Ethiopia
CASE STUDY
Ethiopia
One of the first countries to join the GFF—in 2015—Ethiopia has made substantial progress in reducing under-five mortality, maternal deaths, and adolescent fertility. These achievements are impressive, but the Government of Ethiopia recognizes that continued efforts are needed to strengthen the nation’s health system to achieve the objectives of its investment case. That investment case, called the Health Sector Transformation Plan (HSTP), aims to increase the equitable coverage of, access to, and use of essential health services.
The GFF partnership is supporting these efforts through various streams of work, including:
- Policy dialogue to track, mobilize, and align resources (both domestic and external), improve efficiency of spending, and strengthen the implementation of the HSTP;
- Support to the Health Sustainable Development Goals Program for Results project; and
- Increasing private sector engagement in the health sector.
Recent surveys have demonstrated considerable progress in Ethiopia’s coverage of key maternal and child health services, such as assisted births, contraceptive prevalence, antenatal care, and child nutrition services. Broader progress on health systems has also been demonstrated, through improvement in indicators related to, among others, the availability of community-based health insurance schemes and the coverage of the civil registration and vital statistics system. However, several challenges remain and geographic, gender, and economic inequity in health outcomes persist. There is a need to improve the quality of health services by improving the availability and motivation of key health personnel (e.g., midwives, doctors) and the availability of essential drugs and supplies at the primary health care level. In addition, a greater focus on efficiency in health spending and on creating sustainable financing for health is needed in coming years.
Trends in key RMNCAH-N indicators (2000–2019, DHS)
- Maternal mortality ratio:Declined from 871 to 412 per 100,000 live births
- Under-five mortality rate:Declined from 166 to 55 per 1,000 live births
- Age-specific fertility rate for adolescents (15-19 yrs):Declined from 100 to 80 per 1,000 live births
Country Priorities: The Health Sector Transformation Plan
The 2015/16–2019/20 HSTP, Ethiopia’s investment case aims to increase the use, equity, and coverage of essential health services, such as antenatal care, child and adolescent health services, family planning, and nutrition. To do so, it places a strong emphasis on the need to strengthen health systems through the implementation of systemic reforms. These reforms include, among others, a push for increased domestic health spending as a share of the national budget, as well as improved donor coordination to maximize the efficiency and harmonization of external financing for health. The government’s spending on health has increased in absolute terms over the last 15 years—driven primarily by economic growth—but it has remained flat as a share of general government expenditure. The government is now seeking to increase health spending as a share of the national budget from 6 percent to 10 percent by 2020 as part of the HSTP.
To align and coordinate external resources, with the objective of accelerating progress on maternal and child health outcomes, the federal Ministry of Health manages the Sustainable Development Goals Performance Fund (SDG-PF), a pooled donor fund that includes financing from 11 donors,1 including the World Bank and GFF, with approximately US$700–750 million committed for the 2015–2020 period. At the outset, financing of the HSTP was expected to come from the Ethiopian government (40 percent), international donors (29 percent), community contributions (6 percent), and individual households (5 percent) through Ethiopia’s Community-Based Health Insurance (CBHI) scheme, leaving a financing gap of about 20 percent of estimated costs.
The GFF partnership is committed to supporting the government’s efforts to close this financial gap through improved domestic resource use and mobilization. It is also committed to supporting the achievement of HSTP objectives through (1) policy dialogue to track, mobilize, and align resources (both domestic and external), improve the efficiency of spending, and strengthen the implementation of the HSTP; (2) co-financing of the Health Sustainable Development Goals Program for Results; and (3) increasing private-sector engagement in the health sector.
Policy dialogue to track, mobilize, and align domestic and external resources for health
In 2018, a dialogue that focused on health financing was initiated in order to help policy makers at the Federal Ministry of Health (FMOH), the Ministry of Finance, regional bureaus of health, finance, and economic development, and partners develop a better understanding of how to mobilize and use domestic resources for health. This dialogue included the development and presentation of case studies describing Ethiopia’s accomplishments in domestic resource use and mobilization over the last two decades, as well as Ethiopia’s key challenges and lessons learned from other countries.
