Shortage of PPE, spray pump and its spare parts, absence of proper IRS
documentation and shortage of complete and timely data for evidence based-decision, and data
analysts at all levels
3.2.6. Prevention and Control of Neglected Tropical Diseases
Ethiopia has identified nine NTDs as its priorities, namely: Guinea worm, lymphatic filariasis,
onchocerciasis, schistosomiasis, soil-transmitted helminths, leishmaniasis, trachoma,
podoconiosis, and scabies. During the period of HSTP-I, major interventions that targeted NTDs
were regular mass drug administration to all people at risk of morbidity and/or infection and
intensified disease management within the primary health care system. As a result, remarkable
progress was made towards control and elimination of targeted NTDs even though there are
unfinished agenda.
Soil-transmitted helminthes are among the most common infections worldwide and affect the
poorest and most deprived communities. Soil-transmitted helminthes (STH) are widespread in
Ethiopia but with a varied prevalence rate between geographical areas, which exceeds over 85%
in some districts. National mapping conducted in 2013 identified 297 districts as endemic for
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schistosomiasis with 9.9 million school aged children requiring treatment. It is estimated that at
least 45 million people live in schistosomiasis endemic areas. Ethiopia is exerting efforts to
eliminate schistosomiasis to a level where it is no longer a public health problem by 2020.
The RHB has conducted different activities to prevent, control or eliminate NTDs which are
common in the region, namely: Trachoma, Schistomiasis and soil Transmitted Helminthiasis. The
key activities conducted were mass drug administration for STH and Schistosomiasis in the
targeted areas, Surveillance as part of national mapping for NTDs and Trachoma Trichiasis (TT)
surgery. In addition to this, capacity building, awareness creation and community mobilization
through different mass media was conducted in the last five years. In HSTPI, a total of 31,239
people treated for soil transmitting helminthes in 9 targeted woredas and 96,261 of people were
treated for schistosomiasis.
3.2.7. Prevention and Control of Non-Communicable Diseases and Injuries
Non-communicable diseases and injuries (NCDIs) are the leading causes of morbidity and
mortality in Ethiopia, causing over 52% of the total deaths (39% by NCDIs and 12% by injuries)
and contributing 46% DALYS (disability adjusted life years lost). Cardiovascular diseases
(hypertension, rheumatic heart diseases, and stroke), cancer, Diabetes, chronic respiratory diseases
and injuries are the major contributors.
The major risk factors for NCDIs include tobacco smoking, physical inactivity, unhealthy diet and
excessive alcohol use, khat consumption and indoor air pollution. In addition, other NCDIs of
public health importance in the country like eye health problems, hepatitis, and mental health are
also causing heavy burden and loses. Thus, as integral part of the country’s response to these
problems in HSTP I implementation, NCDIs prevention and control program was adopted and
implemented in the region. The major accomplishments of the program, challenges and way
forward are summarized as follows.
To create public awareness and promote healthy life style among the general population and to
detect and treat NCDIs, different prevention and promotional interventions and Integrated
diagnosis and management of NCDIs services have been implemented in the region. In addition
to these around 100,000 copies of various IEC/BCC materials on major NCDIs (hypertension,
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diabetes, cancers, mental health, eye health, hepatitis) were disseminated, sensitization activities
were also conducted using mainstream and social medias, during world NCDIs day, and car free
days.
In order to improve healthy lifestyle of the community car free day initiative at Regional level
were conducted on monthly bases. During the car free day events, awareness creation, physical
and free health checkups such as body mass index (BMI), Blood pressure (BP) and blood sugar
level measurements were provided for a total of 3029 individuals.
Integrated diagnosis and management of NCDIs Services

Hypertension and Diabetes Mellitus prevention and control
In 2012 EFY, expansion of demonstration sites for implementation of integrated hypertension and
diabetes screening, diagnosis and treatment services has been done, and the number of health
facilities providing this integrated service has increased from 6 health facilities in 2010 EFY to 12
in 2012 EFY. To support the integrated prevention and control activity, 120 health workers from
all health facilities were trained on integrated hypertension and diabetes screening, diagnosis and
treatment. However, according to SARA 2018, percentage of facilities that offer diabetes services
and cardiovascular disease services was 37% and 20%, respectively.
Cancer Control Program

Breast and cervical cancers, are the major NCDs and a public health problem in Ethiopia. An
estimated 65,000 people develop cancer annually in Ethiopia. Two-third of the incident cases
occurred in females (43,000) while the rest occur in males (22,000) with female-to-male ratio of
2:1.
To prevent cervical cancer, a screening program was initiated in 2010EFY and its implementation
is progressing. To date, Capacity building on cervical cancer was provided to 18 health workers.
Percentage of facilities that offer Cervical cancer services was 20% (SARA 2018). As of
2012EFY, a total of 2350 women aged 30-49 were screened for cervical cancer. Among the total
screened, the result showed that 2106 (90%) had normal cervix, 150(6%) had precancerous lesion
and 94 (4%) had cancerous lesion. In addition to these a total of 83 women received treatment of
the cervical cancer (70 for cryotherapy and 13 for LEEP).
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Mental Health
The 2017 global burden of disease estimates that the burden of mental health and substance use
disorders is 12.8% for Ethiopia. Mental health disorders also contribute to significant number of
indirect deaths through suicide and self-harm. Cognizant of these facts, the Ministry of Health
included mental health initiatives in its sectorial plans leading to the adoption of the first five-year
strategic plan. The RHB has also initiated the Mental Health Program by including in HSTP-I. As
part of this initiation, currently, integrated mental health services are provided in 4 health center
and 2 Hospital in the region. Despite these efforts, weak service delivery capacity linked to limited
resource allocation, lack of reliable data on mental health service availability and utilization at
health facilities pose additional challenges to the prevention and control of mental health problems.
Major challenges in the prevention and control of NCDs are problem of providing integrated
quality NCD management at primary level coupled with inadequate health workforce capacity,
shortage of drugs and other technologies for the management of NCDs poses a major challenge.
In addition, poor prioritization, inadequate financial and technical resources, weak data capture
and reporting, along with low level of awareness about NCDs among the community, health care
providers and political leaders has led to low health seeking behavior and limited resource
allocation at all levels.
3.2.8. Public health emergency preparedness and response
Public Health Emergency Management (PHEM) aims to improve how the health system deal with
existing and evolving disease epidemics, and natural disasters of regional, national and
international concern. It is designed to ensure rapid detection of any public health threats,
preparedness related to logistic and fund administration, and prompt response to and recovery from
various public health emergencies. Therefore, the strategies were set towards an effective early
warning, preparedness, response, recovery and rehabilitation system.
To improve the early detection and identification of public health emergencies, Integrated Public
Health Surveillance System has established and currently the Regional PHEM unit is receiving
weekly diseases surveillance report from more than 59 health facilities in the region. As of June
2019, the completeness and timeliness of reports are significantly improving and have reached
91% and 90%, respectively. The weekly data has been analyzed and the feedback reports were
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disseminated on weekly bases.
During the past five years, about 85% of identified risks (mainly acute watery diarrhea (AWD),
measles, malaria and IDP were communicated to concerned bodies within specified period. In year
2012 EFY alone, a total of 27 public health emergency rumors were communicated to the regional
PHEM and confirmed within six hours, with only 3 (11.1%) of them were identified as real public
health emergencies for whom appropriate responses were undertaken. With regard to outbreak
investigation and mitigation, the PHEM has managed to initiate the prevention and control
measures for 90% of PHE within 48hrs of identification of risk and characterization of threats
through verification of rumors and laboratory confirmation of outbreaks.
Emergency Preparedness and Response Plan (EPRP) was prepared for identified and mapped
risks; and based on the EPRP, Humanitarian Requirement Documents (HRD) has been prepared
and submitted annually to EPHI and concerned stakeholders for funding and further actions. The
emergency logistics management system focuses on stockpiling of drugs and medical supplies as
per the guideline.
During the last five years, public health emergency and other health professional were trained in
short and long term trainings on different PHEM skills to boost the human resource capacity in
managing public health emergencies at regional level. About 5 Health professionals were enrolled
to universities in EFTP training program at masters level and number of EFETP graduates
increased from 2 to 7. To strength and standardized the public health emergency management at
all level, emergency management guidelines and specific disease outbreak management guidelines
were disseminated.
The regional PHEM has some areas that need improvement, including the delay implementation
of community based surveillance system, the weak multi-sectorial coordination apart from food
security, and delay in sharing of reports or notifying reportable diseases through DHIS2. Equipping
and ensuring the proper functioning of the established EOC also need to be improved. Emphasis
should also be given to enhance the capacity of the regional laboratory for timely confirmation of
outbreaks. Moreover, woreda level capacity for preparedness and response should be heightened
with support to have a clear planning and budget allocation for emergencies.
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3.3. Quality Improvement and Assurance of Service Delivery
In the last five years, with the intention to ensure access to quality assured clinical services for all
peoples in the region, the regional health bureau has adopted the national strategy on healthcare
quality improvement and has also been implementing different strategic initiatives and reforms.
Some of these strategic initiatives and reforms are Ethiopian Hospital Transformation Guideline
(EHSTG), Health Sector Transformation in Quality (HSTQ), Clean and Safe Health Facilities
(CASH/IPPS), Ethiopian Hospitals Alliance for Quality (EHAQ), Ethiopian Health Center Reform
Implementation Guideline (EHCRIG), Ethiopian Primary Health Care Alliance For Quality
(EPAQ), Primary Health Care Clinical Guideline (PHCG), Access to Specialty Service (like
Rehabilitative and Palliative Care), Learning Health Facility initiative, Saving Lives through Safe
Surgery (SaLTS), and Pain-Free Hospital Initiative (PFHI).
3.3.1. Implementation of Quality Improvement Initiatives
Maternal Newborn and child health Quality of Care initiative (MNHQoC)

The Goal of the Quality, Equity and Dignity for Maternal and Newborn health initiative is to halve
institutional maternal and new-born deaths in health facilities in selected learning districts and
improve experience of care over a period of 5 years. It is a country-led initiative which builds on
domestic resources and national structures for quality of care. This initiative has four strategic
objectives named as LALA:
• Leadership: Build and strengthen national institutions and mechanisms for improving
quality of care in the health sector.
• Action: Accelerate and sustain implementation of quality of care improvements for
mothers and newborns.
• Learning: Facilitate learning, share knowledge and generate evidence on quality of care.
• Accountability: Develop, strengthen and sustain institutions and mechanisms for
accountability for quality of care
Since the launch of this initiative, different activities have been performed in our region. The major
activities conducted includes collection of data on the selected 15 core indicators, mentoring and
coaching of the facility and joint supportive supervision.
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Clean and Safe Health care facilities (CASH)

According to world health organization, clean care is safe care. Cleanliness in health facilities is
about more than just keeping the place clean. Although efforts to improve the situation have been
underway through the implementation of infection prevention standards, the condition of hospitals
with regard to cleanliness remains a challenge. Clean and Safe Health care facilities (CASH)
program has been adopted and implemented in the region since 2008 EFY. Results achieved in the
region so far include improvement in waste management of hospitals, cleanliness of hospital
buildings and compounds, renovation of hospital buildings, and maintenance of medical
equipment. In EFY 2012, the average score of hospitals CASH implementation in the region was
61%.
Saving Lives through Safe Surgery (SaLTS) initiative

Saving Lives through Safe Surgery (SaLTS) initiative as part of the Universal Health Coverage
has been implemented in the region since EFY 2008. In line with this, a standard for post anesthesia
care, day care surgery guideline and surgical mentorship guideline were customized and
distributed to health facilities. Quarterly mentorship and supportive supervision has been
conducted regularly to improve the application of WHO surgical checklist. Moreover, two OR
building blocks were built in two rural health centers, namely Hassengay and Erer Health centers.
The implementation of SaLTS in the region has resulted improvements in surgical service
indicators. The surgical volume in hospitals improved from 2,022 in 2010EFY to 4,053 in
2012EFY. Delay for elective surgery declined from 4.4 days in 2010EFY to 2.3days in 2012EFY.
Perioperative mortality had also stayed below 0.5% from 2010EFY to 2012 EFY.
Learning Health Facility Initiative

In 2011 EFY, cognizant of the real situation on the ground and learning from the past, more
importantly the importance of learning system for quality improvement, Learning Health Facility
Initiative was designed and set with a goal to create a quality culture in selected learning health
facility. In our region, this initiative is being implemented in Hiwot Fana Specialized University
Hospital. Since the launch, orientation has been provided to the hospital’s management, collection
and analysis of baseline data on the selected quality of care measures and joint supportive
supervision has been conducted with MOH as part of major task.
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Pain-Free Hospital Initiative (PFHI)

In EFY 2011, Pain-Free Hospital Initiative (PFHI) was adopted and different activities were
conducted to initiate the implementation in the two public hospitals in the region. Some of the
activities include provision of training on pain free hospital initiative, printing, and distribution of
implementation manual, assessment tools, posters, and pamphlets, and provision of orientation
training on palliative care. However, inadequate access to basic drugs such as morphine according
to the WHO analgesic ladder, lack of follow up by the hospitals management and inadequate
support and monitoring by the regional health bureau were some of the major challenges.
I-CARE Initiative
To improve health service quality in all health facilities, the ministry of health has also designed
an I-CARE initiative (IMPROVE, Compassionate Care , Actual Access to basic services, Redesign
and Revitalize health service delivery system and Engage and Empower key stakeholders) . The
general objective of this initiative is to boost the implementation of HSTP priority initiatives and
to achieve the HSTP targets. This initiative has been launched in 2012EFY.
3.3.2. Hospital and Health Center Reforms

EHSTG in accompany with the health service transformation in quality (HSTQ) operational
manual has been implemented to be the main tools to transform the administrative and clinical
process of hospital functions. The region has started implementing all the standards of EHSTG
and HSTQ since EFY 2008. Since their implementation; the RHB has been conducting capacity
building, mentorship and supportive supervisions. The regional EHSTG and HSTQ attainment in
EFY 2012 was 64.1% and 63% respectively.
Ethiopian hospitals alliance for quality (EHAQ) was designed to create a network of hospitals that
are committed to helping one another, improve services, empowering the hospital industry to self-
improve. In implementing EHAQ in the region, Jugal hospital and Hiwot fana specialized
university hospital have been aligned with hospitals of neighboring regions. Dil Choira hospital
from Dire Dawa City Administration and Hiwot fana specialized university hospital is the lead
and co-lead of the cluster hospitals, respectively. Patient satisfaction in the initial cycle and
maternal neonatal and child health and CASH in the second cycle were the focus areas. Currently,
EHAQ is in its third cycle focused on Clean and Timely Care in Hospitals for Institutional
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Transformation (CATCH-IT). Training was provided on the audit tool for health professionals and
senior management members from Jugal general hospital and Hiwot fana specialized university
hospital. Quarterly supportive supervision is conducted on regular basis to assess the progress and
to provide feedback on identified gaps.
Similarly, Ethiopian Primary Health Care Alliance for Quality (EPAQ), a platform aimed to help
exchange of experiences and collaborative work among health centers has been implemented with
a cluster of one lead health center and three other health centers in the region. However, high staff
turnover, inadequate awareness, lack of commitment and strong follow up at woreda and Health
center resulted in poor implementation of the initiatives.
To strength health service delivery at primary health care level, MOH has been implementing a
number of initiatives such as designing and implementation of Ethiopian health center reform
implementation guideline (EHCRIG) and primary health care clinical guideline implementation
(PHCCG).
The Ethiopian health-center reform guideline, that consists 10 chapters and 81 standards, was
initiated in EFY 2008. To implement EHCRIG in the region, massive training was given on the
guideline by the RHB in collaboration with MOH. Furthermore, mentoring and supportive
supervision has been conducted regularly. The Implementation of EHCRIG has shown significant
improvement from 33.7% in 2009 EFY to 73% in 2012EFY. Lack of space and absence of
supporting partners in the region were the main challenges in implementing the health center
reform.
73%
61.10%
45.50%
33.70%
2009EFY 2010EFY 2011EFY 2012EFY
Figure 16: Trend of EHCRIG from 2009EFY to 2012 EFY of Harari Region.
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Primary health care clinical guideline (PHCCG), an integrated symptom-based algorithmic

approach to address the common presenting symptoms and priority chronic conditions in the
country, is a standard tool to be utilized at the health center level . Its implementation is intended
to standardize the health care delivered at all health centers to improve quality of care as planned
in the health-sector transformation plan. Its implementation was started at all health centers in the
region by providing training to health workers and distributing the guidelines; and the
implementation status was 88% in EFY 2012. However, there was no standardized implementation
monitoring tools
3.3.3. Clinical services
In 2012EFY, the regional OPD attendant per capita was 1.2 which is slightly higher than the
national 1.02 OPD attendant per capita report, but still far from the regional target set to reach 2 at
the end of the year. Despite improved access and quality improvement efforts, the utilization of
health services in health centers remains low. In the same year, the regional admission rate per
1000 population, average length of stay (ALOS) and bed occupancy rate (BOR) was 76%, 3.8 days
and 45% ,respectively. These values also seem to be slightly better than the national report.
However, they are distant from the regional targets set to be achieved at the end of 2012 EFY.
Therefore, in HSTP-II, improving the quality and equity of health services will remain a major
area of focus in the years to come, including strengthening of emergency and referral services,
enhancing diagnostic services, effective coverage of high impact interventions and follow-up on
the adherence to standards.
3.3.4. Emergency and Critical Care Services
Establishing and strengthening emergency, trauma and intensive care medical services is essential
for medical conditions that require lifesaving assistance that organized to carry out services from
scene care to referral services with a continuum of cares. A number of endeavors are taking place
in improving emergency and intensive care services. Provision of important trainings, expansion
of ICU units at hospitals, construction of emergency room, improving access to ambulance
services through decentralization, and other related activities are being implemented.
To support the provision of a pre-health facility emergency service at community level, TOT was
provided to health workers on pre-health facility emergency care service from all woredas in the
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region. To improve ambulance service quality, accessibility and to provide timely response, a
protocol has been developed to establish call center and ambulance dispatch systems. Most
importantly, as part of disaster preparedness, regional disaster medical assistance team (DMAT)
has been established.
In the last two to three years, a better focus is provided to strengthen health facility emergency
services. Currently, health facilities are developing their emergency areas to provide more space
and proper equipment for triage, resuscitation, stabilization and care of patients, as well as
sufficient and qualified staffing. To strengthen this, mentorship and supportive supervisions are
conducted on regular bases.
In EFY 2012, the proportion of patients who stayed more than 24 hours at emergency room and
mortality rate in emergency department was 2% and 0.6%, respectively. In the same year,
Ambulance service response rate was 99% in the region. When we compare these measurements
with the planned targets, all have indicated improvements. However, the 34.8% mortality rate in
intensive care unit (ICU) needs special attention in the coming HSTP period.
In HSTP I, a wide range of activities have been conducted to strengthen the referral system
between all types of facilities. Recruitment and training of liaison officers, development of patient
referral guideline, reference manuals, admission discharge protocol, and regional service directory
were some of the key activities conducted. Moreover, in order to strengthen the referral system
different as well as recurrent trainings and supportive supervisions were conducted in the past five
years. The hospital and health centers alliance for quality was also the key initiative that helped to
strengthen the referral system as a whole.
Despite the presence of progresses in emergency and Intensive care in the region, there are still
challenges that should be addressed in HSTP-II. Lack of adequate training on ICU, poor
implementation of referral system, poor ambulance utilization and the use of ambulances for
unintended purposes, and poor data quality and management specially in trauma and emergency
care were some of the challenges that need improvement in HSTP II.
3.3.5. Blood Bank Service
Safe and adequate availability of blood is critical to avoid deaths due to lack of blood and
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contribute to the quality of health care service delivery. Prior to HSTP-I, the blood bank service
was dependent on replacement donors and was unable to meet patients’ need for adequate and safe
blood supply. Hence, the regional health bureau had prepared a 5 years strategic plan in HSTP-I
to ensure a safe, stable and cost effective supply of blood and blood products to fulfill the needs
of patients in the region and neighboring regions and to assist hospitals in their appropriate use of
blood.
5000
4500 4509
4000 4046
3754 3692
3500 3512
3309
3000 3060 3038
2679 2673
2500
2372
2230
2000 1905
1500 1429
1300 781 1340
1195
1000 899 890 937
728 431 774 839
685 694 654
500 530 463
510 572 350
0
Replacement Voluntary Total blood unit collected
Figure 17: Trend of Blood units collected from 2002 to 2011EC in Harari Region.
In EFY 2012, the regional blood bank planned to collect 5500 blood and collected 3,692 (67%)
units of blood. Despite significantly increased contribution of voluntary blood donation from
baseline 71% in 2007 EFY to 82% in 2012 EFY, it is still far from target planned to ensure 100%
voluntary blood donation by the end of HSTP-I. The total number of blood unit collected has also
increased by 27% in the last five years. Nonetheless, both availability of safe and adequate blood
and the contribution of voluntary blood donation need an improvement. Low awareness of the
community about blood donation and problems associated with the organizational structure of the
blood bank are some of the challenges that need to be addressed in HSTP-II.
3.3.6. Laboratory Quality Improvement Program
Quality laboratory service is an essential component of healthcare delivery services for patient
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care and public health emergency management. As part of this, the region has been working with
the FMOH and Ethiopian Public Health Institute (EPHI) towards quality laboratory service
through capacity buildings, quality assurance programs, and infrastructure development and
maintenance towards laboratory quality assurance and accreditation program. To further improve
the laboratory service in the region, the regional health bureau with support from the MOH is
finalizing the new building of the Harari health research and regional laboratory.
Currently, three laboratories are participating in Strengthening Laboratories Quality Improvement

