General health indicators
The health status of Ethiopia is poor, even when related to other low-income countries including those in sub-Saharan Africa. The population suffers from a huge burden of potentially preventable diseases such as HIV, malaria, tuberculosis, intestinal parasites, acute respiratory infections and diarrhoeal diseases. The health indicators are generally poor, though there are improvements observed.
Statistics on hospital admissions are not readily available. Health sector reviews, however, indicate that patients suffering from HIV/AIDS-related conditions may occupy more than 50% of hospital beds at any given time. Other conditions responsible for admission include tuberculosis, malaria, respiratory infections, trauma, pregnancy-related conditions and complications of measles.
Determinants of ill health
Poverty: About 45% (MEDAC, Poverty situation in Ethiopia, March 1999) of the people of Ethiopia are living on less than one dollar per day (Human development report, 2001).
Lack of access to safe drinking water: Only 33% of the population had access to safe drinking water in 1999. The coverage of 80% for urban areas is better than that of rural areas at 14.3%. Bacillary dysentery (water borne disease) affected 63,417 people in the same year with 545 deaths (same source).
Lack of sanitation facilities: It is estimated that the sanitation coverage stands at 17%. A total of 74% of urban dwellers have access to reasonable sanitation facilities. Disposal of waste is a particular challenge to the authorities at all levels and is not sufficiently addressed.
High rate of migration: Large segments of the population are migrating for climatic, economic and social reasons and sometimes because of social unrest. According to the 1999 National Labour Force Survey, 19.6% of the population in the country were migrants.
Underdeveloped health system: The health system is unable to provide health care for more than half the population. Much of the rural population has no access to any type of modern health care service. In terms of service delivery, it is estimated that only 75% of urban households and about 42% of rural dwellers are within walking distance from a health facility. From the data of the mid-term review (MTR) 2001 report (Ethiopia HSDP) it was seen that the health coverage is only about 50%. However, when there is physical access to the facility, it is reported that some facilities are staffed with health workers of low qualifications and drugs and clinical supplies are not available at many health facilities all of the time. There seems to be gross inequalities when it comes to access to health services amongst different regions of the country. The issue of health care services of pastoralist communities, who represent 10% of the population, calls for special attention.
Low agricultural productivity and recurring droughts contribute to nutritional deficiencies. According to Ethiopia Demographic and Health Survey (EDHS) 2000, 51.5% of children below the age of five were found to be stunted while 10.5% were found to be wasted and 42.7% to be underweight. The same survey found 3.6% of women stunted and 30.1% undernourished.
Health sector strategic plans
The Health Sector Development Program (HSDP 1990-1994 EC) was developed between 1995 and 1998 by the Prime Minister's office, the Federal Ministry of Health, the nine national regional states and the two administrative city councils on the basis of existing health policies and strategies. These strategies served as a basis to elaborate implementation programs jointly with the regional owners and international partners. After presentation of these programs to a Consultative Meeting in 1997, constructive advice was obtained and a plan of action was elaborated, creating favourable conditions for enhanced cooperation and joint implementation with technical assistance from a number of partners. HSDP was completed in July 1998 (1990 EC). The intense central and regional planning preparations were followed by the development of a detailed Program Action Plan (PAP, August 1998) and by a Program Implementation Manual (PIM, October 1998). These two documents define the objectives, the strategies, activities and the responsibilities of all actors at various levels.
The MoH and the Regional Health Bureaus are the implementing agencies, guided and coordinated by the ‘Central Joint Steering Committee' (CJSC) with membership from Ministries of Health, Finance & Economic Development and four participating donor representatives. A similar organisation exists at each regional level known as Regional Joint Steering Committee (RJSC). Most donors active in the health sector work through the Health Population and Nutrition Donor Group (WHO is the elected chairman) to support for HSDP, while many others have committed funds to the program. This is the sector-wide approach in action!
The main objectives of the HSDP for the period 1997-2002 are:
- Increase access/ coverage to health care (and thus utilisation) from 40% to 50-55%.
- Improve service quality through training and an improved supply of necessary inputs.
- Strengthen management of health services at federal and regional level.
- Encourage participation of the private sector and the NGO sector by creating an enabling environment for participation, coordination and mobilisation of funds.
