1. COURSE OUTLINE
UNIT I: THE HISTORICAL DEVELOPMENT OF HEALTH CARE
DELIVERY SYSTEM
1.1: INTRODUCTION TO HEALTHCARE DELIVERY SYSTEM AND
DEFINITION OF TERMS
1.1.1. Introduction
1.1.2. History of the Ethiopian Healthcare Delivery System
1.1.3. Historical Background of Modern Medicine in Ethiopia
1.2: BASIC EVENTS IN HISTORY OF ETHIOPIAN HEALTHCARE
DELIVERY SYSTEM
1.2.1. The Basic Health Service Period (BHS) from 1953-1974
1.2.2. The Primary Health Care (PHC) Period (from 1978-1991)
1.2.3. Sector wide Approach Period (199…….)
1.2.4. The Traditional Medicine Practice in Ethiopia
UNIT II: THE CURRENT ETHIOPIAN HEALTH POLICY
2.1: GENERAL POLICY
2.2: PRIORITIES OF THE POLICY
2.3: GENERAL STRATEGIES
1.2.4. The Traditional Medicine Practice in Ethiopia

2. UNIT II: THE CURRENT ETHIOPIAN HEALTH POLICY
2.1: GENERAL POLICY
2.2: PRIORITIES OF THE POLICY
2.3: GENERAL STRATEGIES
UNIT III: STRUCTURE OF HEALTHCARE SERVICE
ORGANIZATION
3.1: STRUCTURE OF THE HEALTHCARE SERVICE
ORGANIZATION
3.1.1. Introduction
3.1.2. Administrative Structure of the Healthcare System
Organizations
3.2: CONTRIBUTORS OF HEALTH CARE PROVISION IN
ETHIOPIA
3.2.1 The Government
3.2.2 Private Providers
3.2.3 Nongovernmental Agencies (NGO’s)
3.2.4 International Health Agencies

3. UNIT IV: COMPONENTS OF THE HEALTH CARE DELIVERY
SYSTEM
4.1: COMPONENTS OF HEALTHCARE DELIVERY SYSTEM
4.1.1. Introduction
4.1.2. The Current 4 Tiers System
4.1.3. Major Components and Actors of Healthcare Delivery
System
4.2: THE HEALTH CARE FACILITIES AND SERVICES THEY
PROVIDE
4.2.1. The Primary Healthcare Unit (PHCU)
4.2.2. District Hospital and Services Provided
4.2.3. Zonal/Regional Hospitals and Services Provided
4.2.4. Referral Hospitals
4.3: HEALTHCARE WORKFORCE AT DIFFERENT LEVELS
OF HEALTH FACILITIES
4.3.1 Human Resource (healthcare workforce) Requirement

4. UNIT V: HEALTH SERVICE PROGRAMS
5.1: THE HEALTH POLICY, PLANS AND STRATEGIES
5.1.1. Introduction
5.1.2. The HSDP-III
5.2: ESSENTIAL HEALTH SERVICE PACKAGE
5.2.1. Introduction
5.2.2. The Health Service Extension Program (HSEP)
5.2.3. Family Health Services (Maternal and Child Health
Care)
5.2.4. Prevention and Control of Disease
5.2.5. Medical Services
5.2.6. Hygiene and Environmental Health
5.3: HUMAN RESOURCE DEVELOPMENT
5.3.1 Introduction
5.4: PHARMACEUTICAL SERVICE
5.4.1 Pharmaceutical Services

5. 5.5: IEC AND HEALTH INFORMATION MANAGEMENT
SYSTEM (HIMS)
5.5.1. Information, Education and Communication (IEC)
Health Information Management System (HMIS)
5.6: MONITORING AND EVALUATION (M&E) AND
HEALTHCARE FINANCING
5.6.1. Monitoring and Evaluation (M&E)
5.6.2. Healthcare Financing
UNIT VI: HEALTHCARE SYSTEM REGULATION
6.1: HEALTHCARE SYSTEM REGULATIONS
6.1.1 Introduction
6.1.2. Regulation of Credentialing Health Manpower
6.1.3. Professional Associations
6.2. HEALTH INFORMATION SYSTEMS POLICIES AND
PROCEDURES
6.2.1. Introduction
6.2.2. HIS Policies and Procedures
6.2.3. Health Information Related I

6. UNIT VII: HEALTHCARE SERVICE PLANNING
7.1: HEALTHCARE SERVICE PLANNING
7.1.1 Introduction: definitions of key terms
7.1.2 Health Service Planning
7.1.3 Strategies and Approaches used in Health Service
Planning
7.2. RESOURCE IDENTIFICATION
7.2.1 Introduction to Classification (and Identification) of
Resource
TEXTBOOKS/REFERENCE BOOKS AND MANUAL
1. Module Handouts are distributed to the students as textbook
2. HSDP I, II,III, FMoH
3. Harmonization Manual, FMOH
4. Chali Jirra et al. Health service Planning and management
for health science students.
5. Jonathans. Rakich et.al Managing health service
organization, third edition, 1992 Maryland, USA