Program towards Accreditation (SLIPTA). Some of the major activities performed for these
laboratories include baseline assessment, training, and mentorship. Regarding ISO15189/17025
accreditation program, two laboratories (Harar health research and regional laboratory and Hiwot
fana specialized university hospital laboratory) have been supported, monitored and mentored to
enable them to be accredited. From the two supported laboratories, Hiwot Fana specialized
University hospital laboratory has been assessed by Ethiopian accreditation office (ENAO) for
limited scope and received certificate of accreditation in TB Genexpert examination.
On the other hand, regarding external laboratory quality assessment, 15 laboratories are
participating in regional external quality assessment schemes (REQAS), and 5 laboratories are
participating in International External Quality Assessment Scheme (IEQAS) and National External
Quality Assessment Scheme (NEQAS).
Some of the challenges that should be addressed in HSTP II are weak ownership of quality
improvement activities at facility level, shortage of funds to support for malaria EQA programs at
regional level, lack of comprehensive regional EQA database, and lack of infrastructure for EQA
activities at regional level for production different proficiency testing samples.
3.4. Leadership, Management and Governance
The Regional Health Bureau has taken huge steps in transferring some responsibilities, authority,
power and resources to local levels. This transfer of responsibilities created opportunities for
effective governance at local levels. Effective governance at local levels supports the work of
health managers and health workers in the districts and facilities. In order to improve the
governance structure at points of service delivery, the government has introduced facility
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governance boards comprising of various relevant bodies in a given local community.
Various assessment reports have recommended capacity building on leadership, management and
governance in order to address the critical gaps in the health sector. These areas of improvement
include the capacity to: implement a decentralized health care system; improve the utilization of
health services; systematically follow-up on the implementation of policies, guidelines, standards
and protocols; implement reforms in a timely manner; and enhance the coordination of public-
private partnerships in health. Moreover, leadership practices should include the proactive
involvement of staff in prioritizing key activities, aligning and mobilizing stakeholders for a shared
vision.
3.4.1. Evidence Based Decision Making
HSTP identified evidence-based decision-making as one of its strategic objectives to transform the
existing health sector M&E system. In the last HSTP implementation period, HRHB implemented
various activities that enhanced the evidence based decision making practice in the health sector,
including annual plan development, strengthening the implementation of the routine data
collection and aggregation, monitoring and evaluation of health programs, regional integrated
supportive supervision, conducted. Below are summary of each activity accomplished in the last
HSTPI implementation period to improve evidence based decision making.
Strengthening Routine Health Information System to ensure data quality and use
Information Revolution (IR) model Woreda creation
A primary goal of the Information Revolution is to make key data available at the point of service
delivery, and to capacitate the health workforce to use this data for evidence-based decision
making that will improve the quality and equity of care. One approach to measurably enabling the
Information Revolution is the “Model Woreda” and “Connected Woreda”. In addition IR activities
has been supported by CBMP project that aims to improve data quality and information use
through continuous HIS capacity building and mentorship activities.
During HSTP I implementation, regionally, a total of 9 IR model Woredas were selected for
intervention, of which 3 were targeted under the umbrella of the Woreda Transformation
implementation, and 6 Woredas, 7 Health center, and one General hospital were under the Capacity
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Building Mentorship Program (CBMP). Accordingly, data quality and information use were
implemented. Assessment on the status of IR-model woredas were conducted in 6 CBMP woredas
using the IR-model woreda assessment checklist. With this assessment, the health facilities
determined their status and developed facility specific interventions. As the assessment funding’s
indicate out of the total health facilities in the region only one general hospital fall under candidate
categories and the rest 8 heath facilities fall under emerging categories the main reason for under
achievement were poor data use practices, problem of structure of HIS at woreda level and
irregular implementation of data quality assurance . To create IR model woreda in the region, it
needs further focused in the coming HSTP2.
3.4.2. Regulatory System
It is widely recognized that establishing a fully functional regulatory system ensures adherence to
national health and health related standards and regulations by all state and non-state actors.
Improve health regulation satisfaction of the public

IN HSTP I, community satisfaction index was the key indicator to measure the satisfaction level
of the community on health regulatory matters. In the strategic period, it was planned to reach the
level of community satisfaction to 75 %. The planned activities were to conduct different public
consultative meeting forum and survey.
Regionally, the proportion of satisfied communities in the availability of safe and quality medicine
in the market were (48%), and only 53% of them were satisfied in the efficacy of medicine found
in the market. Furthermore seven out of ten (70%) were experienced buying of medicine from
pharmacy, drug vendor, health center and drug store were satisfied also nearly eight out of ten
(80%) were satisfied in their experience of proper use of medicine, and 75 % in information of
counseling given during dispensing.
Concerning food at regional level, the percentage of satisfied communities on the availability of
safe and quality food items, which are commonly consumed, in the market ranges from 27 % to
65 % (combining Excellent and Good ranks as satisfied). The highest percentage of satisfied
communities observed for biscuits (65%) followed by soft drink (62%), bottled water (61%) and
edible oil (52%). the least proportion of communities satisfied with infant formula and
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supplementary food (27%), followed by juice (33%) and milk (37%).
The regional community satisfaction study is the first study in the health regulatory sector as stated
in the research which is significantly important to the regulatory bodies that shows us what to be
done to satisfy community on the health regulatory affairs and this study document use us a source
of information to communicate and for planning & interventions programs.
Improve quality and safety regulation of food

The objective of food regulation and enforcement is to ensure the safety and quality of food served
in the community in a variety of ways and to protect the health risks associated with it.
Food facility inspection coverage has been planned to increase from 60 % - 85 %. As a result, at
the end of fourth year 75 % food facilities were covered which is 95% of the plan as well the IQMS
implementing facilities has been increased from 0 % to 35.5 %. In line with food facility
inspection, implementation of internal quality management system is one of the major strategic
initiatives which was designed and enforced to implement by food facilities. This strategic
initiative stands in categorization of food items as high, medium and low food safety risks based
on this IQMS documents has been published.
This leads to assuring the quality and safety of food products by the Food facilities themselves
which is important to minimize food quality and safety related health risks and potentially decrease
burden of inspection.
85%
80% 95%
90%
75% 87%
80%
65%
70% 65 % 63% 40%
35.50%
60%
30%
50%
19%
40% 20% 2019
30% 9% 2018
20% 2017
10%
10% 3.90% 2016
0%
Inspection coverage Inspection coverage IQMS Implementing IQMS Implemetning
Plan Performance Facility plan facility Performance
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Figure 18 Status of Food facilities inspection coverage and internal quality management system
from 2008-2011 EFY (2015/16 – 2018/19 G.C) in Harari Region.
In the last four years, based on the inspection findings on foods, 78 retailers were given warning
letters and 59 retailers were temporarily closed due to violation of the regulatory and statutory
requirements. Moreover, 238.8Lt Edible Oil, 28packs Sugar Candy, 187Lt Juice, and 125 different
food items were disposed. Soft drinks and juice products that cost 475, 152.00 birr has also been
disposed.
Improve Medicine Regulation

Comprehensive system of quality assurance must be founded on a reliable system of controlling
the quality, safety and efficacy of finished health products in the market. The level of quality of
medicines should be maintained throughout the pharmaceutical supply system or distribution
network. The distribution channel and supply chain need to follow quality assurance system in
order to assure that patients are getting quality medicines. Due to inefficient supply chain
management, there are still poor qualities of drugs in the market. As of June,2019, the number of
licensed Pharmacies and Drug shops are 36 and 46 respectively. By 2018/19, 100% of medicine
facilities (retail outlets) were inspected for the purpose of licensing and compliance check against
the set guideline and directives. In the last two years, risk based inspection approaches, Auditing
inspection and implementation of Internal Quality Management System have been implemented
at all levels in the distribution channel.
85% of medicine facilities have taken the initiation voluntarily and started implementation of
Internal Quality Management System that can strengthen the trust based regulation among each
sector . Facilities have been categorized based on their performance towards the implementation
of internal Quality System. It was recognized that still there is a gap in understanding and
implementing the principle of internal quality Management system at facility level. The good
achievements of product based auditing inspection and internal quality assurance systems helped
to reduce the circulation of substandard products in the market which in turn saved the public from
poor quality products, and health complications resulted from these products.
In the last four year , based on inspection findings, 25 retailers were given warning letters and 15
retailers were temporarily closed for illegal and expired drugs. Most importantly, illegal drugs and
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expired that cost 2,175, 152.00 birr has been disposed. Although there is a good inspection system
in place, to cope with the current Substandard and Falsified medicine circulation in the region the
medicine inspection system needs to be strengthened in terms of automatic identification systems.
Improve Cosmetic Regulation

There is no question that, the need for cosmetic regulation is mandatory. It should be the primary
aim in any consumer protection policy. This is due to the fact that there are a lot of consumer goods
that are heterogeneous and more technologically advanced that are continually being introduced
to consumers. Cosmetic products are currently one of the most popular consumer products. Their
increase in sales is evident globally including in Ethiopia. They are no longer solely associated
with women but are being used by all people, of all ages. With such popularity, cosmetics
producers are eager to make a profit, which sometimes has resulted in the introduction of cosmetics
which are not safe and cause adverse effects.
Improve Tobacco Regulation

The government of Ethiopia has been committed to protect the public health by strongly regulating
tobacco products. Comprehensive system, and appropriate and strong legal frame work has been
introduced in this regard. As part of the HSTP, it was expected that 75% public places would be
tobacco smoke free. Despite the encouraging performances have been made, the percentage of
tobacco smoke free public places in 2018/19 is 42.3% as compared to the plan (60%).
60% 60%
45% 42.3%
37.9%
30% 31.0%
28.9% plan
Ach.
2015/16 2016/17 2017/18 2018/19
Figure 19: Plan and achievement of Tobacco free public places of Harari Region from
2015/16 to 2018/19 G.C
Improve Health facilities Inspection
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Comprehensive system of auditing inspection must be founded on a reliable system of controlling

the quality of health services given in the health facilities. As of June,2019, the number of licensed
General hospitals, Specialty centers , Specialty clinics, medium clinics, health centers and primary
clinics are 3,2,18,25,8 and 4 respectively. By 2018/19, 100% of health facilities were inspected for
the purpose of licensing and compliance check against the set guideline and directives. In the last
two years, risk based inspection approaches, Auditing inspection and implementation of Internal
Quality Management System have been implemented at all levels in the health facilities. By
2018/19, 100% of health facilities were inspected for the purpose of fulfillment of minimum
national requirement that score above 75%. Among 60 health facilities 35 health facilities score
more than 75% and remain score less than 75%.
Improve Health Professional Registering and Licensing

Producing knowledgeable, skillful and ethical health professionals is one of the major strategies
devised by the Ministry to promote and maintain quality of health care delivery. Accordingly, in
the last 5years, a total of 7547 health professionals who passed the MOH licensure examination or
regional competency examination were provided the licensure to practice their respective
profession.
3.4.3. Addressing gender disparities in health
Gender constitutes the other dimension of equity that has been an area of focus for the health
sector. Gender is a crosscutting issue that has to be considered and effectively addressed across all
levels of the health sector structure. The health sector has a good reputation of providing a specific
program on women’s reproductive health. Gender, as a key social determinant of health, has a
profound impact on the health status of individuals, as well as access to and use of health services.
A gender lens has to be applied in all programs and operations to identify priority areas that can
ensure gender equality and empowerment in the health sector. In this regard, the health sector has
also been trying to address the gender disparity in health indicators by introducing a gender lens
to every decision-making process at all levels of the health system. Under the leadership from the
Gender Directorate of RHB, there are good beginnings to address gender in the health sector.
During the last five years progress was made in gender mainstreaming and gender empowerment.
Activities implemented so far were related to promoting empowerment of females in the health
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workforce, developing manuals, providing orientations to the health workforce, conducting gender
analyses and gender audit in few regions and agencies, and building the capacity of selected health
facilities on provision of services for survivors of GBV. Efforts to address gender disparities in
health are in their early stage; there has been no comprehensive gender analyses for the health
sector to systematically guide strategic actions for closing the gender gap in health service
utilization.
Among the major challenges in the addressing gender disparities in health are limited enforcement
of existing laws and policies on the rights of women and girls, limited capacity of health care
workers in designing and implementing gender responsive health services, and limited capacity
for the provision of comprehensive and multi-sectoral services to survivors of SGBV.
3.5. Health System Capacity
3.5.1. Health Infrastructure Development
The health infrastructure and development encompasses the expansion and standardization of
health and health related facilities. It involves
(a) Development of standard design of health infrastructures;
(b) Construction, maintenance, renovation, and rehabilitation of health facilities;
(c) Equipping and furnishing of health facilities;
(d) Availability of adequate utilities (water, sanitation facilities, and power installations);
(e) Enhancing medical equipment management and maintenance; and
(f) Developing basic ICT infrastructure, use, and innovations.
Access to health services in Harari region has 100% before the starting of HSTP I; all health
facilities provide some of the priority services, such as deliveries, in a manner that attracts mothers
and other patients. There are a total of 28 HPs, 8 health centers and 4 hospitals (including private)
available. HSTP I strategic objective on ICT use in the health sector focused on DHIS 2 and
eCHIS, MFR, EMR and health net. Health technology management, including medical equipment
maintenance, is among areas that need to be building on in the coming strategies.
According to annual regional data at the ends of HSTP I, more than half of health facilities have
regular electricity or has functional generator. About 100% of Public hospitals, 100% health
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centers and 100% of health posts have regular power sources. A total of 3 PV solar installations
were made for health centers. Over 57% of all health facilities have an improved water source in
their facility. Additionally, in collaboration with one WASH project 4 incinerator, 1 placenta pit,
2 septic tank and 2 ash pit were constructed for Erer HC, Hassengey HC, Jinela HC and regional
lab. About 100% of health facilities have access to emergency transport.
Construction, Maintenance, Renovation, and Rehabilitation of Health Facilities

In HSTP I, renovation were made for one health center (Jinella HC) and for the regional blood
bank. On the other hand, the construction of an in-service training center at Harar health science
collage and two OR blocks at two rural health centers were completed and installed with necessary
materials. Beside this, the construction of a new building for the regional laboratory and one health
center at Shenkor woreda are finalizing. The pre-construction work has also been made to build
the second generation Health post at sofi woreda.
3.5.2. Human Capital and Leadership
The main focuses of the strategic objective in HSTPI was to promote patient centered, respectful,
and compassionate care by all health professionals. The health workforce density in the region has
increased from 2.9 to 3.6 per 1000 population between 2007 EFY and 2012 EFY, indicative of an
improvement in supply and availability of health workers. Additionally, the doctor, health officer,
nurse and midwife to population ratio is 0.2,0.2,1.7 and 0.4 per 1000 population. At regional level
there is a competency test for all health professionals conducted to ensure students are graduating
with essential competencies for safe and effective practice.
3.5.3. Enhance Use of Technology and Innovations
Information Technology (IT) has the potential to improve the quality, safety, and efficiency of
health care. IT allows healthcare providers to collect, store, retrieve, and transfer information
electronically. Recognizing the benefits of information technology, the Regional Health Bureaus
introduced and tried to enhance the use of IT at all levels of the health system. Accordingly, the
following are the major initiatives that have been executed as part of enhancing the use of
technology and innovation in the health system. Regarding to this The RHB has also made a
concerted effort to transition from the two electronic HMIS to a standardized and customized
District Health Information Software (DHIS2). Besides, an upgrade has been made from DHIS2
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2.27 to DHIS2.30 version to address new requirements and integrate the new features leveraged
by the DHIS2 Community. In addition Health Net is the Virtual Private Network (VPN) was
implemented.
3.5.4. Pharmaceutical Supply Service
Pharmacy service is an essential component of health care delivery. It contributes to

improved treatment outcomes through ensuring availability and rational use of quality, safe and
effective medicines. Provision of effective pharmacy service is also crucial for early recognition
& prevention of medication errors, adverse drug events and for the prevention and containment of
antimicrobial resistance. It also promotes optimal use of meager resources thereby improving
quality of care resulting in better health outcomes. Accordingly, pharmacy services should provide
assurance that quality and safety is maintained at all stages of service provision and clients’
satisfaction is given of utmost importance.
In order to effectively, efficiently and sustainably avail affordable and quality pharmaceuticals and
medical devices to all public health facilities and alleviate supply-related challenges, the sector,
through the Ethiopian Pharmaceuticals Supply Agency - EPSA (formerly PFSA), begun
implementing the Integrated Pharmaceuticals Logistics System (IPLS) in 2002 EFY. All public
hospitals and health centers have fully implemented the electronic Health Commodity
Management Information System (HCMIS/DAGU).
Auditable Pharmaceutical Transaction and Service (APTS) is a data driven package of

interventions that enables efficient utilization of budget, enables making informed decision on
product, finance, and services; and facilitates auditing by improving transparency and
accountability. It also enables to measure human resource needs and level of efforts made by
pharmacy professionals based on workload analysis. Moreover, it increases patient knowledge on
correct dosage, and client satisfaction on pharmacy services. The regional HSTP I plan was to
increase the implementation of APTS to 100%. In EFY 2011, the implementation of APTS in the
two public hospitals was 65%. Currently, the eight health centers have also started implementing
APTS (status). The main challenges in implementing APTS were poor infrastructure of the health
facilities especially in health centers, shortage human resource and inadequate follow up by the
health facilities management and the HRHB.
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Establishing and strengthening Drug and Therapeutics Committees (DTC) at health facilities has
long been one of the capacity building focus areas so as to improve the supply management and
rational use of medicines at health facilities. The regional HSTP I plan was to increase the number
of facilities with functional DTC and DIC to 100%. Despite the presence of Drug and Therapeutics
Committees (DTCs) in all public health facilities in the region, the functionality of the committees
varies significantly among Health facilities. Inadequate follow-up and support, lack of
performance monitoring and evaluation system, training gaps, and staff turnover were the major
challenges identified for DTC performance. Therefore, there is a lot to be done so as to fully exploit
the potential benefits of health facility DTCs. Moreover, the effort being made in establishing and
strengthening clinical pharmacy service for inpatients and chronic outpatients has to be continued
as a key means of ensuring rational drug use thereby improving the quality of health care.
Beyond ensuring the availability of quality, safe and effective pharmaceuticals at health facilities,
providing pharmacy services is also an essential component of health care delivery in health
facilities. It contributes to improved treatment outcomes through ensuring rational use of
medicines. It also promotes optimal use of insufficient resources thereby improving quality of care
resulting in better health outcomes. Accordingly, pharmacy services should provide assurance that
quality and safety is maintained at all stages of service provision and clients’ satisfaction is given
utmost importance.
The development of resistance to antimicrobials that are commonly used to treat Malaria, TB, HIV,
and others is of particular concern and is an impediment in achieving Millennium and Sustainable
Development Goals. Cognizant of this issue, efforts has been made to raise awareness of
antimicrobial resistance to the community through effective communication strategies.
One of the strategy designed to improve the availability of essential medicines is strengthening of
Community Pharmacy service. It is believed that the model community pharmacy (MCP) initiative
helps in ensuring sustainable availability of medicines with affordable price, improved patient
knowledge through proper good dispensing practice, and also promoting rational medicine use.
Besides, it can also help in minimizing pharmacy professionals’ attrition through creating a better
work environment. Therefore, implementation of MCP in the region is one of the priority area in
HSTPII.
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To address the inadequate medical device maintenance capacity, which was identified as one of
the focus areas in HSTP, 1 medical device maintenance workshops has been built and equipped
with the necessary maintenance tools. Human capacity building was also conducted through
trainings and workshops. The workshops are believed to support health facilities in addressing the
pressing problem of having non-functional medical devices at all health facilities across in the
region. Paper based medical device inventory systems have been implemented almost in all health
facilities.
Major challenges in pharmaceutical supply chain
Despite the number of successes registered, many challenges have also been encountered which
undermined the ambitious targets set by the government to ensure the sustainable availability and
rational and proper use of health products. Inadequate and inaccurate quantification of need for
medical products leading to frequent stock out of essential pharmaceuticals and declining
availability of pharmaceuticals, sub-optimal coverage of EPSA’s supply compared to the growing
number of health facilities in the region.
To ensure quality, safety and efficacy of pharmaceuticals, proper environmental control (i.e.,
proper temperature, light, and humidity, conditions of sanitation, ventilation, and segregation)
must be maintained wherever drugs and supplies are stored in the premises. With this regard, the
recent survey indicated that regionally, 70% of hospitals and health centers fulfilled more than
80% of the storage conditions. Hospitals demonstrated better fulfilment of the storage conditions
as compared to health centers.
The HSTP-I had set a target of reducing pharmaceuticals wastage to less than 2% by the end of
2020. But, as indicated in the below graph, the wastage rate for both program and RDF
pharmaceuticals was 4% in 2012 EFY.
Shortage of staff, lack of awareness, lack of support from management, and lack of standards
among the hospitals which provide CPS were some of the challenges identified on the
implementation of clinical pharmacy. Shortage of budget for renovation, delay of APTS
automation software and shortage of pharmacy professional were some of the challenges on the
implementation of APTS. Concerning DTCs functionality, most committees are found to be
focusing much of their time and energy on activities that are non-strategic and which are secondary
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to the DTCs objectives. Insufficient coordination among different stakeholders and weak
monitoring and evaluation were some of the challenges in the execution of the regional
antimicrobial resistance action plan.
3.5.5. Resource Mobilization and Utilization
Increase government allocation to health

In line with the health care financing strategy in EFY1998 in Ethiopia, Harari regional health
bureau have customized regional proclamations, legislations and regulations, which have been
approved in EFY 2001. The implementation of HCF has started in EFY 2003 in all health facilities
in the region that could address access, equity and quality of health services.
Despite increasing of the health coverage, there are also many problems in the health sector.
Among these health care financing can be considered as the major one. The design and
implementation of an adequate health financing system are essential in the achievement of
universal coverage.
Ensuring Resource Mobilization was among the strategic objective of HSTPI. The trend in health
budget in the region shows a significant improvements from year to year. For example, the average
health budget allocated by government increased from 96,526,600 Ethiopian birr in 2008 E.C to
202,804,664 Ethiopian birr in 2012 E.C and increase more than 2 folds in nominal terms in five
years.
250,000,000.00
200,000,000.00
150,000,000.00
100,000,000.00
50,000,000.00
0.00
2008 E.C 2009 E.C 2010 E.C 2011 E.C 2012 E.C
Figure 20: Trends of Total Harari regional Health Budget Allocation from 2008-2012 E.C.
On average, health’s share of the total regional budget, i.e. Government expenditure on
health as percentage of total government expenditure, with some variation it was increased from
6.5 percent to 8.8 percent in the past five years which is below 15 percent, the amount the
members’ African union committed to attain in Abuja declaration in 2001.
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Health Budget as Share of Regional Budget
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
2008 2009 2010 2011 2012
Figure 21: Health Budget as share of Woreda Budget of Harari region from 2008-2012 E.C.
To solve problems on under-financing of the health sector and mobilize the required resources, the
Federal Ministry of Health of Ethiopia developed the Health Care and Financing (HCF) Strategy
in 1991E.C. After adopting with regional context, the strategy was implemented in all health
centers & Jugel hospital, since 2003 E.C.
Revenue Retention and Utilization

Revenue retention and utilization is the foundation of all HCF reform components as it Facilities'
ownership to control leakage and generates resource for quality improvements. Revenue can be
obtained from Sell of drugs and medical supplies, Fees collected from health care and diagnostic
services, beds, etc.
All health facilities in the region have been implementing this component of health care finance.
The retained revenue increases from year to year significantly. The trend in retained revenue in
Jugel hospital approves this fact. The data from this Hospital since implementation of Health care
financing increased sharply except 2012EFY and in 2010 EFY. The reason for the decline in
revenue for 2012EFY was due COVID-19 epidemic, patient flow to health facility was decreased.
Generally Revenue retention and utilization improved availability of drug in all the HFs, Improved
lab reagents and medical consumables/ equipment, utilities, etc.
Community Based Health Insurance Implementation Status

