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UNIVERSITY OF GONDAR

COLLEGE OF MEDICINE AND HEALTH SCIENCES

SCHOOL OF PUBLIC HEALTH

DEPARTMENT OF EPIDEMEOLOGY

Implementation and outcome of health facility (Health Centre

and Hospital) reform towards improving health service delivery
in Ethiopia: Narrative review

By :

Sofeian Seid

Submitted to: Endalkachew Dellie (BSC/MPH)

Department of Health Systems and Policy

May, 2023

Gondar, Ethiopia

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Contents
1. Introduction...................................................................................................................................3
2. Statement of the problem...............................................................................................................3
3. Major findings...............................................................................................................................3
4. Challenges and Opportunities........................................................................................................7
5. Conclusion and Policy Implication................................................................................................7
6. References.....................................................................................................................................8

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1. Introduction
The Ethiopian health sector related reforms are health care financing reform, health facility
insurance scheme, Health Sector Development Program and Woreda based planning,
business process reengineering, balanced score card, decentralization, joint governance and
coordination, health facility governance, and auditable pharmaceutical transactions services
(1).

This narrative review provides an overview of 6 papers chosen for five reforms from among
those related to implementation and outcome of health facility (Health centre and Hospital)
reform toward improving health service delivery in Ethiopia published.

2. Statement of the problem

Reform implies progress. Reforming the health system, however, calls far more than just
general health and medical improvements. Data for Decision-Making put up a definition of
health sector reform as ‘sustained, purposeful and fundamental change’ in 1995.

A ‘sustained’ in the sense that is not a ‘one-shot’ temporary effort that will not have lasting
effects, ‘purposeful’ in the sense that it results from a logical, planned, and evidence-based
process, and ‘fundamental’ in the sense that is addresses significant, strategic aspects of
health systems (2). Reforming the health sector can undoubtedly involve a variety of actions
affecting the health systems. As a result of implementing health sector reforms, over the past
ten years, Ethiopia’s health system has made outstanding strides in terms of a variety of
population, nutrition, and health metrics. The nation completed its Millennium Development
Goals. Early on, set goal for improving child health (3). According to the 2011 (DHS), under-
five mortality decreased by 47% and infant mortality by 42% over the 15 years before to the
study. Over the past 20 years, new facilities have been built, existing facilities have been
renovated, and primary health care centre under gone significant expansion. The number of
health posts has more than doubled and the number of health centres has virtually quadrupled
(4).

3. Major findings
Table 1 the papers included in this review
Authors Title Research Place in which data
methodology collected
USAID Health care financing reform Review report Ethiopia

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in Ethiopia: A path to
FROM THE sustainable financing while
AMERICAN improving quality and equity
PEOPLE
USAID Health facility governance in Review report Ethiopia
FROM THE the health system
AMERICAN
PEOPLE
Federal ministry of HSTP 2015/16 – 2019/20 HSTP Final Report Ethiopia
health
Sameh El-Saharty, Ethiopia: Improving health Book Ethiopia
Sosena Kebede, service delivery
Petros OLango
Dubusho,
Banafsheh Siadat
Lalisa M Gdisa Decentralization and health Journal of scientific Ethiopia
sector reform: Lessons from research
Ethiopia Biomedical
informatics
USAID AND Transforming pharmaceuticals SIAPS Technical Ethiopia
system for services in Ethiopia through brief
improved access to auditable pharmaceutical
pharmaceuticals transactions and services
and
services(SIAPS)

1) Implementation and outcome of health care financing reforms on health service delivery
Ethiopia
In order to achieve long-term sustainability, the health care financing reform approach
recognises that the health care should be paid through a variety of mechanisms. Highlighted
how crucial it is encourage cost-sharing while delivering of health care. Nine separate
interventions were made as part of the reforms.
 Utilisation and retention of revenue at the level of health facility
 Making a fee waiver scheme
 More organised establishing uniform exemption services
 Outsourcing of nonclinical services in public hospitals