7. ABBREVIATIONS
AIDS Acquired Immune Deficiency Syndrome
ART Anti retroviral therapy
BHS Basic Health Service Period
BOC Basic obstetric care
CHP Community health promoters
COC Comprehensive obstetric care
CSRP Civil service reform program
DACA The Drug Administration and Control Authority
DKA Diabetic Keto acidosis
EHNRI Ethiopian health nutrition research institute
EOC Emergency obstetric care
EPA Ethiopian public health association
ESOG Ethiopian society of obstetrics and gynecology
FP Family Planning

8. FMIS Financial management information system
FMOH Federal ministry of health
GO Government organization
HC Health center
HCF Health care finance
HIMS Health information management system
HIV Human immune virus
HOS Hospital
HP Health post
HSEP Health service extension program
IDSR Integrated Disease Surveillance and Report
IMR Infant mortality rate
LMIS Logistics management information system
M&E Monitoring and evaluation

9. MCH Maternal and Child Health
MCHC Maternal and child health care
MDGS Millennium development goals
MIS Management information system
MMR Maternal mortality rate
NAC National advisory committee
NGOS Nongovernmental organization
PASS Pharmaceutical Administration and Supply Services
PHC Primary health care
PMTCT Prevention of mother to child transition
RHB Regional Health Bureau
SNNPR Southern Nations and nationality peoples region
SWOT Strength Weakness Opportunity Threat
TFR Total fertility rate
TLCP Tuberculosis leprosy control program
U5MR Under five mortality rate

10. MCH Maternal and Child Health
MCHC Maternal and child health care
MDGS Millennium development goals
MIS Management information system
MMR Maternal mortality rate
NAC National advisory committee
NGOS Nongovernmental organization
PASS Pharmaceutical Administration and Supply Services
PHC Primary health care
PMTCT Prevention of mother to child transition
RHB Regional Health Bureau
SNNPR Southern Nations and nationality peoples region
SWOT Strength Weakness Opportunity Threat
TFR Total fertility rate
TLCP Tuberculosis leprosy control program
U5MR Under five mortality rate

11. 1.1.1. Introduction
Health care delivery system is a network of integrated
components designed to work together coherently,to
provide healthcare to a population in various settings.
Concepts from general systems theory are useful
inunderstanding the structure and operation of a nation’s
health system. For this purpose the following must
beidentified:
The major actors, which can further be classified as :
– healthcare users/consumers
– healthcare providers
– policy makers/regulators
Their resources, which can be further classified as:
– funding
– personnel
– facility
– technology
– information

12. The mechanism through which they interact
The external forces which affect the process
The healthcare delivery system like all systems is
dynamic with many feedbacks loops among
providers, consumers and regulators, allowing for
change in the system’s performance
1.1.2. History of the Ethiopian Healthcare Delivery
System
Ethiopia has one of the worst health statuses, with
poor environmental condition and inadequate
healthservices. Long periods of civil strife, rapid
population growth and environmental degradation
have furtheraggravated these health problems.

13. The country has a new health policy and
strategy; the health service is to be re-
organized into a more costeffectiveand
efficient system that can contribute better to
the overall socio-economic development
effort of the country. To understand the
current healthcare system we must look back
to the historical background of modern
medicine in Ethiopia, and the role traditional
medicine plays.
1.1.3. Historical Background of Modern
Medicine in Ethiopia

14. There have been occasional contacts between
modern medical practitioners and Ethiopians
prior to the end of the 19th-century.A
Portuguese “barber surgeon” was known to
be at the courts of King Lebne-Dengel in the
15th century: then the German missionary,
by the name of Peter Heiling, was at the
court to Emperor Fasiledes in the 16th
century, and several others have been
recorded.

15. If we reflect back in history, the years just before
and after the turn of the millennium can be
considered as a centenary for health services in
Ethiopia. It was just at the end of the 19th and the
beginning of the 20th centuries that modern
health care was introduced in the country. The
first modern health care facility in the country (a
Russian Red Cross Hospital) was established in
Addis Ababa in 1987 with a capacity of 50 beds. It
is interesting to note that the mission produced a
small booklet in Amharic of 22 pages, which was
to serve as a textbook for Ethiopian staff. The
Russian mission stayed in the country for ten
years,

16. and in 1906 the hospital was closed.
Following that a leprosarium and hospital
were opened in Harar in 1901 and 1903
respectively. In the year 1909 the first public
hospital Menilik II established on the site of
the Russian hospital. At the beginning it had
30 beds .The hospital has been in operation
ever since on the same site and even today
it’s called by its original name, “Menilik II
hospital”.