Pooling resources to cover health expenditures offers the possibility of sharing the risk of health
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costs burden across a group of people. Polling resources as cross subsidization can contribute to
equity and access if the healthy members of the pool subsidize the sick, and the wealthy members
subsidize the poor. To provide risk protection mechanisms for those the informal sectors, the
government of Harari region endorsed community-based health insurance (CBHI) 4 years back.
Finally among nine woredas, in all rural and in two urban woredas on June 2012EFY the program
was launched and members are started utilizing the service. From the total of 10,639 enrolled
CBHI members 63.2% of are paying members and the rest 36.7% are indigent members.
3.6. Strength, Weakness, Opportunity & Threat (SWOT) Analysis

Table 1 SWOT Analysis, opportunities and threats is a crucial step in the planning process. Prior
identification
ENABLERS PAINS
• Improved physical access to health services, • Sub-optimal Quality of health care service
particularly to primary health care facilities delivery
• Improved availability human resources for • Substandard HPs that are not conducive to
health. provide services, particularly skilled delivery
• Increased availability and access of service that enable as per the second generation
ambulance services, HEP.
• Availability of different Guidelines and • Low patients satisfaction
Operation standards documents. • Lack of basic infrastructures at health facilities
• Availability Integrated Supportive such as water, latrine ,electricity, internet and
supervision practice telephone
• Institutionalization of service improvement • Misuse of Ambulance services against the
approaches including BSC. national ambulance utilization guideline
• Started implementation of revised urban • Poor logistics and pharmaceutical supply
and rural CHIS management system including lack of capacity
• Initiation of different reform like for quantification
HSTQ,EHCRIG and APTS (Auditable • Lack of clear accountability mechanisms for
Pharmaceutical Transactions and Services) improving quality
• Institutionalized Health care financing • Week implementation of women development
reform (such as fee retention, private wing, arm.
service fee revision, …) • Unyielding supervision activities due to limited
• Improved internal revenue utilization for capacity of supervisory team, lower frequency of
Health service quality improvement. implementation and lack of follow up
• Strengthened Regional PHEM structure of mechanisms and accountability on findings
the Region • Poor implementation of youth and adolescent
• Establishment regional Disaster friendly services.
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Management Assistant Team(DMAT) • Low/poor capacity of maintenance for Medical

• Experience in implementing large scale equipment and not functioning of regional
successful programs ( HIV, Child health, workshop.
TB/malaria, Urban PHC reform • Poor provider attitude and low commitment of
implementation etc) health work force.
• Engagement of local populations in Health • Lack Human Resource motivation, appraisal &
facility management boards and monitoring retention strategy.
of health services by community • Poor implementation of standardized
representatives continuous professional development (CPD)
• Full implementation of DHS-2 at private programs
and public health facilities. • Poor resource mapping and mobilization
• Establishment of Different technical capacity practice
working group like RMNCAHY, Woreda • Weak financial utilization and timely liquidation
transformation and Quality improvement. at program level.
• Availability supportive regional • Weak Multispectral collaboration in many
management committee. program areas, such as Woreda transformation,
• Strong planning ,Monitoring and Malaria, WASH, NCDs and Nutrition.
Performance review practice • Poor capacity of forecasting, quantification
• Good initiation of Good governance procurement and stock management of supplies
Practice using Community score card and commodities.
• Initiation new initiative to strengthen NCD • Weak M&E & use of info for evidence-based
strategies like Car free ,Screen service of decision making, especially at lower level
NCD • Lack of conducting operational research for
• Improving Health communication through decision making and improving health care
the different media o channels. delivery services.
• Improved regulatory activities of the region. • Low utilization of evidence for decision making
• Establishment of the Deliverology unit. • Poor documentation of success and good
practice
• Poor training database utilization and
documentation.
• Poor implementation of referral system
• Slow progress of health center and Hospital
different initiatives and reforms.
• Poor implementation of woreda transformation,
CRC and Quality and Equity health services.
• Poor technical capacity of planning, monitoring,
Coordination and evaluation of health service
care delivery at woreda level.
• Poor awareness on utilization of health service at
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health center level.

OPPORTUNITIES THREATS
• Availability structural organization at • High donor dependency of the health sector
community level. • Low predictability of foreign funding
• Availability Specialized University • Cultural, traditional practices as barriers to
Hospital and health science colleges essential health services
• Availability multiple private health care • Potential for community fatigue for Women
facilities Development Army activities.
• Improving health care seeking behavior • Perception that WDAs are politically/oriented
• Increased availability of free RMNCH and rather than committed for health promotion
other cost-exempted services • Unpredictable political and security situation
• Improving road infrastructure • Market inflation influence in medical supply and
• Improved literacy rate, particularly girl’s commodities
education • Manmade and natural disasters of health
• Health Insurance Schemes implementation emergency and Outbreak
• Manageable population size • Lack of strong commitment political leaders at
• Good responsiveness of health care delivery woreda level.
of financial support from the Regional • High attrition of trained staff and frequent
BOFED. turnover of political leaders at health facilities
• Democratization and decentralization of the and woreda level.
health system
• Availability of sound health policy
• Increasing community participation
• Emerging global and National health
initiatives
• Increased number of trained health
professionals
• Availability of favorable policy, strategy
and plans for health
• Increase in Community demand for high
quality of health care
3.7. Stakeholder analysis
Stakeholders are individuals, organizations or agencies that could influence or be influenced

positively or negatively during implementation of HSTP-I. Stakeholder analysis process of
analyzing the essence, interests, behaviors, and the nature and level of impact brought about by
these stakeholders. The degree of influence from stakeholders varies depending on their span of
control over the allocation of resources; level of political power; scope of participation in the
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sector; and range in the use of services provided by the sector.
The attainment of missions and objectives of HSTP- II is largely dependent on the collective efforts
and roles played by the different stakeholders. Therefore, stakeholder analysis in HSTP-II is a
critical issue that helps to define the boundaries of all actors in the health system; clarify
contributions expected from each actor; and describe areas of possible collaboration to create
synergy to achieve the strategic objectives set in HSTP-II
Table 2: Stakeholder Analysis of Harari regional Health Bureau

Stakeholders/ Behaviors We Their Institutional
Their Needs Resistance Issues
collaborators Desire Influence response
• Community • Ownership • Access to • Dissatisfaction • High • Ensure
• Healthy life quality of • Option to community
style health care unsafe participation
• Good health • Empowerment, alternatives • Improve
seeking • Transparency • Underutilization Community
behavior and • Poor mobilization
• Participatory Stewardship Participation and awareness
• Information and ownership Creation
• Improve
Quality,
equitable
service
• Regional • Ratification • Implementation • Organizational • High • Put in place
Governments(Regional proclamations, of policy, restructuring strong
Councel,Standing etc proclamations, • Administrative monitoring and
Committee and • Resources etc measure evaluation
Regional Cabinet) allocation • Equity & system and
• Monitoring quality health comprehensive
,evaluation care capacity
and support • Timely Plan building
• Priority for and Reports mechanisms
Health
• Health in all
policy
• Woreda • Strong follow • Capacity • Lack of on time • High • Preparation of
Administrative up and support building planning and WBP
• Resource and • Supportive report • Contentious
logistic supervision • Poor review meeting
allocation with feedback commitment • Improve
• Timely • Supply and • Competency institutional
Planning and commodity gap capacity
report support • Poor building
• Community implementation • Taking
mobilization of planned administrative
• Active activities measure based
participation on performance
and
collaboration
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• Line in sectors (Office • Intersect oral • Evidence-based • Fragmentation • Medium • Collaboration
of Education, Finance, collaboration plan(MOU) • Dissatisfaction • Transparency
Water,Manucipality, • High level of • Reports • Considering • Advocacy and
Women’s Affairs, commitment • Effective and health as low capacity
Agriculture, Labor • Law efficient use of priority building
social affair ,etc) enforcement resources & • Poor
• Health in all coordination commitment
policy • Technical
support
• Development • Harmonization • Financial • Fragmentation • Medium • Government
Partners/NGO and alignment liquidation • High leadership
• Participation • Accountable transaction cost • Transparent
• Additional and transparent • Inefficiency and procedures
financing system ineffectiveness • Efficient
• Technical • Involvement in • Resource resource
support planning, reduction utilization
• Transparency implementation system
& M&E • Build financial
• Coordination management
capacity
• Health proffessionals • Trained, • Technical • Lack • Medium • Policy support
training Universities Competent support collaboration and guidance
/Colleges and Ethical • Policy update • Low quality of • Follow up and
Health • Collaboration education support
professionals • Training and • Incompetent • Participation in
• Research for practicum site health curriculum
evidence professionals development
decision • Lack of
making utilizing
research for
evidence based
• Civil Society and • Technical • Quality health • Poor • Low • Awareness
Health professionals support care collaboration creation and
association. • Participation • Collaboration • Requesting for advocacy on
in license and • Advocacy wright or professional
accreditation • Resource revolution code of
• Promote support conduct
professional • Involvement in
code of planning and M
conducts &E
• Planning
alignment and
Harmonization
• The private for profit • Affordable • Partnership, • Unaffordable • Medium • Transparency,
organization health care Rules & health care Collaboration
service regulations service • Advocacy,
• Adhering with • Technical • Lack of • Law
rule and support and adhering law enforcement
regulation Guidance and regulation • Policy support
• Quality of • Enabling and enabling
health care environment environment
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• Civil servants • Commitment • Conducive • Dissatisfaction • Medium • Developing
• Discipline environment • Low Motivational
/ethical • Transparency productivity • and incentive
• Proactive • Promotion • Attrition package
participant • Capacity
building
• Recognition
Chapter 4: Health Sector Transformation Plan II: Objectives, Targets and

Strategic Directions
4.1. Vision:
To see a healthy, productive and prosperous society in the region
4.2. Mission:
To promote the health and wellbeing of the region’s society through providing and
regulating a comprehensive package of health services of the highest possible quality in an
equitable manner
4.3. Values:
▪ Community first
▪ Integrity, loyalty, honesty
▪ Transparency, accountability and confidentiality
▪ Impartiality
▪ Respecting Law
▪ Be a role Model
▪ Collaboration
▪ Professionalism
▪ Change/Innovation
▪ Compassion
4.4. Objectives
Objectives are operationally defined as high level result statements, equivalent to goal, that leads
to the achievement of the vision of the sector. They are not expected to be SMART; they will be
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measured through targets stated under the “targets Section”.
The overarching objective of HSTP II is to improve the health status of the region’s population
through realization of the following objectives:
• Accelerate progress towards Universal Health Coverage
• Protect people from health emergencies
• Woreda transformation
• Improve health system responsiveness
Improve health status of the population
This objective pertains to ensuring that people live longer healthy lives by reducing the causes of
premature deaths including maternal and childhood health conditions, unhealthy lifestyles,
accidents; expanding access to high-quality health care for all and ameliorating the effects of the
social determinants of health. It is about ensuring all people have quality and long life. In addition,
the objective embraces the inclusion of all segments of the population irrespective of gender, age
groups, places of residence, geographical areas, level of economic status, education, or other equity
dimensions. It aspires that no one should be left behind.
Accelerate progress towards Universal Health Coverage
This objective is about accelerating the progress towards attaining effective coverage of essential
health services and protecting people from financial hardship without leaving no-one behind.
Building upon the long-term determination and achievements of the health sector and aligned with
SDG3, HSTP II aspires to attain UHC through increasing effective coverage of essential health
services by 2030.
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This objective ensures the achievement of the following three components of UHC to all groups
of the population:
• Essential service availability: The Government of Ethiopia has revised its essential health
service packages (EHSP) in 2019. HSTP II intends to ensure that all the components of
care and all the essential interventions are available at the respective service delivery levels,
mainly at the primary health care level, with an acceptable level of quality.
• Essential service coverage: HSTP II intends to ensure that all individuals and
communities receive services they need. Effective coverage combines three widely used
components of need, utilization, and quality of healthcare interventions and is a relevant
and actionable measure for tracking progress towards achieving UHC.
• Financial risk protection: This is a key component of UHC, which is defined as access
to all needed quality health services without being exposed to financial hardship. HSTP II
intends to ensure that the EHSP service components are accessible and utilized by the
community without causing financial hardship to service users.
Protect people from health emergencies
This objective refers to improving health security through protecting the public from the impact of
public and medical (routine) health emergencies caused by human made and natural disasters,
conflicts, recurrent and unexpected disease outbreaks and epidemics, accidents, emergencies due
to infectious or non-infectious causes and new health threats. It also includes safeguarding the
public from cross-border health problems and ensuring the health security of the population.
Public health emergency services mainly focus with the preparedness, prevention, detection,
management and recovery of all public health emergencies, including disease outbreaks,
nutritional emergencies and health consequences of natural and human made disasters. Medical
emergencies include any medical problems that could cause death or permanent injury if not
treated quickly. These emergencies can arise due to infectious, non-infectious disease conditions
or due to trauma that requires stabilization and immediate medical care. To this end, establishing
and implementing emergency, trauma and intensive care medical services is necessary. Protecting
the public from both public health and medical emergencies requires the capacity and resource to
ensure preparedness, prevention, early detection and response. Moreover, post emergency
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assessment, interventions and documenting lessons are important.
Woreda transformation
Woreda transformation was one of the transformation agenda during HSTP-I. During
implementation, it was realized that it is a result of all other transformation agendas. During this
HSTP-II, it is now more emphasized and considered as one of the major objectives of HSTP-II. A
transformed Woreda, operationally defined here as “a Woreda with a transformed district health
system”, is a result of improving key health system investments and implementing high impact
health interventions. A transformed Woreda is expected to have a leadership with an accountable
and transparent system that create an enabling environment to translate plans into results. It will
have the capacity to nurture a meaningful community participation and strives to meet the needs
of the people. It will make evidence informed decisions based on the generationand use of quality
data that is supported by health technologies. Its health workforce that provide health services are
competent, motivated and compassionate. To accelerate progress towards universal health
coverage in the Woreda, health services in a transformed Woreda are provided in an equitable and
quality manner with improved health service coverage, improved service utilization and better
health outcomes. Moreover, transformed Woredas implements health financing strategies that
reduces financial risks of the population.
Therefore, a transformed Woreda will have the following key attributes:

- High performing PHCUs
- Better community engagement
- Decisions made based on evidences
- Motivated, Competent and Compassionate Health Workforce
- Health care financing reforms that improves health financing in the Woreda are
implemented
- Implementation of Woreda Management standards and reforms
Improve health system responsiveness
Health system responsiveness refers to the level to which health services are responsive to the
needs and expectations of targeted individuals and communities. It is about respecting and
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responding to preferences, and values of individuals and communities during health service
provision ensuring that beneficiaries’ values dictate health service delivery processes.
Responsiveness is not about how the system responds to health needs, which shows up in health
outcomes, but of how the system performs relative to non-health aspects, meeting or not meeting
a population’s expectations of how it should be treated by providers of prevention, care or non-
personal services.
Health system responsiveness includes respecting dignity, privacy, non-discrimination, autonomy,
confidentiality, and clear communication; user focus: choice of provider, short wait times, patient
voice and values, affordability, and ease of use. The results of the objective are improving
satisfaction and trust, which will in turn improve service uptake and recommendation of services
to others.
4.5. Targets
HSTP-II targets are set by considering baseline, previous trend, burden of disease, national and
international standards, efficacy of technologies, anticipated availability of resources and others.
One Health tool and wider consultation with experts is used during the target setting process. The
targets are set for the year 2017 EFY (2024/25). The performance of HSTP-II will be measured
against these targets.
General
1. Increase healthy life expectancy at birth from 65.5 to 68
2. Increase UHC index from 0.43 to 0.58
3. Increase proportion of clients satisfied during their last healthcare visit (Client satisfaction
rate) from 68.9% to 85%
Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health and Nutrition
4. Decrease MMR from 401 per 100,000 live births to 279
5. Decrease under 5 mortality from 72 per 1000 live births to 43 per 1000 live births
6. Decrease infant mortality from 57 per 1000 live births to 35 per 1000 live births
7. Decrease neonatal mortality from 34 per 1000 live births to 21 per 1000 live births
8. Increase contraceptive prevalence rate (CPR) from 30.3% to 50%
9. Increase proportion of pregnant women with four or more ANC visits from 38.8% to 85%
10. Increase deliveries attended by skilled health personnel from 64.9% to 100%
11. Increase early PNC within two days coverage from 45.2% to 95%
12. Decrease cesarean section rate from 21% to 15%
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13. Decrease still birth rate from per (1,000) 47 to 20

14. Increase proportion of newborns with neonatal sepsis/Very Sever Disease (VSD) who
received treatment from 26.2% to 45%
15. Increase proportion of asphyxiated newborns resuscitated (with bag & mask) and survived
from 41% to 85%
16. Increase proportion of under five children with pneumonia who received antibiotics from
60% to 78%
17. Increase proportion of under five children with diarrhea who were treated with ORS and
Zinc from 44% to 90%
18. Increase pentavalent 3 coverage from 52.8% to 100%
19. Increase second dose of measles containing vaccine (MCV2) measles coverage from 74%
to 100%
20. Increase full vaccination coverage from 45.8% to 100%
21. Reduce mother to child transmission rate of HIV from 13.4% to <5%
22. Decrease teenage pregnancy from 12.5 % to 7%
23. Decrease stunting prevalence in children aged less than 5 years from 34.7% to 25%
24. Decrease wasting prevalence in children aged less than 5 years from 4.2% to 3%
Disease Prevention and Control

25. Increase proportion of people living with HIV who know their HIV status from 99% to
100%
26. Increase percentage of people living with HIV who receives ART (ART coverage from
those who know their status) from 96% to 100%
27. Increase percentage of people receiving antiretroviral therapy with viral suppression from
97% to 100%
28. Maintain TB case detection rate at100%
29. Increase TB treatment success rate from 99% to 100%
30. Increase number of DR TB cases Detection from 11 to 15
31. Maintain grade II disability among new cases of leprosy at 0
32. Maintain malaria mortality rate at 0/100,000 Population at risk.
33. Reduce incidence of malaria from 6 per 1000 population at risk to 2
34. Reduce risk of premature mortality from Major Non-Communicable Diseases from 18%
to 14%
35. Increase the proportion of women 30-49 years screened for cervical cancer from 2% to
40%
36. Decrease mortality rate from all types of injuries (per 100,000 population) from 79 to 67
37. Increase proportion of hypertensive adults diagnosed and know their status from 40% to
60%
38. Increase proportion of hypertensive adults whose blood pressure is controlled from 83% to
90%
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39. Increase proportion of DM patients whose blood sugar level is controlled from 92% to
100%
40. Increase treatment coverage of severe mental health disorders (Psychosis 20% to 50%;
depression from 5% to 30%; bipolar management from 20% to 50%; epilepsy management
from 60% to 80%; Substance Use Disorders (SUD) from 1% to 20%).
41. Increase cataract surgical rate ( per 1000,000 population) from 44 to 89
Health Extension Program
42. Increase proportion of Model households from 77% to 80%

43. Increase proportion of health centers and primary hospitals providing emergency surgical
care from 0% to 50%
44. Increase proportion of high performing Primary Health Care Units (PHCUs) from 0% to
80%
45. Increase proportion of health posts providing comprehensive health services from 0 to 30%
Hygiene and Environmental Health
46. Proportion of households having basic sanitation facilities from 78.7% to 85%
47. Increase proportion of kebeles declared ODF from 64.7% to 95%
48. Increase proportion of households having hand washing facilities at their premises with
soap and water from 5.5% to 45%
Medical Services:
49. Increase outpatient attendance Per capita from 1.2 to 2.5

50. Increase bed occupancy from 45% to 75%
51. Proportion of patients with positive experience of care from 33% to 54%
52. Reduce institutional Mortality Rate from 4% to <1%
53. Increasing percentage of component production from total collection from 20% to 65%
54. Increase ambulance response rate from 85% to 100%
Public Health Emergency Management

55. Increase health security index from 0.63 to 0.78
56. Proportion of epidemics controlled within the standard of mortality from 85% to 100%
Health System Investments (Financing, Pharmaceuticals & Supply, Information, leadership,

Regulatory, HR and Infrastructure)
57. Decrease out of Pocket Expenditure as a share of total health expenditure from 31% to
23.2%
58. Increase general government health expenditure (GGHE) as a share of general government
expenditure (GGE) from 8.07 % to 12%
59. Increase total health expenditure per capita (USD) from 33 to 59.9
60. Reduce incidence of catastrophic health expenditure from 2.1% to 1.8%
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61. Increase proportion of eligible households enrolled in Community Based Health Insurance
(CBHI) from 35 % to 80%
62. Increase proportion of eligible formal sector employees covered by Social Health Insurance
(SHI) from 0 to 100%
63. Increase availability of essential medicines at health facility level (public and private) from
80% to 90%
64. Increase report completeness from 94% to 100%
65. Increase proportion of health facilities that meet data verification factor within 10% for
selected indicators from 0% to 92%
66. Increase proportion of births notified (from total births) from 80% to 95%
67. Increase proportion of deaths notified (from total deaths) from 53% to 70%
68. Proportion of Primary Health Care facilities implementing Community Score Card from
75% to 100%
69. Decrease the prevalence of unsafe and illegal food products in the market from 40% to
30%
70. Decrease percentage of substandard and falsified medicine in the market from 8.6% to 6%
71. Increase health workers’ density per 1000 population from 3.6 to 4.5
72. Decrease Health care workers’ attrition rate from 6.2% to 4.5%
73. Increase proportion of health facilities with basic amenities (Improved water supply from
65% to 90%, Electricity from 47% to 90%, Improved latrine from 61% to 90%, Basic
healthcare waste-management services from 58% to 90% )
74. Increase proportion of health facilities implementing compulsory Ethiopian health facility
standard from 53% to 80%
4.6. Strategic Directions (Implementation Strategies)
For this strategic plan, 14 strategic directions are identified and each is described along with their
major strategic initiatives.
1. Enhance provision of equitable and quality comprehensive health service
2. Improve health emergency and disaster risk management
3. Ensure community engagement and ownership
4. Improve access to pharmaceuticals and medical devices and their rational and proper use
5. Improve regulatory systems
6. Improve human resource development and management
7. Enhance informed decision making and innovations
8. Improve health financing
9. Strengthen governance and leadership
10. Improve health infrastructure
11. Enhance digital health technology
12. Improve traditional medicine
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13. Ensure integration of health in all policies and strategies

14. Enhance private engagement in the heath sector
4.7. Description of the Directions (Implementation Strategies) and Key /Major