Resource tracking has been a critical input to policy dialogue around resource mobilization and improvement in the efficient use of funds. In Ethiopia, resource tracking has been done at two levels. First, external resource mapping has been conducted by the Ministry of Health to track external resources at all administrative levels (federal, regional and district) that support the implementation of the HSTP (Figure 1), in order to improve efficiency at the regional and district level. The aim is to improve efficiency by tracking budget and expenditure data for annual planning purposes as well as to determine whether existing external funding is aligned with sector priorities and assess whether the resources are reaching intended beneficiaries.
Figure 1
Mapping of resources contributing to Ethiopia’s Health Sector Transformation Plan for 2018/2019
However, this tracking approach is limited in its ability to capture a wider coverage of civil society organizations (CSOs) working at the regional level and track details of region-specific priorities, such as regional health emergencies.
One important pilot of the regional-level external mapping has been a collaboration between UNICEF, the GFF, and the World Bank in the Somali region, where region-specific resource mapping has been conducted and used to integrate emergency response budgets with routine regional annual HSTP planning and budgeting. This is particularly relevant in this region, because it ensures that implementation of the HSTP is not harmed by unplanned, unbudgeted, and uncoordinated emergency responses. Further, as a result of the support for the resource mapping and integrated budget development in this region, the regional government has been better able to reprioritize activities and improve partnerships with regional CSOs and nongovernmental organizations (NGOs) working toward a more resilient health system that is better prepared to address health emergencies.
The second level of resource mapping is oriented toward domestic funding. This is done through the use of the government’s integrated budget and expenditure data base (IBEX). The GFF/World Bank are analyzing the IBEX data with the objective of accelerating budget reforms in the Ministry of Finance so that domestic expenditures can become linked with HSTP priorities. This is to respond to: (1) the lack of a comprehensive mechanism to regularly monitor whether the priorities of the investment case are being invested in; and (2) challenges in the current government’s system of budget and expenditure classification and reporting in the IBEX system, which only permit the tracking of a small proportion of expenditures as investments in HSTP priorities.
To improve the technical efficiency of health spending, the federal Ministry of Health, with support from the GFF partnership, is using results from a recent public expenditure review (PER). The review showed that budget execution in recurring non-salary budgets is limited (equal to 20 percent of the health budget), as well as a need to improve regional budget execution. Regional budget execution is considered to be one of the prerequisites for future increases in health funding, so a subnational public expenditure review is now being conducted to identify the bottlenecks preventing full use of available resources at the regional level, woreda (local administrative district) level, and health facility level. Results from the national and subnational PER may be used to inform the implementation of a system of program-based budgeting and expenditure reporting, one that allows the government to regularly monitor investments in HSTP priorities at all levels.
Policy dialogue to strengthen the implementation of the HSTP
Leaders in the Ministry of Health are exploring how strategic purchasing of an essential package of health services could improve the performance of the health care system. This is in response to results of a midterm review of the HSTP, which identified more than 200 challenges the health system should address to improve the access, quality, and coverage. To better inform this dialogue, the GFF partnership conducted a political economy study to examine how a strategic purchasing mechanism could address these challenges. The study, which is intended to inform the planning process for the next five-year health plan, included discussions with key stakeholders, focusing on concrete topics such as health financing and woreda
transformation.
Support to the Health Sustainable Development Goals Program for Results
The GFF Trust Fund, World Bank, and Power of Nutrition are co-financiers of the Ethiopia Health Sustainable Development Goals Program for Results. Financing for this program is contingent on Ethiopia meeting maternal and child health and health system disbursement-linked indicators. The indicators measure, among other things, woreda-level insurance coverage (the percent of woredas with functional community-based health insurance schemes) as well as increases in the coverage and quality of key maternal and child health services (antenatal care and child immunizations, among others).
The objective of improving financial protection among the poor was developed in response to the problem of the health sector’s over-reliance on household out-of-pocket payments as a source of financing and as the primary source of revenue for improving the quality of health service delivery at the health-facility level. This policy may have contributed to the observed increase in the incidence of catastrophic health expenditures for the poor in Ethiopia, which rose from 2 percent in 2011 to 5 percent in 2015.2 CBHI schemes were established by the Ministry of Health to increase access to health services, reduce household vulnerability to catastrophic health expenditures, and subsidize the poor at the woreda level. A target has been set in the HSTP to increase the proportion of woredas with established CBHI schemes from 15 percent in 2015 to 80 percent by 2020; reaching this target is incentivized through a disbursement-linked indicator under the Health Sustainable Development Goals Program for Results.