17. After Minilk II Emperor Hilesilase I continued and the
reform drive of Emperor Halile Selassie I during
1917- 1935 focused on economic and social
conditions that included health expansion and
management reforms. This drive was interrupted
during the brief occupation of Ethiopia by the
Italians. Until Soon after the liberation of Ethiopia in
1941 the period of reconstruction time that a
Department called “Public Health Directorate” was
established under the then powerful Ministry of
Interior (MOI). The first director of the unit was a
British Doctor known by the name Colonel
Maclean. It was made responsible for the
establishment of the first hospital, and for the
general problems in the health field.

18. During that time, there were several Christian
missions operating in the country, they
provide health care to the people in addition
to their religious and sometimes educational
activities. In 1922 another hospital was
established in Addis Abeba. An American
missionary named Dr. Thomas Lambie
collected money, erected a building in the
Gulele area, and established a hospital with
70 beds. This hospital had 4 medical doctors
and 5 nurses on its staff.

19. The hospital was converted into a research
Institute in 1942, then into the Institutes of
Pasteur in 1950. In 1964 it was converted
into the central laboratory and research
institute, and finally it was merged with
Ethiopian Nutrition Institute (ENI), today it’s
called Ethiopian Health and Nutrition
Research Institutes (ENHRI).

20. Because of expansion of health service
government has taken Major step in the
autonomous development of health care
which did not happen until the formal
establishment of the Ministry of Public
Health (MOPH) in 1948. By 1948 there were
already several hospitals in the country. At
that time, the majority of hospitals, and
health facilities were run by different mission
organizations.

21. In speaking of the historical development of
health services in Ethiopia, one must mention
the contribution of first Ethiopian medical
doctors. Dr. Martin Workineh. As a child of
three years he was found on the battlefield
after the battle of Maqdela (1868). The boy
was taken and educated in India and later in
Britain, sponsored by two officers, Colonel
Charles Chamberlain and Colonel Martin, and
after them he was named Charles Martin.
After the first aborted Italian invasion of
Ethiopia in 1896,

22. Martin arrived in Addis Abeba, where a he
pitched a tent in the center of the city and run
a clinic, treating patients free of charge.
During that time he learned who his parents
were and found his grandmother, who told
him his name was Workineh. Hakim
Workineh as he was popularly known served
not only as a physician but also as a
diplomat, he died at the age of 84 in 1952.

23. The second Ethiopian medical doctor was Dr.
Melaku Beyan, who early in this century
obtained his medical degree at Howard
University in the United States. He was chief
medical officer of the Ethiopia Army during
the Italian invasion from Somalia in 1935.
Dr. Melaku died in exile during the Italian
occupation of Ethiopia.

24. Whatever medical developments there was in
the country, it was disrupted during the
Italian occupation. After the war, another
hospital was established named after
Princess Tsehay who was the first Ethiopian
nurse, having graduated in England during
the war. Look at table 1 for the detail of
historical events in the Ethiopian health care
delivery system Period Date Event 1520-
1526 Foreign medical contacts with
Portuguese Barber surgeon 1830s and
1840s French and British missions,

25. introduced vaccination Period of Unification and
Independence 1856 Use of small pox vaccine
officially promoted by Emperor Tewdros 1896
Battle of Adewa
Russian red cross mission published first medical text
in Amaharic
Dr (Hakim) Workeneh return to Ethiopia
1987 The first hospital in Ethiopia Established by the
Russian red cross mission Power struggle
1909 The first Government hospital Minilk II opened
1930 The first public health low endorsed Emergence
of Absolutism

26. Early 1930s First health budget allocated
Public latrine introduced
1935  Minilk II started training the first medical auxiliaries
Dr Melaku Beyane the first trained Dr return to Ethiopia
Ethiopian Red cross society established in July
Outbreak of Italio- Ethiopian war
From Libration to Revolution
1941 Bureau of Hygiene established with in the ministry of
interior
1942 School of medical service started
1947 Ministry of Health Established
1948 Medical education board established
1950 University collage of Addis Ababa started
1952 Policy decision on developing Health center

27. 1957-1961 The first five year development plan planed
1959 Malaria eradication program launched
1963-1967 The second five year plan planed
1968 Planning division ministry of public health established
1969/1970 Small pox eradication program launched
1970 Malaria eradication program converted to control
program
The Derge Period
1974 Ethiopian revolution
1975 Launching of the National Democratic Revolutionary
program
1976-1980 The 5 year rural health development program
1978 Adoption of primary health care
1984 Ten years perspective Development plan
1991 Fall of Derge Regime

28. EPRDF Regime
1991-1995 Transition time
1993 Development of health policy and
strategy
1998-2002 Health sector development
program I
2003-2007… Health sector development
program II

29. 1.2.1. The Basic Health Service Period
(BHS) from 1953-1974
For Ethiopia (following the WHO
recommendation), BHS was seen as a long
term strategy for providing adequate and
essential health care by making available a
HC for a population of 50,000 and a Clinic
for a population of 5,000. A new chapter in
the development of health services was
opened when, with the assistance of
international organizations, Gondar Public
Health College and training center was
established in 1952.