Activities
4.7.1. Enhance provision of equitable and quality comprehensive health services
Description
This direction is about the provision of health promotion, disease prevention, curative,
rehabilitative and palliative care services in an equitable and at the highest possible quality. These
comprehensive services deal with the triple burden of diseases and are meant to meet the ever
growing needs of people for health services resulting in healthy and productive society. Emphasis
will be given to tackle not only the common communicable diseases, but also on reducing the
alarmingly increasing rate of NCDs and injuries.
Taking in to account the national PHC approach as a foundation of the health system, a full
spectrum of services will be provided based on the recently revised EHSP in an integrated manner
across all level of health care delivery system. Increasing demand for and the provision of the
EHSP to the general population and vulnerable groups is the critical step in ensuring our progress
towards UHC. Decentralization of more essential health services to the comprehensive Health
Posts and integration of HEP packages to all primary level health facilities will play critical role
in this regard.
During health service provision, the following key interventions/activities will be considered:
Demand creation (through BCC, advocacy, social mobilization), provision of services through
different modalities (static, outreach, mobile…), uninterrupted supply of essential commodities,
referral linkage and Service integration when appropriate, which can apply for most programs
stated below.
4.7.1.1. Reproductive, Maternal, Neonatal, Child, Adolescent and Youth

Health-Nutrition (RMNCAYH-N)
These program areas encompass health services provided through the course of life cycle including
adolescent health, preconception and pregnancy care, child birth, child health and nutrition
services. The RMNCAYH-N package contains seven major program areas, namely a). Family
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planning and reproductive health, b). maternal health, c). prevention of maternal to child
transmission of HIV, d). neonatal and child health, e). immunization, f). adolescent and youth
health and g). nutrition. The details of the interventions, strategies and activities are described in
each of the program areas below.
Family Planning and Reproductive Health

Major Strategic Initiatives
- Increase demand for quality contraceptive service through BCC and other demand creation
interventions
- Universal access to quality and comprehensive right based family planning information
and services at all levels of health care delivery system with emphasis to post-pregnancy
family planning services
- Expand family planning and sexual and reproductive health services to workplaces, private
health facility, people with special need, universities and colleges and in humanitarian
settings
- Improve access to screening and management for SRH and medical problems, such as
cervical cancer, infertility, STI
- Strengthen Prevention and management of gender based violence and child marriage
- Expand access to quality comprehensive abortion care service
Maternal, Neonatal and Child Health

Major Strategic Initiatives:
- Provide quality and equitable antenatal, labor, delivery and postnatal care services mainly
through introduction of at least one ultrasound service for all pregnant women before 24
weeks of gestation, expansion of maternity waiting rooms, implementation of 24 hours stay
after delivery and improving community engagement in making transport available
- Improve access to comprehensive emergency maternal and newborn care through
expansion of OR blocks, equipping and staffing of health facilities
- Improve referral network for women and New-born babies during complications, in a way
that can access comprehensive services in 30 minutes
- Strengthen maternal and perinatal death surveillance and response system
- Strengthen prevention and management of obstetric fistula and pelvic organ prolapse
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- Strengthen and expand advanced neonatal care, NICU and Essential New-born Care
(ENBC) services
- Strengthen & expansion of services for low birth weight and preterm babies including
Kangaroo Mother Care (KMC)
- Strengthen prevention of mother to child transmission of HIV (PMTCT)
- Strengthen and expand contextualized Integrated Community Case Management of New-
born & Childhood Illness (ICMNCI) and quality Integrated Management of Newborn and
Childhood illnesses (IMNCI) services
- Introduce and scale-up Early Childhood Development (ECD) implementation through a
multisectoral collaboration approach
Immunization
- Design and implement innovative strategies to build demand, community participation and
BCC (Build trust, confidence and resilient demand for immunization services)
- Improve effective coverage of routine immunization to achieve Universal Immunization
through data driven and evidence based strategies such as implementation of intensified
outreach strategies, RED/C approach, vaccination of missed children during school entry,
expansion of services (such as HPV) and others
- Strengthen vaccine supply chain (planning, forecasting, quantification, CCE) in order to
implement effective vaccine management strategies at all levels
- Enhance and sustain the accelerated vaccine-preventable diseases (polio, measles, MNT)
control, elimination and eradication initiatives
- Introduce and rapidly scale up (achieve high coverage and geographic reach) new vaccines
into the immunization program (HepB birth dose, Yellow Fever, Meningitis A, Measles
and Rubella (MR) etc…)
- Strengthen the second year of life (2YL) immunization service delivery
- Strengthen immunization integration with other Health services to ensure access and avoid
Missed Opportunity for Vaccination (MOV)
- Strengthen VPD and AEFI surveillance to rapidly detect and respond to outbreaks and
enhance immunization safety and Adverse Event Following Immunization (AEFI)
detection and management and Communication
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Adolescent and Youth Health

- Expand provision of comprehensive sexual and reproductive health information,
counseling and services
- Support and facilitate the introduction/adaptation, testing and scale up of high impact,
youth focused, youth friendly and innovative interventions to improve effective and person
centered care
- Expand provision of comprehensive, sexual and reproductive health information,
counseling and services; and access to psycho-social support for adolescents
- Promotion of healthy behavior among adolescents (e.g. nutrition, physical activity, no
tobacco, alcohol or substance use)
- Implement interventions to prevent, detect and manage sexual and other forms of gender
based violence and harmful practices such as child & forced marriage
- Implement parenting skill enhancement program and expand access to life skill training for
adolescents and youth
- Strengthen the integration of adolescents and youth health with school health initiatives
and programs
Nutrition
- Enhance food and nutrition information, communication, coordination, and dissemination
- Scale-up comprehensive integrated nutrition services(CINS) and “the first 1000-days
initiative”
- Implement infant feeding programs in all facilities such as Baby Friendly Hospital
Initiative (BFHI)
- Strengthen and scale up deworming and micro-nutrient supplementation (such as Vitamin
A supplementation) to children, and women in need including pregnant and lactating
women
- Strengthen and expand nutritional screening of children, pregnant and lactating women,
and HIV positive individuals and management of moderate and severe malnutrition
- Strengthen nutrition service delivery for communicable and non-communicable diseases
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- Expand and scale-up lessons from the Seqota declaration in collaboration with other
sectorto end child under-nutrition
- Strengthen multi-sectoral coordination linkage and Nutrition coordination platform across
food and nutrition policy implementing sectors
4.7.1.2. Prevention and control of communicable diseases
Description:
This strategic direction focuses on the prevention, control and management of major
communicable diseases such as HIV, malaria, Tuberculosis, Leprosy and Hepatitis. High impact
interventions aimed at reducing the burden of these communicable diseases will be given adequate
emphasis with appropriate focus on health promotion and disease prevention. In addition,
screening, diagnosis and treatment of communicable diseases will be strengthened.
HIV
- Intensify combination prevention interventions (structural, biomedical and behavioral)

targeting key and priority populations and high incidence geographic localities
- Scale-up pre-exposure prophylaxis for population groups at substantive risk and
experiencing high levels of HIV incidence and strengthen Post-Exposure prophylaxis
- Strengthen case finding through targeted HIV testing especially for KPP using innovative
approaches (such as index case testing, partner notification, social network services and
HIV self-test) and expand the service to health posts and community level.
- Implement Fast-Track Cities Initiative against HIV
- Strengthen implementation of ART regimen optimization & rollout of third-line ART
treatment
- Expand and strengthen viral load testing services
- Strengthen HIV prevention and control mainstreaming and social enablers that includes
gender based violence prevention and mitigation, economic empowerment of women,
elimination of stigma and discrimination, empowerment of communities to respond to the
HIV program
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Hepatitis
- Initiate and expand hepatitis testing and treatment service at hospitals and health center and
also scale up viral load testing
- Strategize program implementation toward the elimination of viral Hepatitis by 2030
- Integrate viral hepatitis service into the existing HIV/SRH, TB, MNCH services and create
linkage between viral hepatitis services with blood safety and infection prevention
activities
Tuberculosis and Leprosy

- Enhance implementation of integrated, patient-centered TB prevention and care (Shift from
a TB control to Ending the TB epidemic mode)
- Strengthen TB and leprosy case finding, contact tracing and screening services
- Strengthen TB/DR-TB diagnostic services, including sample referral network and access
to a more sensitive screening tools such as chest X-Ray and GeneXpert
- Enhance provision of Community TB screening and treatment support services
- Engage private facilities in TB diagnosis and treatment services
- Strengthen and expand TB prevention therapy for HIV+ cases and household contacts
- Strengthen and expand universal drug susceptibility testing services
- Strengthen and expand drug-resistant TB treatment initiating and follow up sites
- Strengthen and expand house-to-house screening, passive case finding and contact
investigation of leprosy cases
- Capacity building of clinical and laboratory diagnosis, treatment and disability prevention
of Leprosy
- Strengthen rehabilitation services for people with a major disability
Malaria
- Strengthen malaria surveillance and epidemic response
- Accelerate efforts towards sub-national malaria elimination
- Strengthen malaria laboratory investigation through microscopic diagnosis and RDT
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- Strengthen vector control activities through community interventions, targeted indoor

residual spraying (IRS), larviciding and maintaining universal coverage of long-lasting
insecticidal nets (LLINs)
- Introduce long-acting anti-malaria drugs to prevent transmission of malaria among
seasonal migrant workers
- Identify and implement potential safe disposal mechanisms for obsolete/expired chemicals
and LLIN plastic covers
4.7.1.3. Prevention and Control of Neglected Tropical Diseases (NTD)

Description:
This direction focuses on implementation of appropriate interventions to prevent and control
neglected tropical diseases in Ethiopia, resulting in the elimination of many. It includes
Schistosomiasis, Soil Transmitted Helmenthiasis (STH), Onchocerciasis, Podoconiasis,
Lymphatic filariasis, Leishmaniasis, Trachoma, scabies and snake bite. Through service
integration, multisectoral approach and large-scale treatment campaigns, also known as mass drug
administration to populations will strengthen and continue in HSTP II. Priority interventions
include preventive chemotherapy, transmission control, Water, sanitation and hygiene (WASH),
innovative case management, prevention of zoonotic diseases and vector ecology management. In
addition, service integration, multi-sectoral approach and large-scale treatment campaigns or mass
drug administration to prevent & control NTDs will be strengthened.
- Advocate multi-sector engagement and promote community awareness and mobilization
for NTD prevention and control
- Coordinate the implementation of WASH and NTD interventions at all levels
- Strengthen integrated environmental management including vector control interventions
- Clear TT surgery backlog cases and build sustainable institutional capacity
- Strengthen integrated Mass Drug Administration (MDA) and implement innovative case
management interventions for NTDs
- Enhance veterinary public health interventions such as rabies vaccination for canines and
rabies post-exposure prophylaxis
- Sustain Guinea worm diseases surveillance and eradication interventions
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4.7.1.4. Prevention and control of non-communicable diseases
Description:
The priority NCD prevention and control interventions are targeted to the reduction of risk factors
for the major non-communicable diseases and promotion of healthy life style. In addition,
reduction of premature mortality from NCDs is one of the focus areas of this strategic direction.
Priority will be given to prevention of NCDs and injuries, treatment of childhood cancer, early
treatment of breast cancer, basic palliative care, treatment of acute pharyngitis in children to
prevent rheumatic fever and implement high priority multi-sectoral interventions.
Mental health is also identified as one of the top priorities in this HSTP II. Prevention and
management of common mental health problems such as depression, bipolar disorder, and
schizophrenia will be given a due attention. The major interventions that will be implemented
include social mobilization, behavioral change communication, strengthening social support,
capacity building, expansion of access to medication, cognitive therapy and social rehabilitation.
Non-Communicable Diseases (NCDs)

- Facilitate the development and enforcement of comprehensive policies and legislations to
address the rising burden of unhealthy diet and khat consumption
- Establish a multi-sectoral coordination mechanism for prevention and control of NCDs and
their risk factors
- Implement awareness-raising programs on NCDs and risk factors for the general public, at
workplaces and schools
- Enforce the implementation of articles on tobacco and alcohol
- Promote institutionalization of interventions on the reduction of exposure to environmental
and occupational risk factors for NCDs
- Scale-up programs for primordial, primary and secondary prevention of Rheumatic heart
disease
- Expand implementation of interventions on NCDs and risk factor to primary health care
through task shifting, task sharing, and improved referral networks
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- Support health facilities to fulfill minimum standards to deliver screening, diagnosis,

treatment, and care services for NCDs and risk factors
Mental Health
- Facilitate the development of mental health legislation to protect the rights of people with
mental health conditions
- Strengthen integration and coordination of mental health care implementation and scale-
up at each level of the health system
- Advocacy, social mobilization and SBC interventions to create public awareness on mental
health and mental illnesses
- Introduce and strengthen promotion and preventive mental health services in schools, work
places, health facilities, religious and traditional treatment settings
- Expand and strengthen prevention and rehabilitation interventions against substance use,
suicide and self -harm
- Ensure availability of mental health services to vulnerable groups or special populations
- Expand access to rehabilitation services for substance abuse
- Ensure a dependable and affordable supply of essential medicines and diagnostic
technologies for mental health and access to psychosocial care at community level
4.7.1.5. Hygiene and environmental health

Description:
This focuses on impacting environmental determinants of health and thereby promoting health,
preventing diseases and other conditions and improving quality of health services. It encompasses
implementation of multi-dimensional interventions to ensure adequate and safe sanitation;
personal hygiene; water safety and quality; food hygiene and safety; indoor air quality; healthy
living environment; occupational health safety; and liquid and solid waste management. It also
includes contributing to building climate-resilient health system and water, sanitation and hygiene
(WaSH) in institutions including health care facilities and emergencies situation that requires
concerted efforts of various sectors. The interventions will be implemented at various levels and
settings including at household, community, health care facilities and other institutions level; and
in rural and urban areas.
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- Design and implement context and culturally tailored behavior change approaches and
interventions to improve universal hygiene, sanitation, and environmental health practices
- Develop and implement an effective and sustainable market-based system for hygiene,
sanitation and environmental health services
- Design, promote and implement inclusive hygiene, sanitation and environmental technology
options
- Ensure and fulfill water, sanitation and hygiene services at all health facilities
- Promote and monitor water, sanitation and hygiene services and practices in all institutions
- Implement regular and sustainable water quality/safety monitoring and surveillance system
- Implement interventions to make the health system climate-resilient
- Strengthen occupational health and safety
- Promote environmental pollution prevention
- Implement Menstrual Hygiene Management interventions
- Strengthen Infection prevention and control interventions
- Strengthen hygiene and environmental health institutional arrangement and implementation
capacity
- Strengthen WASH intra-sectoral and multi sectorial integration and coordination
4.7.1.6. Health extension and Primary Health Care
Description:
This program encompasses two major areas that are platforms to deliver PHC services to accelerate
progress towards UHC; namely the HEP and service delivery at health centres. In this strategic
period, the Health Extension Program (HEP) will continue to be an effective program for
community participation and an effective vehicle or service delivery platform to reach individuals,
families and communities with a comprehensive package of PHC services. As such, huge emphasis
will be given to scale up the implementation of the optimized HEP to address the evolving
community needs for quality health services and fully embrace emerging public health challenges.
In addition, the program will be contextualized to fit urban, rural, and pastoralist settings.
Community quality improvement systems and health posts level reforms will also be implemented
in this strategic period.
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In addition, it also focuses on improving the readiness of the PHCUs to provide quality care to its
catchment population. Therefore, enhancing the PHC management capacity to provide support and
oversight to both the clinical and community based activities; improving quality and expanding
package of services; implementing reforms and collaborative learning platforms; expanding
surgical services at the health centres; ensuring strong PHCU linkage and strengthening multi-
sectoral collaboration will be given huge focus.
- Adopt and scale up optimization of the health extension program
- Develop a regional HEP roadmap
- Expand services provided through the HEP to meet UHC requirements and community
needs
- Devise and implement strategies to a more inclusive HEP service provision (women, men,
children and youth)
- Implement different reforms and standards to ensure quality health service at PHCU level
- Enhance the implementation of collaborative platforms including EPAQ, twinning
partnerships, catchment area mentoring
- Strengthen and expand family health team approach in urban settings
- Strengthen and expand mobile health team approach for pastoralist and semi-pastoralist
settings
- Accelerate creation of model kebeles and high performing primary health care units.
- Improve the capacity of the woreda health system leadership
- Develop and implement innovative SBCC interventions fitting the changing needs and
various contexts at community and facility levels
- Increase access to health information and services at schools, youth centers and other
public institutions
- Introduce emergency obstetric and surgical care services at selected health centers
4.7.1.7. Medical Services
Description:
During HSTP II, the sector strongly aspires to create a medical system in which comprehensive
medical services including pre-facility care. These services will be made safe, effective,
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efficient, equitably accessible and internationally acceptable through designing and implementing
various strategic interventions. This strategic direction includes clinical services, emergency and
critical care, quality of health services, blood transfusion services, laboratory and diagnostic
services.
Regarding clinical services, preparedness of health facilities to provide high-quality clinical care
is important to improve health outcomes of the population and develop community trust. Emphasis
to standardization of diagnostic and treatment of curative, rehabilitation and palliative services in
health facilities will continue to be the focus during HSTP II. Standardized and improved clinical
care leadership, innovative financing in health facilities, improved surgical and anaesthesia care
availability and accessibility, improved rehabilitative service accessibility and quality of care,
medical tourism, introduction and scale-up of I-CARE will also be priority strategic areas.
Emergency care system is a critical component of national health systems in low- and middle-
income countries. It provides an integrated platform for delivering accessible, quality time-
sensitive health care services across the life course. Due to the rapid urbanization, motorization,
industrialization, and rapid population growth in big cities, the demand for emergency, trauma and
critical care services in different health sectors is rising in Ethiopia and worldwide. The services
range from scene care to facility care with an appropriate referral and communication to maintain
continuum of care. Establishing and strengthening emergency, trauma and intensive care medical
services is essential for ensuring timely care for the acutely ill and injured. Besides meeting the
everyday health needs of the population, a well-organized, prepared and resilient emergency care
system has the capacity to maintain essential acute care delivery throughout a mass event, limiting
direct mortality and avoiding secondary mortality altogether. During emergencies that require a
public health response, links will be made with the national PHEM system to respond in a
coordinated and integrated manner.
Blood transfusion service is a life–saving intervention that involves mobilization, recruitment and
selection of blood donors, use of appropriate blood collection procedure, processing and testing of
blood units and cold chain maintained storage and transportation, issuing and transportation of
safe blood units to health facilities. It also includes compatibility testing and administration to
patients. To meet the ever-increasing demand for quality blood and blood products, strengthening
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volunteer blood donation program, locating blood banks across the country and consolidation of
key blood transfusion service functions, strengthening coordination of blood transfusion service,
strengthening quality management system to the level of accreditation and appropriate use of blood
and blood products in health facilities will be implemented.
Regarding laboratory service, the health sector will continue to improve access to quality
laboratory service through laboratory capacity buildings, quality assurance programs,
infrastructure development and maintenance and expansion of basic and advanced lab services at
health facilities. Moreover, Laboratory Quality Management System (LQMS), step-wise
accreditation process, preventative and curative equipment maintenance and Laboratory
Information System (LIS) will be emphasized.
Clinical services
- Improve health service availability and readiness based on EHSP
- Expand and improve accessibility of services such as ophthalmology service, basic dental
service, dermatology service, basic mental care and other specialty services
- Expand the availability and accessibility of high quality surgical and anesthesia care
- Expand tertiary medical care (specialty and sub specialty programs)
- Build clinical governance and leadership capacities of health facilities
- Improve and standardize health facility Leadership and Governance
- Implement Teaching Hospital Improvement Program
- Implement health technology (Tele Medicine, Tele pathology, Tele- radiology, Robotic
surgery, 3-D printing for prostatic supplies etc.)
- Strengthen home-based clinical care
- Strengthen accessibility & quality of rehabilitative and palliative care including pain
management
- Implement and improve geriatric care
- Intensify clinical auditing and mentorship
Pre-Facility, Emergency, trauma and critical care services

- Advocacy for emergency care systems, trauma and critical care
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- Expand and strengthen community first aid response

- Standardize and strengthen basic, advanced ambulance and pre-hospital services
- Create surge capacity for responding to emergencies and building resilience at all level
- Expand and strengthen basic and advanced critical care services
- Expand and strengthen trauma care including poisoning care
- Expand and strengthen burn care
- Standardize liaison and referral system
Blood transfusion services

- Strengthen coordination of blood transfusion services and use of blood and blood products
- Advocacy and awareness creation to increase total blood collection from voluntary non-
remunerated blood donors
- Strengthen blood donor recruitment and management including post-donation counseling
service
- Strengthen quality-assured testing for transfusion-transmissible infections, blood grouping,
compatibility testing, and component production and transport of blood
- Promote the safe and appropriate use of blood and blood products at the clinical interface
and strengthening heamo-vigilance program
- Strengthen blood transfusion quality management system covering the entire transfusion
process
- Introduce newer blood transfusion technologies
Laboratory and other diagnostic services

- Strengthen the implementation of Laboratory Quality Management System (LQMS)
- Strengthen Stepwise Laboratories Quality Improvement Process towards Accreditation
(SLIPTA) to ISO 15189 or 17025 standards
- Improve availability of national and regional lab infrastructures including Biosafety Level
Three (BSL3) capacity at the national level
- Improve lab equipment management and maintenance capabilities for preventive and
curative maintenance, and calibration services
- Equip laboratories with state-of-the-art technologies
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- Improve accessibility of essential diagnostic service (laboratory, imaging and pathology)

- Improve and strengthen access and quality to pathology services
- Improve and strengthen Imaging services including nuclear medicine
- Standardize laboratories testing capacity at each tier of the health care delivery system
- Strengthen the regional EQA program
- Introduce and expand auditable laboratory services in hospitals and beyond
- Strengthen laboratory information system (LIS)
- Enhance specimen referral linkages and networks, including backup services
- Improve the capacities of laboratory system to support surveillance of ant-microbial
resistance (AMR)
- Strengthen laboratory bio safety and bio security at all levels of laboratory system
- Improve laboratory waste management
4.7.1.8. Quality Health Care
Description:
High quality health care can be realized through: System that ensure universal health coverage that
embeds quality of care into the foundation of the health care systems; standardize and
implementing evidence-based interventions that demonstrate continual improvement; ensure that
all people with chronic conditions are able to minimize its impact on the quality of their lives;
ensure a culture, system and practices that will reduce harm to patients and resource wastes,
benchmark against similar systems that are delivering best performance, give emphasis for
continuous learning and knowledge management for improvement, and the patient and community
engagement is also of paramount importance to ensure health care quality.
Building on the gains made and to address the major health care quality challenges, emphasis will
be given to cultivate competent and companionate health care providers that are engaged to ensure
quality of care being provided to those in need is safe, evidence-based, timely, people-centred and
well communicated to the patient. Similarly, various approaches will be made to ensure that
patients and communities are engaged to optimize the health care service and improve the outcome
of care. Measurement will be made to monitor the health care quality focusing on outcome of care,
trust of the community, and effective coverage and competency of care.
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- Adopt and implement the national health care quality and patient safety strategy
- Institutionalize health care quality concept and practice
- Establish Regional quality council
- Standardize and strengthen health care quality structures and their functions
- Standardize health care and scope based practice
- Reform, redefine and standardize scopes and functions of health facilities
- Establish and strengthen quality learning collaborative platforms
- Adopt and implement support package to public and private health facilities for accreditation
- Establish quality improvement incubation hubs
- Strengthen regular quality of care measurement and response
4.7.1.9. Equity in Health service initiatives and interventions
Description:
Equity is aimed at reducing disparities between geographic areas and groups with different levels
of underlying social advantage/disadvantage (women, youth, children, the uneducated, the poor
and people with disabilities) in the provision of quality health service. While ensuring equitable
access to health services, due focus will also be given to quality planning and quality improvement
activities in the health care delivery system with provision of people-centered, efficient, effective,
timely and safe health services. It is expected that better and equitable access to high-quality health
services will lead to improvements in the health of mothers, neonates, children, adolescents and
youth, and the elderly.
Achieving universal health coverage, including financial risk protection, access to quality essential
health-care services and access to safe, effective, quality and affordable essential medicines and
vaccines for all stipulates the importance of addressing equity and ensuring that all, no matter their
geography, gender, age, wealth, education or disability status, are able attain the same high levels
of health outcomes and access to essential services. Accordingly, HSTP-II is committed to working
across the following dimensions of health equity in the region:
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- Access to and uptake of healthcare: the region will continue to scale-up access to essential
healthcare and ensure all members of society have equal access to essential health services
such as reducing physical barriers, distance, price, socio- cultural barriers.
- Difference in health status (or outcomes) such as life expectancy, mortality and nutritional
status can occur not only due to differences in health service access and uptake, but also to a
wider social, economic and environmental determinant rather (“the wider determinants of
health”) pointing to the critical importance of health promotion and the wider “woreda
transformation” agenda.
Equitable accessibility to high quality health services will then lead to improvements in the health
of the population with particular emphasis to mothers, neonates, children, adolescents and youth,
persons with disability, elderly and other vulnerable groups.