Increasing private sector engagement in the health sector
The Ethiopian government has identified private sector engagement in the equitable delivery of RMNCAH-N services as a priority area in the health sector. The GFF partnership, including the World Bank, is supporting this engagement with private sector analytics, capacity building, and technical assistance activities, such as:
- A private sector health assessment to understand the landscape of private sector health actors, identify the regulations and policies applied to the private health sector, and identify the opportunities for and challenges to leveraging the private sector for health;
- Capacity building for the Federal Ministry of Health to enable a more strategic engagement with the private sector in health, including the design and management of public–private initiatives;
- Development of public-private dialogue structures for Ethiopia’s private health sector, which has already resulted in the creation of a federation for private sector stakeholders in health, comprising 12 actors from private hospitals, pharmaceutical companies, civil society organizations, and others; and
- Strengthening regulatory and quality control functions at the Ethiopian Food and Drug Administration for the local production of pharmaceutical and health commodities.
Results
With the support of the GFF partnership, a national Service Availability and Readiness Assessment was conducted in 2018 and a “mini” Demographic and Health Survey (DHS) was conducted in early 2019. The Service Availability and Readiness Assessment survey demonstrated improvements in the availability of essential inputs for service delivery. Preliminary results of the mini-DHS show considerable progress in coverage of key maternal and child health services, such as assisted birth deliveries (including in emerging and low-performing regions such as Oromia, Afar, and Somali), contraceptive prevalence, antenatal care, and child nutrition services (Table 1). In addition, several health system indicators—such as functional CBHI schemes, data collection, data use, reporting, and civil registration—have also demonstrated improvements. For example, the share of health centers reporting their health management information system (HMIS) data on time (84 percent) exceeded the initial target of 80 percent, and an annual data quality assessment of HMIS was conducted. The coverage and the completeness of civil registration have also increased, with the proportion of kebeles (subdivisions of woreda districts) providing civil registration service increased to 89 percent in 2018. From 2017 to 2018, the number of registered births increased by 20 percent, and the number of registered deaths increased by 19 percent (data not shown).
Table 1
Health and Nutrition outcomes in Ethiopia, 2016 and 2019
| Outcome | Baseline (2016) (percent) | Baseline Date | July 2019 (present) |
|---|---|---|---|
| Deliveries attended by skilled birth providers | 28 | October 13, 2016 | 50 |
| Deliveries attended by skilled birth providers in the three bottom-performing regions (Afar, Oromia, and Somali) | 19 (average) | October 13, 2016 | 41 (average) |
| Contraceptive prevalence rate | 32 | October 13, 2016 | 41 |
| Pregnant women receiving at least four antenatal care visits | 32 | October 13, 2016 | 43a |
| Woredas in nonemerging regions delivering vitamin A supplements to children through routine systems | 48 | October 13, 2016 | 69 |
| Children 0–23 months participating in growth monitoring and promotion | 27 | December 30, 2016 | 44 |
| Primary care facilities having available all drugs from the Ministry of Health’s list of drugs | 42 | December 30, 2016 | 48 |
| Health centers reporting HMIS data on time | 50 | March 30, 2012 | 84 |
| Pregnant women taking iron folic acid tablets | 42 | October 31, 2016 | 60 |
| Woredas with functional community-based health insurance schemes | 21 | June 19, 2017 | 43 |
Conclusion
The GFF partnership will continue supporting the implementation of interventions and reforms prioritized in the HSTP and the country's health care financing strategy, focusing on improving efficiency, equity, and effectiveness of Ethiopia’s health system. In addition to programmatic support from IDA, GFF, and Power of Nutrition through the SDG Health Program for Results project, the GFF will continue to support analytics, policy dialogue, and implementation research that will expand the evidence base for future investments in the health sector. The next five-year HSTP will be prepared in the coming year, and the GFF will continue to contribute to the development and implementation of the HSTP to improve lives and quality of lives of mothers, children and adolescents.