The five-year health program is designed to emphasize the preventive aspects of care and to develop comprehensive and integrated primary health care services. The focus is on communicable diseases, common nutritional disorders and environmental health and hygiene. In particular this program aims to support activities for improvement in reproductive health care, family planning, immunisation, control of epidemic diseases such as malaria and tuberculosis, and control of sexually transmitted diseases. The current vertical programs will be gradually phased out as capacity at woreda level increases.
The eight components of HSDP are Service delivery and quality of care; Health facility rehabilitation and expansion; Human resource development; Pharmaceutical supply and management of essential drugs; Information, education and communication (IEC); Health management/ Management information system; Health care financing; and Monitoring and Evaluation (M&E + research).
Health care financing
The financing of health care services in Ethiopia is made by government and donors/ partners (grants), user fees, insurance and community contributions. The government contributes approximately 55% of the annual health budget, while donors contribute 42.5% and user fees amounts to 2.1%. The proportion of health expenditure attributable to the utilization of the private health services (both modern and traditional) is not fully documented, but is believed to be considerable.
In Ethiopian fiscal year (EFY) 1990 (98/99), a total of 776.15 million Birr was made available by the Government to the health sector, in EFY 1991 (99/00) about 813.74 million Birr and in EFY 1992 (00/01) 1,030.0 million Birr was made available. The overall budget includes categories for capital development and recurrent costs. The per capita expenditure on health in Ethiopia is about USD 1.4 compared to an average of USD 10 per capita for health in the rest of sub-Saharan Africa.
Health sector expenditures in Ethiopia have tended to emphasize on urban-based, curative services rather than rural-based, preventive primary health care services. The regions whose populations predominantly live in urban areas tend to have more budget allocation per capita than the predominantly rural counterparts.
The budget allocated by the government to the health sector is highly inadequate and there is a considerable dependence on donors and other partners to supplement the resources of the MoH. The proportion of salaries in the recurrent budget has been declining and stood at 53% in 1996. However, there has been a corresponding increase in health expenditure on drugs and other non-salary items. The decrease in the proportion of health budget allocated to salaries may have led to the stagnation of salaries, leading to high attrition of staff.
Health delivery system
In 2000, there existed a total of 103 hospitals (all denominations), 338 health centres (HC), 2,029 health stations (HS), 833 health posts (HP) and 1,119 private clinics in Ethiopia. There is no data on the number of traditional healers available in the country, whose services many Ethiopian households use for various health problems. The population per primary health care facility is 27,456, which is three times higher than in the rest of sub-Saharan Africa. The total number of hospital beds is 11,685, which means that there is only one bed for a population of 4,900, which is about five times lower than the average for sub-Saharan Africa. Currently as part of HSDP, the existing six-tier health care management system is being transformed into a four-tier system characterized by a PHC-unit (1 HC and 5 satellite HPs), the district hospital, zonal hospital and specialized hospital. HSs are presently being either upgraded to HCs or downgraded to HPs.
Within Ethiopia there are 304 pharmacies, 250 drug shops and 1,950 rural drug vendors, about 95% of these privately owned. The limited number of health institutions, the poor distribution of medical supplies among regions and the disparity between urban and rural areas are all responsible for the inaccessibility of health care services to the population. In Ethiopia, drugs that are required to reduce morbidity and mortality from common illnesses are mostly in short supply, the majority of which are imported and expensive. According to the mid-term review of the Health Sector Development Program, 2001, problems related to essential drugs utilization include inadequate budget, weak drug supply system, poor logistic support for distribution and irrational drug use.
The HCs are on average staffed by at least one medical officer, several nurses and health assistants (who have 18 months basic health training), one laboratory technician and one pharmacy technician. At the average health station, there are three health assistant staff. The physician per population ratio is one per 48,000 and the nurse per population ratio is one per 12,000 (one third and one sixth, respectively, of the average of the rest of sub-Saharan Africa). Overall there are 20 trained HWs per 100,000, a very low ratio even for sub-Saharan standards.
There are presently 14 nursing schools in the country with an annual output of 2226 nurses. Based on the present number of trained health workers, a population growth rate of 2.9%, an annual attrition rate of 3% among the public health service health work force and an assumed 2.8% continued expansion of the output from health worker training schools, it will take more than 25 years to reach an agreed minimum standard health worker population ratio of 100 trained health workers per 100,000 population. The medical and nursing schools and training institutions for paramedical professionals are available in the country and do make attempts to increase the annual output of trained personnel to meet the demands. However, the quality of some trained manpower is believed to be unsatisfactory. An evaluation of the human resource system has been recommended by the mid-term review of the HSDP.