- Mainstream equity agenda across all programs and all levels of the health system
- Conduct continuous and regular health equity analysis and disseminate the findings for
intervention and policy decision
- Develop equity index dashboard and update regularly to monitor health equity status
- Provide CBHI coverage to all households under the poverty line to ensure financial protection
of the poor
- Accelerate the roll-out of contributory and non-contributory community-based health
insurance to financial protection of the poor and general population against catastrophic out of
pocket health expenditures there by driving the UHC target
- Implement contextualized urban and rural HEP to better reach hard to reach and vulnerable
populations
- Implement alternative health service delivery modalities (such as mobile health, private
engagement, application of technologies...) to reach hard-to-reach and special need
communities.
- Provide targeted technical and financial support to strengthen health planning, implementation
and health systems capacity areas with the lowest capabilities
- Explore financial modalities for better targeting populations with the greatest health needs of
low performing areas, the most vulnerable groups and incentivize stronger performance
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- Enhance multi-sectoral coordination among line ministries and other relevant sectors that have
stake on health equity at all levels
- Enhance health workers’ retention and motivation mechanisms
- Address health infrastructure and basic amenities (water, electricity, communication
technologies, road access …) needs of health facilities for the provision of quality health
services
4.7.2. Improve public health emergency and disaster risk management
Description:
This strategic direction is about public health emergency and disaster risk management that
includes the process of effective and timely anticipation, prevention, early detection, rapid
response, control, recovery and mitigation of any crises, which directly or indirectly impact the
health, social, economic and political wellbeing of the society. The range of threats to public health
faced by countries worldwide is broad and highly diverse and includes infectious disease
outbreaks, food and water contamination, chemical and radiation contamination, natural and
technological hazards, wars and other societal conflicts and the health consequences of climate
change.
The health sector requires strong coordination, relationship and capacities with other sectors to
implement a spectrum of emergency risk management measures at the community, regional,
national, and international levels. During HSTP II, emphasis will be given to strengthen the
capacity for preparedness, detection, prevention, response and recovery to all health emergencies
and disasters. An integrated approach of public health emergency management and clinical
emergency care reduces the impact of all these conditions. The end result of this strategic direction
is minimizing the occurrence and consequences of public health emergencies and disasters.

- Develop and implement public health emergency management strategy which will address
public health threats and build a resilient health system
- Strengthen health sector and public health emergency multi-sectoral coordination,
collaboration and partnership
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- Strengthen regular risk assessment, profiling (hazard, vulnerability, and capacity analysis),
risk communication and early warning system
- Strengthen and sustain the International Health Regulation (IHR) core capacity through
implementing and monitoring multi-sectoral National Action Plan for Health Security
(NAPHS)
- Increase the capacity of Woredas for emergency preparedness and management
- Strengthen Emergency Operations Center (EOC) a
- Ensure the availability of adequate and trained surge capacity for PHE response(Disaster
Medical Assistant Team (DMAT)/Emergency Medical Teams including Rapid Response
team (RRT) at all levels
- Improve the capacity to forecast, detection, prepared and respond to public health
emergency learn and improve from emergency experiences, maintaining the course
towards long-term goals
- Build the capacities required to create a resilient health system to promptly respond,
recovered and rehabilitate in the context of health emergencies
- Ensure availability and functionality of adequate isolation, quarantine and treatment
centers at identified and designated point of entries
- Ensure adequate regulatory measures are in place at PoE to prevent importation of
communicable diseases
- Mobilize the resources required to adequately fund emergency preparedness, emergency
response operations, and recovery
- Coordinate and Strengthen the implementation of diseases and health events that are
targeted for elimination/ eradication
4.7.3. Enhance Community Engagement and Ownership
Description:
Community engagement is a process of developing relationships that enable stakeholders to work
together to address health related issues and promote wellbeing to achieve positive health
outcomes and impact. Community empowerment is a process where people work together to make
change happen in their communities by having more power and influence over what matters to
them.
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This direction focuses on ensuring active participation and engagement of the community in
planning, implementation, monitoring and evaluation of health and health related activities. It is
about enabling communities to increase control over their lives through creating health literacy
and decision power. Re-designing, testing and implementing a package of alternative approaches
tailored to address emerging challenges to the existing community engagement strategies will be
a key milestone in this strategic period to advance community engagement and ownership and
accelerate the progress towards UHC. The expected result of this direction is to achieve a
community with improved health behaviour, health outcome and improved accountability.
- Design and implement interventions to increase health literacy and health system literacy
- Optimize existing community structures to effectively accommodate health interventions
- Introduce new and strengthen existing social accountability mechanisms such as community
scorecard primed to enhance accountability of the health system to the public
- Strengthen town hall meetings
- Strengthen competency based training for community level structure representatives and
model household trainings
- Engage other sectors to coordinate kebele level activities to accelerate creation of model
kebele
- Introduce and implement “self-care” initiatives
- Test and introduce innovative motivation mechanism for community volunteers
- Strengthen the engagement of communities in decision making processes such as board
members in health facilities
- Design and implement approaches to enhance community resource contribution
- Engage school community members to reach households with health message
- Engage the community in prevention of public health risks
- Strengthen community engagement in health service delivery
- Apply Human Centered Design (HCD) and other frameworks to foster social innovation in
designing novel solutions tailored to prevailing people’s desires and local contexts
- Use existing community potentials and indigenous resources such as associations, faith
based and community based organizations as platforms for engaging communities in health
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- Cultivate and incubate local community led innovations for health problems of the
community.
4.7.4. Improve access to pharmaceuticals and medical devices with rational and
proper use of it
Description:
This strategic direction focuses on strengthening the pharmaceutical supply chain, pharmacy
services and medical device management systems to ensure uninterrupted availability and
accessibility of safe, effective and affordable medicines and medical devices that are needed to
address the health problems of the community and ensure that they are used rationally and
properly. Moreover, the strategic direction addresses the reduction of pharmaceutical wastage and
strengthening of systematic and environmentally friendly disposal of expired and damaged
pharmaceuticals and non-functional medical devices. Development and implementation of
strategies that strengthen local manufacturing of medicines and medical devices is also a focus of
this direction. Additionally, standardization for procurement and management of medical devices
will be given a due attention during the HSTP II period.
- Strengethen the procurement system through the introduction of e-procurement, establishment
of international and regional pooled procurement and long-term fixed price procurement
mechanisms
- Implement nationally established market shaping strategies for pharmaceuticals and medical
devices
- Institutionalize robust information system to ensure end-to end data visibility for the supply
management of medicines and medical devices across the supply chain.
- Adopt and implement the national track and trace system for medicines and medical devices
across the supply chain
- Strengthen private and other stakeholders’ engagement in areas of supply chain and medical
devices management
- Scale-up hospital-based intravenous and non-sterile pharmaceuticals compounding Service
- Strengthen medical device maintenance workshops, refurbishment centers and maintenance
referral system
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- Implement reverse logistics at health facilities and pharmacy retail outlets that extends to
households
- Adopt and implement strategies to reduce medicine wastage and to implement pharmaceuticals
waste management and medical devices decommissioning
- Establish Regional Medicine and Poison Information Center
- Promote the rational use of medicines by healthcare professionals and the public
- Strengthen the prevention and containment of Antimicrobial Resistance (AMR)
- Strengthen Drug and Therapeutic committee (DTC)
- Strengthen implementation of Auditable Pharmaceutical Transactions and Services (APTS)
- Strengthen clinical pharmacy and drug information services
- Adopt and implement the revised national medicine policy
- Strengthen integration of modern and traditional medicine
4.7.5. Improve Regulatory Systems
Description:
This strategic direction assures safety and quality of health and health-related products and services
to protect the public from health risks that arise from poor and substandard products and services.
It focuses on ensuring the safety, quality, efficacy and proper use medicines; performance of
medical devices; safety of food; quality of health and health related services against standards;
competence of health professionals, and regulation of tobacco and alcohol. It also includes the
implementation of digital regulation system to establish an effective, transparent and accountable
system that ensures adherence by all state and non-state actors to the health regulatory standards
and legal frameworks of the region. Engagement of all stakeholders such as the industry, academia,
communities and consumers will be a mainstay of this strategic direction. The ministry engages
professional associations in the process of licensing of health professionals (such as developing
exams, participating in the examination process etc…) with in this strategic period and aspires
towards transferring this task afterwards.

Regulation of food, medicines, equipment and other health products
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- Build and maintain adequate food regulation systems and infrastructures to respond and
manage food safety risks along the entire food supply chain
- Control food adulteration and develop rapid alert system for health products
- Transform the pre and post-licensing inspection of food and medicine facilities to product
and risk-based auditing inspection
- Ensure that all procedures, premises and practices used to manufacture, store, distribute and
dispense pharmaceutical products are based on the regulatory requirements
- Implement and strengthen quality management system and global bench marking tools
- Strengthen the system on controlling substandard/falsified medicines and illicit and abusive
drugs and medical devices
- Strengthen pharmaco-vigilance and vaccine safety and improve interface with clinical
surveillance
- Establish regulatory system for safety and quality of blood, blood products, human tissues
and organs
- Strengthen capacity to ensure conformity of medical research involving human subjects
with ethical principles
- Strengthen regulatory activities related to antimicrobial resistance
- Ensure the use of standard cold chain equipment in both public and private service delivery
points
- Strengthen regulation of narcotic drugs, psychotropic substances
- Strengthen implementation of tobacco and alcohol regulations
- Standardization, registration & regulation of the safety and efficacy of traditional medicine
and practice
Regulation of Health professionals and health care facilities

- Regulation of health professionals and traditional medicine practitioners (professional
ethics and code of conduct) and health facilities both public and private (Enforcing
adherence to the Ethiopian health facility minimum standard)
- Competency Assessment and Licensure of all graduates before joining the health
workforce
- Introduce and scale-up clinical audits to ensure quality of practice in health facilities
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- Engage private health care facility associations in health regulatory system
4.7.6. Improve human resource development and management
Description:
This direction entails human resources planning, development and management (training, capacity
building, recruitment, deployment, performance management and motivation) to ensure the
presence of motivated, competent, compassionate and committed health professionals in adequate
number and skill mix. It focuses on improving the quality of pre-service training and continuous
professional development. Promoting ethics and professionalism in the pre-service education and
in-service training programs will be given a critical attention. Human resource management aspect
of this direction focuses on need based recruitment, deployment, performance management and
motivation. It also includes leadership development with due attention to the involvement of
women in leadership positions. Generally, this direction requires multifaceted interventions
starting from recruiting students with the drive and motivation to be health professionals, to
continuously engaging health science students to reflect on being a health professional and
inspiring practicing health professionals to demonstrate commitment to their country, people and
care for their patients.

- Strengthen system of compassionate, competent and motivated health workforce through
quality pre-service education, appropriate retention and motivation mechanism, continuous
Professional Development (CPD) which is integrated with professional re-licensing
- Strengthen health facility based education and training in the health system and also make
health facilities conducive for health science training
- Enhance demand driven health workforce forecasting, planning and development
- Establish health professionals council and engagement of healthcare workers
- Integration of academic activities, service provision & research functions at teaching
hospitals
- Redesigning health workforce intake approaches through joint education-health planning
and integration mechanisms
- Develop and implement strategies to enhance health workforce safety
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- Shift HEW career to a level IV and above and improve career structure of the health
workforce in general
- Ensure the distribution and availability of health workforce to health facilities with
adequate number and appropriate professional and gender mix in an equitable manner
- Establish National Health Workforce Accounts (NHWA) and Regional Health Workforce
Observatory
- Conduct provider competency assessment survey in a year basis
4.7.7. Enhance informed decision making and Innovation

Description:
This strategic direction focuses on enhancing evidence-based decision and health innovation. It is
about enhancing decision making at individual household, community and all levels of the health
system. It also gives emphasis on use of the existing technology, introduction of new technology,
technology transfer and development and use of local technology in order to support informed
decision.
It promotes use of data from institution based and population-based data sources supported with
appropriate information communication technology (ICT) and using established HIS governance
framework. The process of evidence generation and decision-making comprises all sources of
information including census, civil registration and vital statistics (CRVS), surveys, surveillance,
routine information systems, researches, monitoring and evaluation systems. More specifically,
strengthening routine health information system entails, data collection, data quality assurance,
data analysis, interpretation, use of information, data access and sharing, security, and data
warehousing. It also includes institutionalizing knowledge management system.
This strategic direction also addresses the process of ideation, evaluation, selection, development
and implementation of new or improved products, services or programs to improve the health
outcomes of the population. It is about finding better ways of doing things through more effective
products, processes and services using technologies or ideas. Health innovation identifies new or
improved health policies, systems, products and technologies, and services and delivery methods
that improve people’s health and wellbeing.
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- Enhance implementation of “one plan”, “one budget” and “one report” approach at all levels
of the health system
- Strengthen culture of information use at all levels
- Create forums that translate evidence to policy at regional and woreda levels
- Mainstream data use in all health professional training curriculum
- Nurturing leadership role in championing information use culture, including political leaders.
- Strengthen the routine health management information system (HMIS, LIS, HCMIS, LMIS,
CHIS, HRIS, RIS, Health Insurance Information System etc…)
- Implement data quality improvement, assurance and auditing
- Strengthen evidence-based planning and policy formulation
- Generate and translate evidence to policy and action by triangulating data from different
sources
- Strengthen monitoring and evaluation
- Enhance the capacity of academic and research institutions to undertake research, surveys and
surveillances.
- Enhance the availability and management of resources for research activities
- Regularly conduct household, community and facility-based surveys
- Strengthen system for surveillance information system
- Establish and enhance Knowledge Management system at different levels
- Establish Regional Health research council
- Strengthen birth and death notification for civil registration and vital statistics (CRVS) system.
- Adopt and implement data generation system on cause of death
- Strengthen health information system governance
- Strengthen the development and use of biotechnology
4.7.8. Improve Health Financing
Description:
This strategic direction is about ensuring adequate and sustainable financing to realize Ethiopia’s
progress towards “Universal Health Coverage through strengthening Primary Health Care – UHC
through PHC” without financial hardship for citizens. This strategy can be achieved through
mobilizing adequate and sustainable financial resources, pooling of resource and risk, purchasing
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and paying for health services and improving health system efficiency. It will also include
improving accountability and transparency in management and utilization of financial resources.
This strategic direction will ensure a transition to a more sustainable financing for health, through
gradual replacement of resources from external to domestic sources.
This strategic direction can be realized through devising new implementation modalities and
governance arrangements. The strategy will employ current local and global opportunities that
take advantage of the dynamisms of the health sector to transform supply- and demand-side health
financing mechanisms.

- Mobilize adequate resources through existing and innovative approaches, from domestic and
external sources
- Develop and implement strategies to increase government budget allocation for health
- Adopt the national Initiation and scale up social health insurance
- Expand and strengthen Community Based Health Insurance (CBHI)
- Provide CBHI coverage to all households under the poverty line
- Conduct regular financial audit and risk assessment
- Establish higher level (regional and national level) CBHI pools
- Conduct regular revision of premium, based on capacity and willingness to pay
- Strengthen health facility revenue generation and effective utilization to ensure sustainable
services
- Standardize health service fee setting process across woredas
- Strengthen investment on high impact and cost-effective interventions
- Strengthen different financial resource tracking systems
- Design and implement performance linked strategies to improve efficiency and effectiveness
(performance based Financing and Result based financing)
- Strengthen coordination platform to improve health care financing
- Implement Public Private Partnership (PPP) projects in clinical and non-clinical services
- Increase health sector’s/organizational capacity for Health Financing at all administrative,
management and service delivery levels
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4.7.9. Enhance Leadership and governance
Description:
This direction is about ensuring accountable and transparent leadership & governance system for
effective implementation of strategies. It addresses public accountability on resource management
and optimal health service provision. It includes designing and implementing sound regulation
mechanisms, building effective teams and institutionalizing appropriate implementation
mechanisms and platforms. Sound leadership is vital for seamless translation of strategic plans
into impactful actions by creating enabling environment for stakeholders including individuals,
households, communities, firms, governments, nongovernmental organizations, private firms and
other entities while holding them accountable for their actions or responsibilities entrusted on
them. All actions of leadership should be derived by credible evidences especially in areas local
and/or global evidences are available.
The components include transparency, accountability, responsiveness, effectiveness and

efficiency, participatory, consensus building, equitable and inclusiveness and follow the rule of
law. It assures that the views of minorities are considered, corruption is minimized, and that the
voices of the vulnerable segment of communities are heard in decision-making and
implementation of decisions.

- Build leadership capacity through different mechanisms such as Leadership Incubation
Programs, CPD for leaders and twinning
- Promote merit-based assignment of health sector leaders alongside gender equity goals
- Design and implement mechanisms that promote gender equality in leadership and other roles
- Reorganize and implement institutional structure and management system to embrace
dynamism
- Revitalize harmonization and alignment for health (one plan, one budget and one report
principles)
- Engage formal and informal community organizations in ensuring good governance practices
- Institutionalize grievance handling and monitoring mechanisms at all levels
- Design and implement innovative mechanisms to improve Social Accountability in health
sector
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- Implement mechanisms that address inequality in health

- Strengthen partnership among public sectors, private for profit, CSOs and NGOs
- Design and implement legal frameworks (proclamation, regulations, directives and guidelines)
- Design and implement incentive and accountability mechanisms in the health sector
- Design and implement transparent resource allocation mechanism
4.7.10. Improve Health Infrastructure
Description:
This strategic direction aims at improving access to health facilities that are well equipped and
furnished and ensures that existing and new health institutions meet minimum standards. It
encompasses developing standard construction designs, building health institutions, expansion,
renovation and maintenance of health and health-related facilities. It also includes equipping and
furnishing health institutions and availing utilities (such as water and electricity) and ICT
infrastructure. Construction quality assurance is an integral part if this direction.
Health and health related facilities include: - health posts, health centers, hospitals (primary,
general and specialized), blood banks, quality control laboratories, Regional and National
Laboratories, staff residences in remote areas, rehabilitation centers, medical equipment
maintenance workshops, drug distribution hubs, and administrative institutions at different levels
including Woreda Health Offices, Zonal Health Departments, Regional Health Bureaus and
Federal institutions.

- Prepare design of health facilities that suits health service demand considering environmental,
climate and geographic factors
- Construction, expansion, rehabilitation, maintenance and renovation of health and health-
related facilities to meet national standards
- Upgrade and/or construct health posts located in kebeles far from catchment health centers for
provision of comprehensive PHC services
- Establish medical equipment maintenance centers and strengthen its capacity and functionality
- Introduce standard procedures for preventive maintenance of health and health-related
facilities, equipment, and furniture
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- Accelerate the expansion of utilities (water, electricity…) for health institutions

- Deployment and expansion of ICT infrastructure at all levels of the health system
- Construct primary hospitals and upgrade sub-standard health centers
- Construct, equip and furnish operation rooms in selected health centers
4.7.11. Enhance digital health Technology
Description:
Digital technologies provide concrete opportunities to tackle health system challenges, and thereby
offer the potential to enhance the coverage and quality of health practices and services. It includes
four major components: Digitization targeted to clients, health workers, health system managers
and health data services.
- For clients, it includes digitalization of client-provider interaction, access to health information

for individuals, personal health tracking and public feedback mechanism to the health system.
- For health workers, it includes digitalization and use of decision support system, telemedicine,
health worker-client interaction, client health records, referral coordination and health worker
capacity building and laboratory & imaging management
- For health system managers, it includes digitalization and use of human resource management,
supply chain management, public health event notification, health financing, facility
management, equipment and asset management
- For data services, it includes digitalization of data collection and management and use, civil
registration, data coding, location marking, data exchange and inter-operability
The range of ways digital technologies can be used to support the needs of health systems is wide,
and these technologies continue to evolve due to the inherently dynamic nature of the field. The
digital health technologies and interventions should be linked to the broader digital health
architecture. All digital health systems should be developed through applying interaction design
methods to make them user friendly.