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 Determining and changing user fees

 Launching health insurance programmes
 Building private wings in public hospital
 By implementing a governance of system, establishing health facility autonomy
Outcomes on health service delivery
The reform gave health care facilities the ability to keep their income and use it to raise the
standard of their income and use it to raise the standard of their services. The three major
areas’ hospital and health centres started to keep money. In 2005-2006, and now being
implemented across the country as a nationwide programme. Budgets for health care facilities
have greatly improved as a result of revenue retention. In 146 health centres, the revenue kept
in 2011 represented an average of 36.3% of the overall health budget.
The quality and scope of services have improved as a result of the health facility’s increased
revenue. The general efficacy and effectiveness of the health system have increased as a result
of better health care quality, the introduction of new fee waiver programme, which prioritises
underserved populations, defends the under privileged, and encourages equity within the
system. Key preventive and health promotion initiatives that lessen illness burden can now be
more widely implemented thanks to standardisation and promotion of exemption schemes.
Improved administration of healthcare facilities, increasing outsourcing of nonclinical
activities in public hospitals, increased financial management ability, and increased utilisation
of health care as a result of health insurance scheme pilot programmes are other significant
reform accomplishments.
2) Health facility governance reform in the Ethiopian health system
As part of a larger health care financing reform, the government implemented facility
governance boards to enhance the governance structure at locations of service delivery.
Meetings of the hospital board and the management committee for the health centre must be
convened quarterly in accordance with regional laws. There are three main areas that
highlight the significance of governance structures in improving the performance of health
care institutions, according to the numerous supporting supervision reports produced by
health sector financing reform report.
 Boards and governing boards are promoting community involvement
 Boards are now vocal supporters of greater resource mobilisation for infrastructures
 The main governing and decision-making body are facility boards
3) Health Sector Development Program(HSDP) and Woreda based planning implementation
arrangements and outcomes in service delivery
The Ethiopian health service is restructured into three tier system; primary, secondary and
tertiary level of care. The primary level of care includes primary hospital, health centre and
health post. The primary health care unit is made up of five satellite health posts and health

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centre. A total of 25,000 persons receive service from these. It offers both curative and
preventive therapies. It acts as a resource centre and a place where health extension workers
can receive practical training. A health centre has five inpatient beds available. An average
population of 100,000 people receives inpatient and outpatient care from primary hospital. In
addition to what a health centre may offer, a primary hospital offers access to blood
transfusion services and emergency surgical treatments, including caesarean sections.
Additionally, it acts as a training facility for nurses and other paramedical health
professionals, a referral centre for health centres within its catchment areas, and a centre for
practical training. A primary hospital has an inpatient capacity of 25 to 50 beds. An average
of 1,000,000 people receives inpatient and outpatient treatment from a general hospital. There
are typically 234 experts working there. It functions as a referral hub for primary hospital. It
functions as a training facility for the types of health workers known as health officers,
nurses, and emergency surgeons. An average of five million individuals receives care at
specialised hospital. It is referral for general hospitals.
Two planning cycles make Ethiopia’s health planning. The five-year strategic planning cycle
known as the HSDP is the first and most important reference planning cycle. It acts as the
model from which all other plans, such as Regional health plans, are created. The second is
the annual planning cycle, which converts the five-year HSDP into annual plan of work that
contains information about practical goals, plans, and initiatives for the varies tiers of the
health care system.
Outcomes of the implementation
Improvement were seen in the outcomes and health service delivery output levels following
the introduction of both HSDP I and II between 1998 and 2005, including indicators for
mortality, morbidity, coverage, and utilisation. During the period 2000-2005, substantial
according to the EDHS, maternal health showed modest improvement while child health
indicators showed gains.
4) Decentralization implementation modalities and outcomes on service delivery in Ethiopia
The assumption beyond health service decentralization is that will enhance the delivery of
medical care. One presumption is that local communities have a better understanding and
circumstances in their area and can if given the power to organise and provide health services,
manage resources, and make choices, they will do so more effectively. Decentralisation is the
transfer of power and responsibility from central agencies to branch offices at several levels,
including local, regional, provincial, and/or state. Transferring power and responsibility from
central agencies to groups that are not immediately under their direct control. This often
includes semi-autonomous organisations in the health sector such health boards and hospitals
as well as agreements where non-governmental organisations carry out specific service
provisions on the behalf of the central government.