- Keep the national eHealth architecture and interoperability framework up to date
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- Adopt the nationally developed standards and guidelines for selection, development and use
of digital health solutions
- Strengthen digitization of routine and non-routine data collection, management, analysis and
use
- Strengthen digitization of Health Commodity Management Information System
- Strengthen digitization of Human Resource Information System and national health workforce
account
- Strengthen digitization of regulatory systems
- Strengthen digitization of health insurance management system
- Develop digital solutions for health worker decision support on prioritized health services
- Develop digital solutions to provide capacity building for health workers
- Digitize digital health interventions for clients that improve client-provider interaction and
increase health literacy
- Digitize client level data recording system
- Implement Telemedicine and tele-radiology in selected health facilities
- Strengthen ICT infrastructure at all levels of the health system
- Establish data warehouse
- Develop capacity of health workforce in implementing digital health interventions
4.7.12. Improve Traditional Medicine
Description:
This strategic direction refers to the registration, licensing, research, production, use, and
integration of traditional medicine and traditional medical practices. Traditional Medicine and
practices is directly or indirectly related to protection of societal health, equitable distribution of
public health care services, right to exercise profession, intellectual property right, biodiversity
conservation, protection and promotion of indigenous knowledge and culture. It also aims to
promote public health by ensuring safety, efficacy and quality of locally produced traditional
medicines as well as to standardize and regulate the practice of traditional healers.
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- Collaborate with relevant stakeholders to improve conservation and documentation efforts of

traditional medicines Knowledge and Practices
- Adopt and implement nationally denveloped inclusive and integrated policy framework and
legislation for traditional medicine and practices
- Establish a responsible body for traditional medicine which can direct and coordinate the
fragmented efforts
- Promote intellectual property right and indigenous knowledge right registration & market
authorization of traditional remedies
- Promote research and development of traditional medicines and engage academia and research
institutions
- Support clinical trial of traditional medicine
- Establish incubation center for laboratory formulation of traditional medicines
- Increase laboratory scale formulation of scientifically validated traditional medicines
- Build the capacity of traditional healers and tertiary level researchers on traditional medicine
- Establish/Strengthen documentation, central and peripheral data repository on medicinal
plants, other source of traditional medicine and traditional practices
- Build capacity of the workforce involved in the production and supply management of
traditional medicines
4.7.13. Health in All Policies
Description:
Health in All Policies (HIAP) is a systematic approach of considering the health implications of
decisions of public policies across all sectors. It anticipates synergistic effect of public policies,
prevent and mitigate harmful health effects in order to advance population health. It advances
accountability of policymakers for health impacts through efficient and effective multi-sectoral
actions. It emphasizes the need to be watchful of the consequences of public policies on
determinants of health, well-being and health system. HIAP fosters inclusive and sustainable
development and helps in addressing the social determinants of health, reducing multi-sectoral risk
factors, and promoting health and well-being through promoting healthy practices across all
sectors.
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- Advocate for the inclusion of health and health related perspectives in all relevant sectorial
policies and regulation
- Advocate for allocation of sector specific budget line for social determinants of health
initiatives
- Scan existing policies and strategies of all sectors and identify priority collaborative areas for
multi-sectoral engagement
- Build the capacity of all sectors to implement social determinants of health initiatives
- Conduct joint planning, monitoring and evaluation of multi-sectoral actions, including
evidence generation and use
- Develop and implement legal framework and implementation arrangement for effective
implementation of multi-sectoral actions
- Formulate lessons from and strengthen existing multi-sectoral initiatives such as One WasH
program, Seqota Declaration and multi sectorial woreda transformation
- Promote environmental impact assessment to mitigate health impacts of huge projects
4.7.14. Enhance private sector engagement in health
Description:
This strategic direction is about a deliberate and systematic collaboration of the government and
the private sector to move national health priorities forward, beyond individual interventions and
programs. It aims to improve the engagement of the private sector in improving access and quality
of health services. It their engagement in a wide range of activities including service delivery,
production of medicines and medical supplies, and products, supply chain management, health
financing, health information system, human resource development, health care administration and
management and capacity building contributing to the strengthening of the health system. This
direction includes the engagement of both private for profit and private not for profit institutions.
Partnership, a subset within the engagement arrangement, with the private sector could strengthen
the health service delivery through improving the quality, quantity and affordability of essential
health inputs by facilitating local manufacturing of pharmaceuticals and medical devices. It also
increases production of skilled health human resources; mobilize additional resources for the
health sector; and, contribute to meet the increase demand for access and utilization of health care.
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- Review and revitalize the policy framework and strategies to enhance public-private
engagement in health
- Create an enabling environment for Public Private Partnership for health including
establishment of transparency, accountability and responsiveness with in the partnership
modalities
- Support private sector in the development of competent health force
- Promote the private sector engagement in the planning, implementation and monitoring
and evaluation of the health system
- Strengthen the involvement of the private sector in the production and distribution of
medical products and supplies
- Strengthen collaboration between public and private health facilities for quality health care
- Strengthen mutual accountability system between government and private health sectors
- Introduce PPP arrangement in selected areas of health services
4.8. Priorities/Transformation Agendas of HSTP II
From the 14 strategic directions, the health sector has identified the top key priorities or health
sector transformation agendas based on the major challenges identified by the situational analysis.
These are investment areas that form the foundation of our health system and if successfully
implemented, they will transform the health sector and enable it to provide competent care that
result in better health for all. Accordingly, the following are the priorities/focus areas of HSTP-II.
Quality and This transformation agenda refers to ensuring delivery of quality health care (reliable, patient centered and
Equity efficient) to all in need in an equitable and timely manner. It is about ensuring availability of the best care
to all whereby the quality of care provided does not differ by any personal characteristics including age,
gender, socioeconomic status or place of residence, disability status. Improving quality of care needs broad
solution space that address both the demand for quality of care by the community and the care itself. Only
a few methods have been used up to now to improve the demand side. People with high expectation demand
quality of care and vice versa. Some of the interventions are describe here, but more innovative approaches
are needed. Facilities should also design accountability mechanisms to redress poor quality of care and
should be transparent to inform people about the level of care provided. In addition, addressing the supply
side that improve quality of care will be emphasized during HSTP-II. Activities will include regular
monitoring of state of equity at all levels of the health sector implementation of tailored interventions, such
as redesigning mode of service delivery, incentive package and others, to reinforce quality of care.
Information The overall goal of information revolution is improving the capability of the health system to generate and
Revolution use high quality data for evidence-based decision-making and drive towards a better health systems
performance. Information revolution is not only about changing the techniques of data and information
management; it is also about bringing fundamental cultural and attitudinal change regarding perceived
value and practical use of information. During HSTP-II, efforts will be exerted to three pillars of information
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revolution, which are transforming culture of high quality data use, digitization of health information system
(HIS) and improving HIS governance.
Motivated, This priority area/transformation agenda refers to ensuring the availability of adequate number and mix of
Competent and quality health workforce that are Motivated, Competent and Compassionate (MCC) to provide quality health
Compassionate service. Creating motivated, competent and compassionate health workforce depends on several but inter-
(MCC) health related factors including well-regulated and quality pre-service education, in-service training and continued
workforce professional development opportunities to create adequate number of well qualified professionals and
managers; fair recruitment, selection, orientation and placement, and creating enabling work environment
with clear roles and responsibilities, equitable remuneration packages, performance support (supportive
supervision and timely feedback) through strong human resources management policy and practices.
Health Transformation in health financing is about reforming the financing and management system of the health
financing system so as to mobilize adequate and sustainable health finance and improve efficiency. High out of pocket
expenditure, catastrophic expenditure, efficient allocation and utilization of resources are major challenges
of the health sector in stride towards universal healthcare coverage. Hence, ensuring sustainable healthcare
financing is an imperative factor to address these challenges and improving health outcomes. To achieve
this, focus will be given for the following major interventions: proactive mobilization of adequate resources
from domestic and international sources, reforming resource allocation & prioritization, optimization of
the health insurance system, public-private partnership, reforming the cost recovery mechanisms,
implementing performance based financing and design & implement strategies for efficient use of resources
and capacities.
Leadership Transformation in leadership is about enhancing the leadership and governance system at all levels of the
health system to drive attainment of the strategic objectives. Lack of clear accountability, transparency,
shared vision, evidence-based decisions, regulation and coordination are some of the leadership and
governance challenges of the sector. Leadership is a crucial pillar of a health system that has a direct
influence on the performance of health systems. Translation of plans to results can be achieved if the
leadership at all levels of the health system functions well. Hence, to transform leadership at all levels the
following are critical interventions which will be implemented in the HSTP II: redesigning & restructuring
the health system, institutionalize accountability mechanisms, strengthen clinical governance, ensuring
regulatory system autonomy, and strengthen stakeholder engagement and partnership, building leadership
capacity at all levels, and incorporating the Health in All Polices approach throughout the government.
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Chapter 5: Costing and Financing

5.1. Costing
Costing and financing of HSTP II is computed using OneHealth Tool (OHT). This tool is built on
six health system building blocks, drawing upon the WHO framework on health systems that
include: health workforce, infrastructure, logistics and supply chain, health information system,
health systems financing, leadership and governance. OHT is a policy projection-modelling tool
that allows users to create short and medium term plans for scaling up health services. It is used
for health planning, costing and budgeting with a focus on integrating planning and financial space
analysis. The tool is also organized in three components namely: The health systems, the health
services delivery and the impact module.
Figure 22: One Health tool framework

Where there are financial limitations, a process of prioritization and/or scenarios with more
realistic levels of ambition is facilitated to set the actual plan.
One Health tool uses a modular approach; the user can either decide to only use one module (e.g.,
Malaria or Human Resources) independently, and/or can make use of other modules in sequential
order. Once the user selects which interventions s/he intends to focus, s/he then allocates these into
different modules. After this, the disease modules are defined. This flexible approach allows for
the variation between makeups of vertical disease programs in countries
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OneHealth tool is based on Spectrum, which is a Windows-based system of integrated policy

models. The integration is based on DemProj, which is used to create the population projections
that support many of the calculations in the other components, such as FamPlan, the AIDS Impact
Model (AIM), and the Lives Saved Tool (LiST)
The assessment of costing and financial feasibility is integrated into the planning process. In
addition to this investment are linked to results in terms of system outputs and predicted health
outcomes and impacts. The cost estimate is based on:
1. The best accessed information on disease profiles

2. Official figures for base year population demographics
3. Assumptions that all available facilities are functioning
4. Assuming that the required staffs are in place
5. National protocols and expert opinions are used for clinical practices
6. Expansion targets are set to meet the standards as based on population figures and other
criteria
Some of the major impacts that will ensure using the estimated cost of expenditure are shown
below. As indicated on the following figure, the maternal mortality ratio (MMR) has reduced from
401 to 279 and 222 per 100,000 live births in the first and second five years, respectively. When
it is compared with SDG target (MMR 140 in 2024 and 70 in 2029 per 100,000 live births), the
targets in this strategic plan is much higher than the SDG target. Neonatal mortality (NNMR) is
planned in this strategic plan which is 18 per 1,000 live births at end of 2029 is higher than the
SDG target to reach 12 per 1000 live births by 2030. Besides to this, the target for under five
mortality rate in this strategic plan is to reach about 37 per 1,000 live births but SDG targets at
least as low as 25 per 1000 live birth by 2030.
As indicated in the above, there is gap in targets among SDG and HSTP II targets. This gap can
be reduced through mobilization of huge amount of money from government, partners and
community which is more than the planned estimated cost stated below. These will enhances
performance of the health sector to improve the coverage’s of health output, outcome and finally
will enables to reach expected level of impacts. The following figures indicates that the MMR,
NNMR, IMR and under 5 years CMR.
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450
400 401
350
300
279
250
200
150
100
50
0
2019 2020 2021 2022 2023 2024
Figure 23: Maternal Mortality Ratio targets (per 100,000 live births) of Ethiopia
from 2019 to 2024
40
35 34
30
25
20 21
15
10
5
0
2019 2020 2021 2022 2023 2024
Figure 24: Neonatal mortality rate (per 1000 live births) targets of Harari Region
from 2019 to 2024
80
70 72
60
50
40 43
30
20
10
0
2019 2020 2021 2022 2023 2024
Figure 25: Under five mortality rate (per1000 live births) targets of Harari region from
2019 to 2024
As it is mentioned above, the OHT provides output information including targets of coverage of
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intervention, impacts and cost require for each programs in planning period.
5.2. HSTP-II Cost estimation
The overall cost estimation of the region’s health sector for the next five years (2020/21 – 2024/25)
is 3.89 Billion ETB. The average yearly total estimated cost is 779 Million ETB (Table 3). Out of
the total cost, 38% (1.49 Billion ETB) is costed for procurement of medicine & medical
equipment, 20% (794 Million ETB) for health infrastructure (construction, rehabilitation and
maintenance of health facilities, equipment and furniture, ICT materials, vehicle), 15% (562
Million ETB) for human resource development and management, and 12% ( 459 Million ETB) for
health service program management cost which includes short term trainings, supervision,
advocacy other program specific costs (Figure 22).
Table 3.Harari regional health Bureau HSTP II Cost Summary for 2013-2017 E.C
S/N Cost Area Years in Ethiopian Calendar Total
2013 2014 2015 2016 2017
1 Health Services Program Cost 94,783,888 79,638,145 99,532,959 78,436,124 107,393,788 459,784,904
2 Human Resources 99,726,643 107,259,176 112,791,320 119,294,124 123,774,720 562,845,983
3 Infrastructure 85,399,459 103,950,203 59,751,564 110,630,678 435,197,429 794,929,333
4 Logistics 27,117,000 26,676,000 26,376,000 26,301,000 25,935,000 132,405,000
5 Medicines, commodities, and 253,080,781 270,839,903 309,683,886 317,005,387 344,054,920 1,494,664,877
supplies
6 Health Financing 28,662,242 46,680,427 55,701,673 60,051,373 58,077,703 249,173,418
7 Health Information Systems 31,142,490 27,226,513 29,614,347 23,420,830 24,851,663 136,255,843
8 Governance 12,200,430 14,442,390 12,963,780 12,678,780 13,203,780 65,489,160
Grand Total 632,112,933 676,712,757 706,415,529 747,818,296 1,132,489,003 3,895,548,518
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4% 2% Total Programme Costs
12% Total Human Resources

6%
Total Infrastructure
15% Total Logistics
Total Medicines, commodities, and

supplies
38% Total Health Financing
20%
Total Health Information Systems
Total Governance
3%
Figure 26. Harari Regional Health Bureau HSTP II Cost Share
The total estimated cost for all health service program areas of HSTP-II in the next five years
(2020/21–2024/25) is 1.94 Billion ETB, which is around 50% of the overall cost estimate needed
for the health system . Of this, 76% (1.49 Billion ETB) is intervention cost including and the rest
24% (459 Million ETB) is program management cost. The average yearly total estimated cost for
all health service program areas in the next five years (2020/21–2024/25) is approximately 389
million ETB (Table 4).
Table 4. Harari Regional Health Bureau Cost Summary by health service program area for 2013-2017
E.C
S/N Health Services Years in Ethiopian calendar Total

2013 2014 2015 2016 2017
1 Maternal and Newborn 34,448,26 25,771,99 37,180,39 32,319,86 43,754,278 173,474,800
6 0 9 7
2 Child health 20,692,98 17,169,37 20,367,00 16,243,54 19,835,422 94,308,322
0 1 6 4
3 Immunization 12,376,16 11,977,51 21,229,47 17,211,83 19,214,271 82,009,255
9 1 2 2
4 Malaria 29,401,13 30,395,79 33,663,95 18,492,48 18,586,702 130,540,067
2 1 5 7
5 TB 81,472,81 74,963,90 78,056,97 77,113,62 72,743,948 384,351,260
1 0 3 8
6 HIV/AIDS 37,857,71 39,325,30 41,875,65 42,670,59 45,781,206 207,510,473
5 9 2 1
7 Nutrition 20,554,45 30,344,36 28,547,04 30,358,64 33,445,108 143,249,613
0 1 9 5
8 Hygiene and Environmental Health 5,368,441 2,666,364 7,070,293 5,055,841 8,546,540 28,707,479
9 Non-communicable diseases 5,091,464 5,246,510 5,412,186 5,589,009 5,778,214 27,117,382
10 Mental, neurological, and substance 1,453,197 1,795,354 2,054,173 1,777,202 2,224,861 9,304,786
use disorders
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11 Adolescent health 6,723,688 4,124,015 7,565,229 6,097,861 9,412,765 33,923,559

12 Neglected tropical diseases 9,698,856 8,938,429 9,807,128 9,356,393 10,035,980 47,836,786
13 Family Planning 3,406,570 2,521,880 3,171,497 2,280,203 3,391,518 14,771,669
14 PMTCT 4,442,642 4,086,685 4,326,835 4,325,057 4,778,026 21,959,246
15 Hepatitis 193,910 1,120,193 1,978,188 3,299,296 4,848,236 11,439,824
16 Health Extension Program 8,222,032 11,595,11 16,595,30 20,695,60 26,466,955 83,575,003
1 5 1
17 Clinical Services 10,097,65 14,386,83 18,934,50 23,840,71 36,624,593 103,884,301
5 5 0 8
18 Emergency and Critical Care 28,272,62 32,055,76 36,313,03 40,279,47 43,912,378 180,833,267
2 0 3 4
19 Quality of Health Services 3,367,500 3,658,500 3,804,000 3,840,000 3,888,000 18,558,000
20 Blood Bank Services 8,502,965 9,671,061 10,524,80 11,604,19 12,879,237 53,182,265
5 7
21 Public Health Emergency 11,202,96 12,940,18 14,776,27 16,704,98 18,723,923 74,348,326
Management 9 2 2 1
22 Equity of Health Services 443,760 443,760 344,790 410,760 407,760 2,050,830

23 Laboratory Services (Regional) 2,115,000 2,628,000 2,781,000 2,934,000 3,087,000 13,545,000
24 Traditional Medicine 477,000 477,000 477,000 477,000 477,000 2,385,000
25 Gender 742,500 787,500 817,500 907,500 877,500 4,132,500
Total costs (all program Service 346,626,295 349,091,371 407,674,241 393,885,687 449,721,4191,946,999,013
areas)
5.3. Cost estimate by strategic Directions
Regarding the share allocated for strategic directions, the highest cost allocation for the strategic
direction “improve access to equitable and quality health services”, “improve health
infrastructure” and “improve human resource management” accounts for 45.4%, 20.4% and
14.4% respectively (Table 5).
Table 4.Harari regional health Bureau Cost summary by Strategic Directions for 2013-2017 E.C
S/N Strategic Directions Years in Ethiopian Calendar Total %
2013 2014 2015 2016 2017
1 Enhance equitable and quality 324,238,722 321,449,852 372,129,885 350,854,199 398,821,312 1,767,493,970 45.4
health service provision
2 Improve health emergency and 11,202,969 12,940,182 14,776,272 16,704,981 18,723,923 74,348,327 1.9
disaster risk management
3 Ensure community engagement 8,856,472 12,957,975 18,994,598 24,462,941 30,342,495 95,614,481 2.5
and ownership
4 Strengthen pharmaceutical and 28,355,375 28,062,677 27,918,604 27,856,824 27,662,289 139,855,769 3.6
medical equipment supply
management
5 Improve regulatory systems 12,200,430 14,442,390 12,963,780 12,678,780 13,203,780 65,489,160 1.7
6 Improve human resource 99,726,643 107,259,176 112,791,320 119,294,124 123,774,720 562,845,983 14.4
development and management
7 Enhance informed decision 13,461,300 11,045,490 13,235,490 9,710,490 10,497,990 57,950,760 1.5
making (information, research
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and knowledge management)

8 Enhance health financing 28,662,242 46,680,427 55,701,673 60,051,373 58,077,703 249,173,418 6.4
9 Strengthen governance and 742,500 787,500 817,500 907,500 877,500 4,132,500 0.1
leadership
10 Improve health infrastructure 85,970,891 103,950,203 59,751,564 110,630,678 435,197,429 795,500,765 20.4
11 Enhance digital health and 17,681,190 16,181,023 16,378,857 13,710,340 14,353,673 78,305,083 2.0
innovation
12 Improve traditional medicine 477,000 477,000 477,000 477,000 477,000 2,385,000 0.1
13 Health in all policies and 287,349 231,849 231,849 231,849 231,849 1,214,745 0.0
strategies
14 Enhance private engagement in 249,850 247,013 247,137 247,217 247,340 1,238,557 0.0
the sector
Grand Total 632,112,933 676,712,757 706,415,529 747,818,296 1,132,489,003 3,895,548,518 100.0
5.4. Cost estimate by Funding sources and Budget Category
The total cost is estimated by budget category. From the total estimated cost, the total recurrent
cost accounts 78% (3.02 Billion ETB), while the total capital cost accounts 22% (873 Million
ETB) (Table 6).
Table 5. Harari Regional Health Bureau Cost summary by Budget category for 2013-2017 E.C
S/N Budget category Years in Ethiopian Calendar Total %
2013 2014 2015 2016 2017
1 Recurrent 528,460,851 556,581,531 630,285,109 623,477,278 682,937,901
3,021,742,670 78
2 Capital 103,652,082 120,131,226 76,130,420 124,341,018 449,551,102
873,805,848 22
Total 632,112,933 676,712,757 706,415,529 747,818,296 1,132,489,003 3,895,548,518
100
The total cost is also estimated by funding sources. Out of the total estimated cost, 47% (1.83
Billion ETB) is expected to be covered by the regional government with the average yearly total
estimated cost of 323 Million ETB. The rest 53% (2.05 Billion ETB) of the total estimated cost is
expected from external sources (MoH, local and international partners and donors). From the total
estimated cost to be covered by the regional government, the recurrent cost and capital cost
accounts for 76% (1.4 Billion ETB) and 24% ( 436 Million ETB), respectively (Table 7).
Table 6.Harari regional health Bureau Cost Summary by funding Source for 2013-2017 E.C
S/N Funding Sources Years in Ethiopian Calendar Total %
2013 2014 2015 2016 2017
1 Regional Government 283,516,398 319,240,051 328,075,905 363,013,608 543,352,524 1,837,198,486 47
• Recurrent 231,690,357 259,174,438 290,010,695 300,843,099 318,576,973 1,400,295,562
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• Capital 51,826,041 60,065,613 38,065,210 62,170,509 224,775,551 436,902,924
2 Other External Sources 348,596,535 357,472,707 378,339,623 384,804,688 589,136,479 2,058,350,032

53
(MOH/Partners/…….)
• Recurrent 296,770,494 297,407,093 340,274,414 322,634,179 364,360,928 1,621,447,108
• Capital 51,826,041 60,065,613 38,065,210 62,170,509 224,775,551 436,902,924
Grand Total 632,112,933 676,712,757 706,415,529 747,818,296 1,132,489,003 3,895,548,518 100
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Chapter 6: Implementation Arrangements

The implementation arrangement of HSTP-II aims at facilitating the implementation of the health
sector transformation plan by relevant stakeholders. Eight main implementation arrangements are
identified for the HSTP-II period as described below.
The first two requires the attention of the leadership of the sector at all level to keep them focused
on integration of efforts and practice good governance to keep the implementers deliver on their
missions towards common vision. Hence, identifying integrative efforts is important including the
transformation agenda. Building on the transformation agenda of HSTP-I, systematically
packaging of sets of initiatives/programs or major activities of transformation agenda to streamline
communication, resource utilization and monitoring of HSTP-II implementation. Furthermore,
good governance practices are important to ensure that plans are owned and implemented in a
manner that foster accountability.
The third implementation arrangement helps to address the lack of detail implementation plan in
cascading the strategic plan into operationalization plan to align existing resources or inputs
(financial, human, time and other relevant assets) with anticipated services to be rendered to clients
of the sector. The Ethiopia’s health sector planning and budgeting exercises, Woreda based
national health sector planning, has been there for about a decade serving as planning framework
at all levels. Optimizing the Woreda based national planning as a planning and budgeting
mechanism of the sector by objectively assessing the lessons will be critical in translating HSTP-
II to tangible actions. Additionally, detail implementation plans need to be prepared for flagship
initiatives/programs showing a clear pathway and actors with resources required (human, financial
and time) for meaningful impact in reasonably faster time. Based on the experience to date,
emergencies happen all the time to the extent that we cannot any more leave such incidences under
assumptions. Hence, the strategic and annual operational plans should factor in the need to respond
to public health emergencies including the resource mapping exercises with relevant stakeholders
(Risk oriented planning and budgeting).
The fourth arrangement is tailored towards addressing the challenges faced on organizational
structures at national, regional and sub- regional health sector arrangements for supporting
implementation of sector specific and multi-sectoral strategies. Based on the situational analysis
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observed in chapter II & III, restructuring needs to be considered towards building quality health
system.
The fifth implementation arrangement aims at optimizing the monitoring and review systems of
the sector to inform decisions in adjusting plans in the course of strategic periods. Furthermore,
the evidences need to strengthen existing efforts if are working well, drop/abandon existing efforts
if are not taking the sector anywhere, trigger new actions or developments including innovations.
Researches should be considered as part of monitoring and review of sectoral performance
alongside generating new evidences. Research agenda should also be purposefully tailored to
development of solutions (including innovations and product development) that respond to
addressing challenges of the health sector in improving health status of the nation and building
quality health system.
The sixth and seventh implementation arrangements focuses on fostering partnership and
collaboration by promoting multi-sectoral collaboration and private sector engagement,
respectively. Though, these coordination arrangements have been there in HSTP-II, they were not
backed up by relevant structure, resources and monitoring frameworks.
The eighth approach is forward-looking in expediting the implementation of the plans and
fostering innovation through introducing health technology assessment and adaptation mechanism
including development aspects of local researches.
The details of the eight approaches will be narrated in detail as follows.
6.1. Integration Efforts

Building on the experiences of the implementation of HSTP-I, sets of initiatives and programs will
be packaged and put into practice for the realization of the transformation agenda within HSTP-II.
The implementation of these initiatives will be made in a harmonized manner so that they are
aligned and mainstreamed across the program activities. Mid-term and annual reviews will be used
as platforms for monitoring the success and challenges of the initiatives for appropriate review
measures or for recommending them to be further scaled up and cascaded to all levels of the health
management and facility structures. Furthermore, based on review and evaluation results as well
as to respond to the changing external environment, activities within the transformation agenda
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will be dynamic to the extent of adopting major shifts in the redesign of the health care system to
withstand the consequences of epidemiologic transition as well as those of unexpected
emergencies and pandemics.
At Regional level, efforts will also be made to integrate and mainstream elements of the health
policy within the policies and programs of all other sectors within the perspective of inter-sectoral
collaboration. Health sector plans and activities will be particularly linked with sectors like food
security and nutrition, education, environment and climate change, governance, information,
communication and technology, agriculture, etc. for the realization of universal healthcare.
Alignment of health activities with global initiatives and agreed upon international declarations
are also to be given particular focus. All of the planned activities are designed in a way to
incorporate dimensions of equity across gender, geography, socio-economic, and special
vulnerability categories.
6.2. HSTP-II Governance

Ensuring good governance is crucial in the realization of the ideals put in the vision and mission
of the plan, and in ensuring the outlined activities are executed in an efficient and accountable
manner. As a plan that is being implemented within the perspective of the sector wide approach to
development, the HSTP is designed to be linked to the concerted efforts of development partners,
the private sector, non-governmental organizations and the community at large. Therefore, its
governance encompasses the development as well as the organization and management of the plan
across the different stakeholders involved in its operationalization. As the plan is a wholistic and
multi-sectoral effort, its management and ownership involve entities beyond the health sector.
All citizens, non-government and community organizations, development partners, and civil
society and professional associations are stakeholders with different levels of governance
responsibilities in the implementation and evaluation of the HSTP-II activities. Therefore, it is
mandatory that the governance of the plan should be structured in such a way that encourages:
responsiveness (making services need-based); inclusiveness (taking different groups and needs
into consideration); accountability (making roles and responsibilities clear); transparency (being
clear on the where, when and how decisions were reached); and participatory (involving all
relevant stakeholders).
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The organizational structure and institutional culture (that includes different management and
communication related guidelines and protocols) are the basic frameworks on which all the other
components and stakeholder elements coalesce for the effective governance of the plan. All
necessary legal and regulatory frameworks to support and backup the enforcement of health
actions are in place, even though they need to be properly compiled for easy reference by the public
and generalist audience. There are also initiatives towards capacity building and enhancing the
leadership skills of the health sector management at all levels.
Based on the above considerations, the coordination and implementation of the HSTP-II will have
the following consultative and review institutional framework:
RHB Management Committee

The regional management committee is composed of the RHB directorate including the Vice RHB
which will be chaired by the RHB head and it is the highest governance body which decide, guides,
oversees, and facilitate the implementation of HSTP II. The RHB management committee should
meet every week and as needed.
Regional Joint steering Committee

The RHB –RJC- is a forum that brings together the Regional Health Bureaus, RHB Directorate,
Woreda administrative, Woreda Health Coordinator, and DD EPSA, Harar HSC dean, Haramaya
University HSC chief executive, Head of Regional Education Bureau, Municipality Head and
Hospital CEO. The meeting is chaired by the RHB head. The Committee should meet every two
months.
The basic objective of this forum is to facilitate the effective and smooth implementation of the
HSTP priority issues. This is done by bridging communication gaps between the two levels; by
improving internal harmonization and coordination; by closely monitoring progress and problems
at the operational level and by taking joint corrective measures. The Regional Joint Steering
Committee will focus on several implementation issues including: overview of implementation
progress and problems; identification of major implementation bottlenecks such as resource flows,
utilization, reporting etc.; introduction of new initiatives, policy guidelines and programs and
creating systems and mechanisms for information and experience sharing most importantly to
encourage collaborative leadership.
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6.3. Planning and budgeting

As in HISTP-I, HSTP-II also follows the “one plan, one budget” strategic initiative where “one
plan” signifies that all the major activities happening at various levels of the health system are
included in one joint plan in which all stakeholders agree to be part of. While still having their
own internal plans for their own use, development and implementing partners position their inputs
in a way that fits the broader “one plan:” of the sector. Development partners also ensure their
implementing partners and sub-contracted NGOs adhere to the HSTP harmonization manual
(HHM) so that their activities and resources are reflected in the health sector’s plans and budgets.
Based on the health sector Code of Conduct signed by major development partners, agreements
with all funders need to reflect the priorities and targets of the strategic and annual plans of the
government. This also stipulates that finance from all sources will be translated into the Ethiopian
chart of accounts and fiscal year.
The overall planning framework consists of strategic and annual plans, and strategic plans such as
HSTP-II are to be cascaded to annual operational plans for their actual implementation. Both
strategic and annual plans are the results and consultations of top-down and bottom-up processes.
The top down process ensures alignment of regional and national priorities and targets with that
of the woreda’s. It also helps to create consistency between the health sector plans and those of the
Growth and Transformation Plans (GTP). The bottom up process ensures that the priorities and
targets of regions and districts and take local capacity into account. Furthermore, each
decentralized entity (health facility and health management structure) as well as the RHB should
have two plans - a Strategic Plan and an Annual Plan. The Strategic Plan is a reflection of HSTP
in that particular entity or structure, while the annual plan breaks down the strategic plan further
into shorter periods of time.
The principles governing both strategic and annual plans are:

- Government ownership and leadership to all health planning processes. It means that the RHB
and WorHOs have the responsibility to organize and lead the planning sessions and other
processes in which all stakeholders (government, development partners, NGOs, CSOs, private
sector, etc) will have active roles in the consultation. The plan and budget should also be
approved by the relevant local government authority through the formal political process.
- Linkage to resource mapping from all stakeholders (government, development partners,
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NGOs, CSOs, private sectors, etc.) which includes financial and non-financial resources in
line with the “one budget” strategic initiative
- Alignment to other plans vertically (strategic-annual) and geography (federal → regional →
woreda) as well as horizontally (including activities of all stakeholders operating at that
particular level). Annual plans represent the detailed operationalization of the five-year
strategic plan reflecting the priorities as well as the stipulated targets in sufficient details
within the specified time frame.
- Comprehensiveness in terms of: scope of covering all relevant activities (including those of
stakeholders) in the health sector; resource mapping with estimates of the total amount of
resources available from all sources; implementation schedule (quarterly/monthly) with major
activities and responsible bodies for implementing each activity; monitoring framework with
key performance indicators, baseline data, annual targets, sources and mechanisms of
collecting data; as well as reporting and feedback mechanisms.
6.4. Health Service Delivery Arrangements
The Ethiopian health service is restructured into a three-tier system- primary, secondary and
tertiary level health care13.
Figure 27. Ethiopian Health Tier System
The primary health care unit (PHCU) consists of health posts, health centre, and primary hospital.
These provide services to approximately 25,000 people altogether. Health posts are staffed by
13
Federal Ministry of Health (FMOH), Ethiopia. Health sector transformation plan (2015/16- 2019/20). Addis Ababa;
FMOH, 2015.
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health extension workers, and provide various preventive and health promotive services, in
addition to treating cases such as trachoma, scabies, malaria, pneumonia. They also refer clients
to health centers for services requiring higher level care. Health centers provide both preventive
and curative services, and also serve as referral canters and practical training sites for health
extension workers. Primary hospitals are engaged in the provision of inpatient and ambulatory
services to about one hundred thousand people. They also provide emergency surgery (including
caesarean sections and blood transfusions)14.
General hospitals are categorized under the second tier of health care. These hospitals provide
similar health care services as those of primary hospitals, and serve on average one million people.
They are referral canters for primary hospitals, and training centers for health officers, nurses, and
emergency surgeons.
The third tier in the Ethiopian health care system is the tertiary health care is that consists of a
specialized hospital that covers a population of approximately five million. It also serves as a
referral center for general hospitals.
Strengthening and expanding health services facilities within the framework of primary health care
through improving governance, ensuring equitable access to and utilization of quality health
services will continue to be the focus of HSTP-II. In addition, the transformation perspective will
work to redesign the service delivery system in a systemic reform that rationalizes the health
system such that high quality services are provided at the right level, by the right provider and at
the right time to optimize outcomes15. This implies that the health services delivery would be
transformed in a manner that enables it to respond to the dynamicity of epidemiologic transition
that is sweeping the country, in addition to making it resilient to withstand situations of emergency,
epidemics, as well as pandemics.
14 WHO. Primary health care systems (PRIMASYS): case study from Ethiopia, abridged version. Geneva: World
Health Organization; 2017.
15 The Lancet Global Health Commission. High-quality health systems in the Sustainable Development Goals era:
time for a revolution. Lancet Glob Health. 2018;6(11):e1196-e1252. doi: 10.1016/S2214-109X(18)30386-3.
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6.5. Optimizing Monitoring and Review Systems
The monitoring and evaluation framework for HSTP-II has been extensively outlined in chapter
seven. The critical issues in optimizing the monitoring and evaluation system are strengthening
the health management information system, and creating and strengthening linkages between
health-related evidence with policy and practice.
The health management information system within the sector is being updated with recent
technological development, and DHIS2 is being rolled out at all levels of the health delivery
system. Issues of completeness and timeliness of data are among the critical challenges that are
expected to be addressed within the information revolution – one of the key transformation agenda
of the HSTP. There is also an ongoing initiative to catalyze and accelerate the process of data use
within the health sector.
The FMOH and EPHI collaborate and closely work with the CSA and the newly restructured
Immigration, Nationality and Vital Events Agency (INVEA) through the conduct of population
and facility-based surveys as well as in streamlining and strengthening the vital events registration
system within the country.
Despite these efforts and initiatives, the monitoring review system within the health sector remains
plagued by the absence of functional linkages across central, regional and woreda levels; inability
to sustain timely and complete reporting; and low level of data use for action and decision making.
With regard to research in particular, there is concern at all levels that the linkage of evidence to
policy and practice is very poor. Research activities also tend to be mostly descriptive rather than
being operational for helping in monitoring performance of plans or for being translated into
concrete practice at policy and program levels. Concerns have also been expressed over poor
coordination and the limited funding resources available for research. Strengthening functioning
and linkages for research advisory councils (RACs) in the health sector is among the steps in
tacking these challenges. In addition, initiations of the RHB to closely work with Higher
Educations will be further strengthened with commitment at the level of senior management within
the sector.
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6.6. Inter-Sectoral Collaboration
Health being among the crucial element within the overall socio-economic development of a given
society, its realization requires the effort of various sectors, and not only that of the health sector.
Inter-sectoral collaboration for health is one of the five principles within the primary health care
movement, and its recognition has also been re-affirmed within the Millennium Development
Declaration which focuses on broad multi-sectoral approach for any national development plans,
including health.
In the implementation of HSTP-II, inter-sectoral collaboration will be realized within the

perspective of addressing all the determinants of health (personal, social, environmental,
economic, as well as political). This implies that improvements in the health status of populations
cannot be achieved by only focusing on health sector activities. This rather requires the rallying of
the collective actions by wide-ranging actors outside the health sector such as education,
environment, agriculture, housing and infrastructure, water, etc. within the ecological framework
of health determinants. Engaging these sectors involve the coordination different stakeholders
within the public sector, private sector, non-government agencies, civil services as well as
community level organizations. Among the key sectors and collaborations required include those
with:
- Education on training of health workers and school health promotion;

- Water resources for ensuring availability of adequate and safe water supply’
- Agriculture on nutrition, prevention and control of zoonotic diseases;
- Finance and economic development for harmonizing and improving resources for health;
- Media for creation of health awareness and dissemination of health-related messages;
- Women, youth, and sports affairs for gender equity as well as addressing adolescent health
needs;
- Transport for the prevention and control of road traffic accidents; and
- Housing and environment for proper infrastructure development and addressing issues of
pollution.
As the health sector alone cannot take such a huge role, a regional level mechanism is required in
bringing all of these different actors together for a common pursuit and towards improving health
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through concerted action.
The mechanisms for the realization of inter-sectoral collaboration include joint planning,
implementation, and evaluation of HSTP-II programs at all levels of the health system. The RHB
management coordinates the inter-sectoral effort together with Regional Joint Steering Committee
(RJSC).
6.7. Public Private Partnership
It is obvious that the private sector has strong presence in the health sector in the region, even
though largely limited to urban areas. Historically, it has existed much before the public health
system was properly organized. In addition to its quality gradient for some services, it expands the
resource base within the sector since the investments it brings are additional. Therefore, through
proper regulation, it can be delegated to provide and finance most curative services (and some
preventive care) that are of low public good nature. The government can also subsidize or facilitate
the development of the insurance system to deal with those curative services with catastrophically
costly private good nature.
Furthermore, the government will facilitate the private sector’s usual engagement in the expansion
of health infrastructure, local production of pharmaceuticals, as well as training and continuing
development of health professionals.
As almost all categories of health workers have their respective associations and societies,
provisions will be in place for delegating professional associations the responsibility of monitoring
and regulating proper practice in their respective specialties within the private sector.
6.8. Fostering Innovation through Health Technology Assessment and

Adaptation
Although research and development of technologies is the domain of the Ministry of Innovation
and Technology, the Federal Ministry of Health should also foster technological innovations that
facilitate and expedite the process of implementation of the HSTP-II activities.
The government can create the conducive environment for the smooth realization of the process
of innovation of health technologies across the spectrum of invention, technological assessment,
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adoption, and diffusion. In terms of innovation, the health sector can support the basic and applied
research efforts of universities and other research institutions. Governments can and should play
active part in supporting innovative approaches and facilitating the health technology assessment
process for effective adoption of successful endeavors. Particularly nowadays, there are promises
with the growing presence of mobile technology which can have positive influence in the
implementation of health care activities. Mobile and other IT related applications can foster
solutions for challenges of expanding health care access across large geographic areas, local
communities, and individual patients and providers.
In terms of health technology assessment, the FMOH also has established the health economics
and financing analysis team within the Cooperation and Resource Mobilization Directorate which
is tasked with spearheading the application of evidence-based health care decision making through
the compilation of evidence as well as in defining effectiveness measures for different health
technologies and programs16. Health technology assessment has been established as a tool for
priority setting in the health sector that helps to systematically evaluate innovative interventions,
and inform policy decisions in their application and resource allocation. The EPHI and AHRI are
among the institutions that are conducting research related to different interventions and
technology assessment programs.
Therefore, the process of health technology innovation and assessment is critical in the adoption
and diffusion of new and cost-effective health technologies that are relevant in improving the
performance of the sector.
6.9. Risks and Mitigation
During the implementation of the plan, the sector may encounter risks that may hamper the
achievement of results and the risks are identified through SWOT and stakeholder analysis. In
order to mitigate the major risks that the health sector may face, mitigation strategies are identified.
The following table summarizes the major expected risks and its mitigation strategies.
16Zegeye EA, Reshad A, Bekele EA, Aurgessa B, Gella Z. The state of health technology assessment in the
Ethiopian health sector: Learning from recent policy initiatives. Value in Health Regional Issues 2018; 16:61-
68.
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Table 7. Risks and mitigation strategies
S.No Risks Mitigation Strategy

1 COVID-19 and its The RHB, in close collaboration with the regional government and different Sector
effect on the health Bureaus, will actively work on the prevention and control of COVID-19. As a priority
system public health concern, its control will be enhanced through implementation of
appropriate and effective public health measures. In line with COVI-19 control, RHB
will implement strategies that ensures the continuity of the other essential health
services. Strengthening treatment centers, quarantine and isolation centers, making
adequate availability of logistics at health facilities, such as PPEs and appropriate
focus on the safety of health workers will be given a due attention.
2 Occurrence of The RHB will strengthen the public health emergency management system by
Health Emergencies improving the capacity for emergency preparedness, prevention, early detection and
response of emerging and re-emerging diseases and other emergencies. The RHB will
also strengthen the intra-sectoral and multi-sectoral collaboration, coordination among
different stakeholders, improve capacity as per the IHR recommendations and
enhance regular risk assessment at all levels. Emergency preparedness will be
strengthened for an effective emergency response to any emergency at all levels.
Strengthen health screening at POAs will also be strengthened
3 Inadequacy of The health sector will focus more on domestic financing to fill the financial gap
financial resource required during the HSTP II period. The following efforts will be done:
- Implementation of innovative domestic financing strategies to mobilize adequate
Reduction of sudden finance domestically will be implemented
donor fund (Low - Strengthen the implementation of CBHI and initiate implementation of Social
predictability of Insurance as an internal mechanism to increase financing to the health sector
external funding due - Strengthen public-private partnership
to world economic
recession)
4 Inadequate budget The health sector will work with the government and use strong evidence informed
allocation by the advocacy on adequate budget allocation to the sector. Improve political commitment
government to health at all levels of the health system
5 Weak inter-sectoral The RHB will work closely with the regional government and line Bureaus to
collaboration collaborate in addressing social determinants of health
6 Inadequate private The RHB will work with other Government Bureaus and Agencies, Civil Society
sector Organizations, the private sector to attract investment; strengthen Public-Private
involvement Partnership
7 Population The RHB will work closely with other government Bureaus and Agencies, Civil
displacements, in- Society Organizations, and neighboring countries to prevent and control cross-border
migrations and health and health related issues and health challenges at IDPs and refugee centers.
instability of Establishing service delivery points at IDP sites, refugee centers and strengthening
neighboring health services in these sites
countries
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Chapter 7: Monitoring and Evaluation Plan

7.1. Description of the Monitoring and Evaluation Framework
This M&E framework is an integral part of the HSTP II and will be used as a guide to monitor and
evaluate the performance of HSTP II implementation. The logic model is adapted from the recent
WHO’s Monitoring and Evaluation framework and includes the logical relationship from health
system inputs to outputs to outcomes and then ultimately to impact. It is depicted in figure -- below
and description of the domains and subdomains of the framework is also included. In addition to
the logic model, monitoring equity, quality, universal health coverage and other indices are
included in the M&E plan.
Figure 28. HSTP II Monitoring and Evaluation Framework
7.2. HSTP II Indicators
A total of 76 Core indicators are selected to monitor and evaluate the HSTP II. The impact,
outcome, output and input indicators were selected in a balanced way, using thoroughly defined
selection criteria including relevance, availability of data sources, measurability, sensitivity, and
alignment with national and international priority health interventions and requirements. Besides
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the most commonly used types of indicators, indices/composite indicators are included. The
indicators include baseline, midterm targets (2022), and end line targets (2025).
The period for data collection and analysis varies for each indicator. Some indicators are analyzed
on a monthly basis, others quarterly, annually, at 2-3 years, and at 5 years’ time. Target setting
was done using a One Health tool and considering criteria such as previous trend, baseline,
capacity, and national and international commitments. The process was participatory, with
iterative, consultative engagement of program experts and stakeholders; and participants—
learning from HSTP-I lessons—sought to make the targets realistic.
The current list of indicators identified in the HMIS will be revised according to the HSTP-II
requirement. In addition, agencies and programs in the health sector will have specific indicators
related to their operational and program monitoring and evaluation. The indicator matrix for the
76 core indicators is detailed in Annex I.
7.3. Index measurement in HSTP II
Monitoring Equity
In addition to measuring average or aggregate levels of indicators, it is essential to look at
performance by disaggregation (equity measures) to determine the equity of health service use,
health outcomes, and desirable healthy practices using key equity lenses. The commonest equity
parameters include demographic (age and sex), geographical (urban/rural and regional differences)
and socioeconomic characteristics (wealth and education).
Selected tracer indicators will be analyzed by equity parameters. The plan is to regularly monitor
and design interventions to reduce the inequality in selected parameters. Equity analysis report
will be developed at least every year or two, based on the type of indicator, and distributed to
stakeholders. The targets for the tracer equity indicators appear in Annex 2.
Monitoring Quality of Care

Quality measurement and improvement is an ongoing process and is an integral part of the national
health M&E system. In this HSTP, quality of services at health facility level will be measured
based on the quality standards and measurement tools set for selected health services at hospitals
and PHCU levels. The aim is to continuously measure and improve quality of health care at point
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of service delivery, based on various quality dimensions. Quality of services will be measured with
quality of health care indicators such as reports of “positive user experience” during essential
services, safety assurance during the care process, and effectiveness of the care process.
Monitoring Universal Health Coverage