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5) Implementation and outcomes of Auditable Pharmaceutical Transactions and Services(APTS)

The implementation of APTS entails a number of procedures, each of which include a number
of interventions. These procedures may be carried out concurrently and are controlled at
various levels of the health system.
They include:
 Creating and implementing federal and regional regulations
 Regional federal APTS tool design and printing
 Workforce development and modification(facility, regional/federal)
 Baseline evaluation(facility)
 Inventory of all medications and APTS launch(facility)
 Infrastructure upgraded and pharmacy unit reorganisation
 Progress and performance are continuously monitored at the regional, federal, and
facility levels

Outcomes of APTS are as follows performance data management, transparent and

accountable transactions, effective workforce deployment and development, reliable
information, efficient budget utilization, and improved customer satisfaction.

4. Challenges and Opportunities

Challenges are inadequate health infrastructure, shortage of qualified health professionals,
limited financial resources, poor quality of services, weak health management and
information system, limited community participation.

Opportunities are decentralization and local governance, collaboration with the private sector
and non-governmental organization (NGO), leverage technology and digital health, capacity
building and human resources development, expanding health insurance coverage, and
inclusive policy-making and community engagement.

5. Conclusion and Policy Implication

In conclusion, the implementation of health facility reforms in Ethiopia has shown a positive impact
on the quality and accessibility of health care services for its population. This is evidenced by
decentralization of the health system, the expansion of infrastructure, and the increased number of
qualified health professionals. Additionally, improvements in service areas as family planning,
maternal and child healthcare, and the treatment of infectious disease have been reported.

However, challenges still persist in terms of equity, human resource management, and financial
sustainability of the health care system. Therefore, it is necessary for the Ethiopian government and its

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partners to the continue working together to improve the country’s healthcare sector. Some policy
implication to consider for future health facility reforms include:

 Strengthening the decentralization process: It is crucial to focus on strengthening the

decentralization process by increasing decision-making authority and resource
allocation at the regional and district levels. This can lead to improved
responsiveness, better planning, and efficient allocation of resources to local health
needs.
 Addressing equity concerns: Policy interventions should target the provision and
accessibility of healthcare services for vulnerable and marginalized populations,
focusing on rural areas and populations living in poverty.
 Improving human resource management: To improve the quality of healthcare in the
long-term, Ethiopia needs to invest in the training, development, and retention of
healthcare professionals. This includes addressing issues such as inadequate staffing,
poor working conditions, lack of opportunities for career advancement, and low
morale among healthcare workers.
 Ensuring financial sustainability: In order to achieve sustained improvements in
health outcomes, the Ethiopian government should develop strategies for mobilizing
adequate resources and using resources efficiently. This could include increasing
government spending on healthcare, exploring alternative financing mechanisms such
as insurance schemes, and promoting public-private partnerships.
 Enhancing accountability and governance: Finally, strengthening accountability and
governance at all levels of the health system is essential for progress in health reform.

6. References
1. (2017). LMG in service training manual for manager at hospital and health centre participant
guide.

2. Berman, P. (1995). Health Sector Reform : Making Health Development Sustainable. Health
Sector Reform In Developing Countries: Making Health Development Sustainable. P.
Berman. Boston, Harvard University Press(13-33).

3. (2012). Health sector development programme IV (HSDP IV) midterm review report. Addis
Ababa, Ethiopia, Ministry Of Health.

4. (2012). Health and health related indicators Addis Ababa, Ethiopia, Ministry of Health.

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