Universal health coverage (UHC), which is about attaining effective coverage of essential health
services and protecting people from financial hardship, will be measured using an index in this
HSTP-II period. The index is composed of 18 tracer indicators selected based on international
recommendations, and adapted from WHO’s tracking UHC. Definitions for the index were
developed to ensure international comparability. The tracer indicators may be changed, as there is
an international revision process by WHO that we may adapt to the Ethiopian context. In 2019,
the UHC index for Ethiopia was 0.43; the target in 2024/25 is 0.58.
Monitoring Health system responsiveness

The description and component of health service responsiveness is clearly stated in the separate
“Monitoring and Evaluation Plan of HSTP-II” document. It is adapted from WHO’s framework to
assess the status of health and health systems. The health service responsiveness index mainly
measures the quality of the non-clinical aspect of health care provision. Health service-
responsiveness assessment will be conducted every 2-3 years. Currently the baseline is 0.52, and
the target at the end of the HSTP-II period is 0.60.
Monitoring Demand Index
Effective demand for essential services reflects the potential for households and communities to
utilize the essential preventive and curative services they need. Demand can be analyzed based on
repeat services to identify how well the services provided are aligned to the needs of the people.
The poorer the demand, the lesser value given by the population to the services. The demand index
will be measures using the following indicators:
1. ANC1 _ ANC 4 dropout rate
2. Penta1 _ Penta3 dropout rate
3. BCG – MCV1 dropout rate
4. TB treatment dropout rate
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Monitoring Health Security Index

The health security index is measured by IHR core competencies, which are organized under four
major health security domains (prevention, detection, response, and others). The Ethiopian Public
Health Institute will conduct a health security assessment on a yearly basis. HSTP-II plans to
increase the health security index from 0.63 to 0.78.
Resilience index
The resilience index is derived from analysis of responses from key informants in relation to
resilience attributes in their systems, which include awareness, diversity, versatility and self-
regulation, and mobilization, adaption and integration. This assessment will be conducted every 5
years. The Ethiopian Public Health Institute will be responsible for conducting a survey to
determine the resilience of the health system. Based on the report from WHO for Africa region,
the resilience score for Ethiopia in 2019 is 0.49, and the plan in the HSTP-II period is to increase
it to 0.50.
7.4. Transforming data into information and action: the data cycle
HSTP identified evidence based decision-making as one of the strategic directions to transform
use of information in the sector, including the M&E system. The cycle includes how data is
gathered, analyzed, interpreted, reported, shared and used in decision making.
This section will describe components of data cycle. It highlights the current situation and indicates
improvements to be made in the coming years. To address the requirements for M&E of the HSTP,
a national HIS strategy will be developed and implemented.
Data sources
The common data sources used to measure and inform HSTP-II include routine and non-routine
data sources.
Routine health information sources: This includes routine sources such as HMIS, the regulatory
information system, the health commodity management information system, the human resource
information system, civil registration and vital statistics, the health insurance information system,
the integrated financial management information system, and administrative reports. Data from
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both public and private sectors will be gathered to provide a full picture of health system
performance.
Non-Routine health information sources: This includes population and housing census surveys,
Demographic and Heath Surveys, and other surveys and assessments, as well as research findings
and other non-routine data sources such as burden of disease studies, modeling for HIV estimates,
and others.
E-health architecture
The Ethiopian eHealth Architecture illustrates how distinct IT components form a coherent and
holistic national HIS that provides an increasingly sophisticated set of business capabilities to the
health sector. The eHealth architecture supports coordination of IT choices and appropriate
resource utilization, minimizing duplication of effort and facilitating access to and integration of
data. During the strategic period, the e-Health architecture will be implemented with the aim of
improving data quality and use, interoperability between and across eHealth applications,
performance monitoring, and sharing of information.
Data quality
Improving the quality of data for a meaningful decision-making process will be a focus in this
HSTP. Interventions in this domain will tackle technical, organizational, and behavioral factors
affecting the quality of data. Improving data quality requires the effort of every actor in the health
sector, primarily every health workers, and comprehensive implementation of techniques for
improving data quality.
Data quality-assurance techniques will be implemented holistically at each level of the health
system. As part of external verification process, and to enhance reliability and credibility, data
quality audit (DQAs) will be conducted every two years by the Ethiopian Public Health Institute.
Data reporting
A standard reporting format, channel and schedule will be used for reporting of routine health data.
HSTP-II will regularly assess reporting mechanism and implement interventions to ensure
accountability towards “Zero Tolerance for Parallel Reporting.” Ethiopia will contribute to global
reporting to produce global statistics and assessment in support of global goals (such as Sustainable
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Development Goals) and will comply with International Health Regulations concerning selected
epidemic-prone diseases and public health emergencies of international concern.
Use of information for action
Improving data demand, information culture, knowledge management, learning, and capacity to
change data into meaningful information and use it for action will be priority at all levels,
particularly service delivery points. Local levels will employ simple analysis mechanisms, while
regional and federal levels will apply advanced data analytics to produce estimates, projections,
and modeling, and to synthesize research and findings and articulate insights for coordinated
development and revision of policies and strategies. Development and use of digital tools will
enhance data analysis, reporting, visualization, and tracking.
Data use at the facility level will predominantly be led by the performance monitoring team, which
will also guide and oversee other data use platforms, such as departmental-level data reviews,
quality improvement processes, clinical review sessions, and other data use forums. Additional
platforms will also be employed for data use.
Performance review
Regular, participatory performance review meetings will be undertaken every two months,
quarterly, biannually and annually at different levels. During performance reviews, all relevant
stakeholders will meet and review the performance of the sector. The overall annual performance
of the sector will be reviewed during the Annual Review Meeting. Each level of the health system
will conduct programmatic and general evidence-based performance review regularly.
7.5. Evaluation
Evaluation of HSTP-II activities will take place at mid-term (2022/23) and end-term (2025) to
assess the status of attainment of set objectives and targets. The mid-term evaluation will assess
progress towards achievement of results and generate lessons learned, while the end-term will
inform development of the subsequent strategic plan. In addition, Joint MPH-HPN Review
Mission (JRM), will be executed as scheduled in the HHM. MOH will strengthen the capacity of
regions to conduct self-evaluation that considers their specific context. Impact evaluation will also
be conducted for selected interventions as deemed necessary.
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7.6. Dissemination and communication
Monitoring and evaluation findings will be disseminated to stakeholders using different channels.
Monthly, quarterly, and annual reports will be produced according to the Health Harmonization
Manual. Biannual and annual performance reports will be produced and submitted to the relevant
government bodies; and M&E digests, health bulletins, newsletters, and fact sheets will be
produced as per established schedules. Health and health-related indicators will be produced
annually at RHBs and MOH level. MOH will strengthen electronic outlets, such as the website
and social media, for dissemination of results. Documentation of best practices and dissemination
of results will also be promoted at the international level through participation in international
conferences, contribution to the debate on global health issues, and publication of scientific articles
in international journals.
Data access and sharing

A data access and sharing protocol will be developed and implemented in the strategic period,
designed to institutionalize a proactive approach for releasing data to stakeholders and to the
public. The protocol lays out a process for routine and ad-hoc release of health data at all levels of
the health system. Relevant data will be shared with the public via websites and other channels.
7.7. Coordination, Policy and Institutional Environment for Monitoring

and Evaluation
▪ The Ethiopian public health institute is mandated to conduct health related survey and research.
However, overall coordination of M&E in the sector is the responsibility of the unit responsible
for M&E of HSTP. Additionally, this unit will map, coordinate and lead the planning and
execution of surveys, operational research and evaluations and also documentation and sharing
of findings.
▪ HSTP promotes the involvement of all stakeholders (community, health workers, Partners,
civic societies etc) in the planning, implementation, review and M&E process. The community
will be involved in rating the health system as well as the level of community involvement/
contribution in the health sector will be assessed. Community scorecard will be implemented
to regularly measure the responsiveness of the health system, satisfaction of the community
and identify priority areas of the health sector.
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▪ Joint coordination platforms will be used for planning, monitoring and evaluation. The
platforms include, Joint Steering Committee, Joint Consultative Forum, and Joint Core
Coordinating Committee (described in the “Implementation Arrangement” chapter) .
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ANNEXES
Annex 1: Indicators and Targets of HSTP II
The indicator matrix includes the name of the indicator, its category, type, data source, baseline and targets of HSTP-II
Table 8: Harari Regional Health Bureau HSTP- II core indicator matrix
Baseline
Frequency of Target
Type of Level of Data Routine Baseline
S/N Indicator Data Source data collection 2017EFY
Indicator Collection 2012 Survey
/Analysis (2024/25)
EFY
General
1. Healthy Life Expectancy at Birth (years) Impact Population World health 5 years 65.5 68
Statistics
2. UHC Index Outcome Facility Mixed (HMIS, 2-3 years 0.43 0.58
DHIS, EHIA)
3. Proportion of clients satisfied during their last
health care visit (Client satisfaction rate) Outcome Facility KPI Report Quarterly 46% 60% 75%
Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health and Nutrition
4. Maternal Mortality Rate per 100,000 live births Impact Population EDHS- National 5 years 401 279
5. Under5 mortality rate per 1000 LB Impact Population EDHS 2016 5 years/2-3 yrs 72 43
(Harari)
6. Infant mortality rate per - 1,000 LB Impact Population EDHS 2016 5 years/2-3 yrs 57 35
(Harari)
7. Neonatal mortality rate - per 1,000 LB Impact Population EDHS 2016 5 years/2-3 yrs 34 21
(Harari)
8. Contraceptive Prevalence Rate (CPR) Outcome Population Mini-EDHS 2019 5 years/2-3 yrs 30.3% 50%
9. Proportion of pregnant women with four or more Outcome Facility/population HMIS/Mini-EDHS Monthly/ 5 years 50% 38.8% 85%
ANC visits
10. Proportion of deliveries attended by skilled health Outcome Facility/population HMIS/ Mini-EDHS Monthly/ 5 years 84% 64.9% 100%
personnel
11. Early PNC within two days coverage Outcome Facility/population HMIS/ Mini-EDHS Monthly/ 5 years 91% 45.2% 95%
12. Caesarean Section Rate Outcome Facility/population HMIS/EDHS Monthly 21% 21% 15%
13. Still birth rate (Per 1000) Impact Facility HMIS Monthly 47 20
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Baseline
Frequency of Target
/Analysis (2024/25)
EFY
14. Proportion of asphyxiated new-borns resuscitated Outcome Facility/population HMIS Monthly 100% 41% 85%
and survived
15. Proportion of newborns with neonatal sepsis/Very Outcome Facility/population HMIS/EDHS Monthly/ 5 years 100 26.2% 45%
Sever Disease (VSD) who received treatment
16. Proportion of under five children with Pneumonia Outcome Facility/population HMIS/EDHS Monthly/ 5 years 33% 60% 78%
who received antibiotics
17. Proportion of under five children with diarrhea Outcome Facility/population HMIS/EDHS Monthly/ 5 years 13% 44% 90%
who were treated with ORS and Zinc
18. Pentavalent 3 Immunization coverage Outcome Facility/population HMIS/ Mini-EDHS Monthly/ 5 years 100% 52.8% 100%
19. Measles (MCV2) immunization coverage Outcome Facility/population HMIS/ Mini-EDHS Monthly/ 5 years 74% 58.7% 100%
20. Fully immunized children coverage Outcome Facility/population HMIS/ Mini-EDHS Monthly/ 5 years 90% 45.8% 100%
21. Mother to Child Transmission Rate of HIV Impact Population Modelling/Spectrum 2-3 years 13.4% <5%
22. Teenage pregnancy rate (%) Impact Population HMIS/EDHS Monthly/5 years 23% 12.5% 7%
23. Stunting prevalence in children aged less than 5 Impact Population Mini-EDHS 5 years/2-3 yrs 34.7% 25%
years (%)
24. Wasting prevalence in children aged less than 5 Impact Population Mini-EDHS 5 years/2-3 yrs 4.2% 3%
years (%)
Disease Prevention and Control
25. Proportion of people living with HIV who know Outcome Population EDHS 5 years 99% 100%
their HIV status
26. Percentage of people living with HIV who Outcome Facility HMIS Monthly 96% 100%
receives ART (ART coverage)
27. Percentage of people receiving antiretroviral Outcome Facility HMIS Monthly 97% 100%
therapy with viral suppression
28. TB case detection rate for all forms of TB Outcome Facility HMIS Quarterly 100% 100%
29. TB treatment success rate Outcome Facility HMIS Quarterly 99% 100%
30. Number of MDR TB cases detected Outcome Facility HMIS Quarterly 11 15
31. Grade II disability among new cases of leprosy Outcome Facility HMIS Quarterly 0 0
32. Malaria mortality rate (Per 100,000 population) Impact Population HMIS Monthly 0 0
33. Malaria incidence rate (per 1000 Population) Impact Population HMIS Monthly 6.3 2
34. Risk of premature mortality from Major Non- Impact Population WHO report 2016 2-3 years 18% 14%
Communicable Diseases
35. Proportion of Women age 30 - 49 years screened Outcome Facility HMIS Monthly 2% 40%
for cervical cancers
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Baseline
Frequency of Target
/Analysis (2024/25)
EFY
36. Mortality rate from all types of injuries (per Outcome Facility HMIS Monthly 79 67
100,000 population)
37. Cataract Surgical Rate (Per 100,000 population) Outcome Population HMIS Quarterly 44 89
38. Proportion of hypertensive adults diagnosed for
HPN and know their status Outcome Facility/Population STEPS/HMIS 5 years/Annual 40% 50% 60%
39. Proportion of hypertensive adults whose blood Outcome Facility HMIS Monthly 83% 90%
pressure is controlled
40. Proportion of DM patients whose blood sugar Outcome Facility HMIS Monthly 92% 100%
level is controlled
41. Coverage of services for severe mental health
disorders
• Psychosis Outcome Facility HMIS Monthly 20% 50%
• Depression Outcome Facility HMIS Monthly 5% 30%
• Bipolar management Outcome Facility HMIS Monthly 20% 50%
• Epilepsy management Outcome Facility HMIS Monthly 60% 80%
• Substance Use Disorders Outcome Facility HMIS Monthly 1% 20%
Hygiene and Environmental Health
42. Proportion of households having basic sanitation Outcome Household HMIS/survey 5 years/Quarterly 78.7% 85%
facilities
43. Proportion of kebeles declared ODF Outcome Kebele HMIS Quarterly 64.7% 95%
44. Proportion of households having hand washing Outcome Household EDHS 5 Years 5.5% 45%
facilities at the premises with soap and water
Health Extension Program and Primary Health Care
45. Proportion of Model households Outcome Household HMIS Quarterly 77% 80%
46. Proportion of health centers providing emergency Input Facility HMIS Annual 0% 50%
surgical care
47. Proportion of high performing Primary Health Outcome Facility HMIS Quarterly 0% 80%
Care Units (PHCUs)
48. Proportion of health posts providing
comprehensive health services Input Facility HMIS Annual 0% 30%
Medical Services
49. Outpatient attendance per capita Outcome Facility HMIS Annual 1.2 2.5
50. Bed Occupancy Rate Output Facility HMIS Monthly 45% 75%
Page 145
Baseline
Frequency of Target
/Analysis (2024/25)
EFY
51. Proportion of patients with positive experience of Outcome Facility Survey 2-3 years 33% 54%
care
52. Institutional mortality rate Impact Facility HMIS Monthly 4% <1%
53. Percentage of component Production from total Output Blood Banks Blood Bank Annual 20% 65%
collection Reporting System
54. Ambulance Response rate Output Facility HMIS Monthly 85% NA 100%
Public Health Emergency management (PHEM)
55. Health Security Index Outcome Facility Assessment of Annual 0.63 0.78
health institutions
56. Proportion of epidemics controlled within the
standard of mortality Outcome Facility PHEM Report Monthly 85% NA 100%
Health system Input Indicators
57. Availability of essential medicines by level of Input Facility SARA/HMIS Annual/Monthly 79.20% 90%
health care
58. Prevalence of unsafe and illegal food products in Outcome FDA-Regional National food 2-3 years 40% 30%
the market consumption survey
59. Percentage of substandard and falsified medicine Outcome Regional- regulatory Regulatory survey 2-3 years 8.6% 6%
in the market
60. Out of Pocket Expenditure as a share of total Outcome Population NHA 2-3 years 31% 23.2%
health expenditure (THE)
61. General government expenditure on health Outcome Population/FMOH NHA/Finance report 2-3 years/Annual 8.07% 12%
(GGHE) as a share of total general government
expenditure (GGE)
62. Total health expenditure per-capita (USD) Input Population NHA 2-3 years 33 59.9
63. Proportion of eligible households enrolled in Out come EHIA Insurance Annual 35% 80%
Community Based Health Insurance (CBHI) Information System
64. Proportion of eligible Civil servant employees Input Population Insurance Quarterly 0% 100%
covered by Social Health Insurance (SHI) Information System
65. Incidence of catastrophic health spending Impact Population Household Survey 2-3 years 2.10% 1.80%
66. Proportion of Primary Health Care Facilities Input Facility Admin report Annual 75% 100%
implemented Community Score Card
67. Reporting Completeness Input Facility HMIS Monthly 94% 100%
Page 146
Baseline
Frequency of Target
/Analysis (2024/25)
EFY
68. Proportion of health facilities that met a data Input Facility Facility Annual 0 92%
verification factor within 10% range for selected Assessment/RDQA
indicators
69. Proportion of births notified (from total births) Input Facility HMIS Monthly 80% 95%
70. Proportion of deaths notified (from total deaths) Input Facility HMIS Monthly 53% 70%
71. Health workers density per 1,000 population Input Facility HRIS/HMIS Annual 3.6 4.5
72. Health care workers’ attrition rate Outcome Facility HRIS Annual NA 6.2% 4.5%
73. Proportion of health facilities with basic Input Facility HMIS Annual
amenities (water, electricity, latrine etc.) 57% 90%
- Improved water supply 76% 90%
- Electricity 61% 90%
- Improved latrine
58% 90%
- Basic healthcare waste-management
services
74. Proportion of health facilities implementing
compulsory Ethiopian health facility standard Input Facility RIS Annual 53% 80%
Page 147
Annex 2: Equity Indicators

Table 9. Core Equity Indicators
No Equity Indicators Data Source Baseline Target

1 Ratio of deliveries assisted by Skilled Birth Attendants between HMIS/Survey 0.25 0.50
Rural and Urban
2 Ratio of SBA between lowest and highest wealth quintiles Survey 0.16 0.50
3 Ratio of pentavalent 3 coverage between the lowest quantile EDHS 0.57 0.75
and highest quantile
4 Ratio of OPD attendance between Males and Females HMIS 0.89 0.92
5 Ratio of OPD attendance between Rural and Urban HMIS 0.21 0.90
6 Ratio of Stunting between urban to rural EDHS 0.65 0.75
7 Ratio of “Coverage of currently on ART” between pediatrics HMIS 0.54 0.80

(<15) and Adults (>15)
8 Ratio of facilities with basic amenities (water, electricity, SARA 0.62 0.90
sanitation facilities and ICT network) between rural and urban
9 Availability of essential drugs by Rural and Urban facilities LMIS NA 0.90
Page 148
Annex 3: Health facilities planned to be constructed and rehabilitated from 2013-

2017EFY
Table 10. facilities planned to be constructed in Harari Region from 2013-2017

S/N Types of Health Facility Years in Ethiopian Calendar Total
2013 2014 2015 2016 2017
1 2nd Generation Health Post 2 2 2 2 2 10
2 Primary Hospital 0 1 0 1 0 2
3 General Hospital 0 0 0 0 1 1
Table 11.Facilities planned to be rehabilitated in Harar region from 2013-2017

S/N Types of Health facility Years in Ethiopian Calendar Total
2013 2014 2015 2016 2017
1 Health post 1 2 1 2 1 7
2 Health center 0 1 1 0 1 3
3 Rehabilitation Center 0 1 0 0 0 1
Page 149

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የሐረሪ ህዝብ ክልላዊ መንግስት

Harari People`s Regional State

Health Sector Transformation Plan- II

(2013 EFY – 2017 EFY)

3.3.6. Laboratory Quality Improvement Program............................................................................... 51

Chapter 5: Costing and Financing……………………………………………………………………..115

AIDS Acquired Immunodeficiency Syndrome

EHSTG Ethiopian Hospital Services Transformation Guideline

JSC Joint Steering Committee

PMTCT Prevention of Mother to Child Transmission of HIV

List of Tables and Figures

Despite significant improvements, the prevalence of non-communicable diseases (NCDs) and

Ibssa Ibrahim (BSC, MSC)

Head of Harari RHB

Planning Core Technical Team

Planning Technical Working Group

making an in-depth situational analysis and performance evaluation of HSTP-I, and in

• Strengthen governance and leadership;

Chapter 2 Regional Profile

2.3. Education status

2.5. Administrative System

2.6. Health system Organization

Chapter 3: Performance and Situational Assessment of the first

3.1. Progress of HSTP I Transformation Agendas

3.1.1. Woreda Transformation

 Ensuring transparency and accountability at primary health care unit level.

3.1.2. Quality and Equity in Health Care

3.1.3. Information Revolution

Regional DHIS-2 Rollout

Cultivating an Information Use Culture

Improving Health Data Quality

3.1.4. Producing Compassionate, Respectful and Caring (CRC) Health Workforce

3.2.1. Improve Health Status

Figure 3: Life time expectancy at birth of Ethiopia (2007-2018)

Major causes of morbidity and mortality

Figure 4:Major Cause of premature death in Ethiopia 2017

Figure5:Top ten causes of disability of Ethiopia,2007-2017

Risk factors driving morbidity and mortality

7 Burden of Disease Analyses for Ethiopia. http://www.healthdata.org/ETHIOPIA

3.2.2. Health Extension and Primary Health Service

3.2.3. Hygiene and Environmental Health

3.2.4. Reproductive, Maternal, Neonatal, Child, Adolescents and Youth Health

8 UN inter-agency estimates on maternal mortality

Maternal health services

ANC-4 Skilled Delivery PNC

Expanded Program Immunization

34.1% 42.2% 45.8%

Penta3 Measel Fully Immunized Penta3 Measel Fully Immunized

Stunting Under Weight Children Wasting

Adolescent and Youth Health

Prevention and control of HIV/AIDS

Prevention and control TBL, TB/HIV and MDR TB Disease

Tuberculosis Treatment Outcome

TB Treatment success rate and cure rate

MDR-TB Case Finding

100% 100% 99% 100%

Leprosy prevention and control