30. The Institute trained three categories of health
personnel; public health officers, community
nurses and sanitarians, who were intended
to serve in the health centers, a new type of
the institution. One health center was
supposed to serve 50,000 people, with the
help of satellite health stations.
The first organized training of health personnel
can be traced back to 1945, when a six-
month course was offered to all hospital
orderlies, who were then upgraded to the
status of “dressers”.

31. • The first nursing school was established in
Addis Abeba by the Red Cross society in
1950. The training center for medical and
health technicians was established in 1963
within Menilik II hospital. The first medical
school was established in 1962.
• Due to the slow development of general
health services and subject to some
international pressure, special projects to
combat individual disease were embarked
upon. The most important project is the
Malaria eradication project, established in
1959;

32. the TB control project, a Leprosy control
project, the Ethiopian nutrition institutes, and
the small pox eradication service are
examples of the bigger projects. Some of
these projects are still in existence.

33. 1.2.2. The Primary Health Care (PHC)
Period (from 1978-1991)
Change in Government from Imperial Rule to
Military Rule followed by subsequent political
orientation into socialist ideology after 1974
brought with it radical changes in the health
policy of Ethiopia which in some ways
provided the foundation for further
development of health care delivery system.
Also in 1977 the WHO set a goal of
providing “health for all by the year 2000”
which aims at achieving a level of health

34. that enables every citizen of the world to lead a
socially and economically productive life. The
strategy to meet this goal was later defined in
the 1978 WHO/UNICEF joint meeting at
Alma-Ata. In this meeting it was declared that
the primary health care strategy is the key to
meet the Goal of “Health for all by the year
2000”.

35. After the World Health Assembly (in 1978),
Ethiopia fully endorsed that the target of
governments and WHO should be the
attainment of a level of health that would
enable all people to lead a socially and
economically productive life by the year
2000. This was commonly known as “Health
for All by the year 2000”, also known as the
“Declaration of Alma-Ata”

36. • A) The declaration of PHC
• The declaration of PHC focused on the following
main concepts:
• 1. Equitable distribution
• Health services must be shared equally, distributed
by all people irrespective of their ability to pay and
all (rich or poor, urban or rural) must have access to
health services. Primary health care aims to
address the current imbalance in health care by
shifting the centre of gravity from cities where a
majority of the health budget is spent to rural areas
where a majority of people live in most countries.

37. 2. Active community
participation/Involvement
Active community participation/involvement is:
The process by which individuals and families
assume responsibility for the community and
develop the capacity to contribute to their
and the community’s development.
A means by which communities can play a
more influential role in health development,
in which the emphasis is on strengthening
the capacity of communities to determine
their own needs and take appropriate action.

38. Community Involvement is the process of
involving the community in the planning,
implementing and monitoring and
evaluation unlike participation.
Communities should not be passive
recipients of services everybody should be
involved according to his ability and the
Health system is responsible for
• Explaining and advising
• Providing clear information about the favorable and
adverse consequences of the interventions being
proposed as well as their relative cost.

39. – The communities should be actively involved in
The assessment of the situation
Problem Identification
Priority setting and making decisions
Sharing responsibility in the planning
implementing, monitoring and evaluation

40. 3. Intra and Inter-sectoral linkages
Primary health care involves in addition to the
health sector, all related sectors and aspects
of national and community development, in
particular agriculture, animal husbandry,
food, industry, education, housing, public
works, communication and other sectors.

41. B) The four cornerstones in Primary Health
Care
The four cornerstones in Primary Health Care
(or Pre- requisites for PHC) are:
1. Active community
participation/Decentralization/
2. Intra and Inter-sectoral linkages
3. Use of appropriate Technology
4. Political commitment /Support Mechanism
made Available/

42. C) The Components/Elements of PHC
There are twelve elements of PHC on
implementation in Ethiopia. Of these
elements from number one to eight are the
components by which implementation began
while the last four were added later on.
1. Immunization-immunization against the
major infectious diseases (six childhood
diseases)
2. Food supply and proper nutrition-promotion
of food supply and proper nutrition

43. Improve food supply and proper nutrition.
Correction of faulty feeding practices.
Treatment and rehabilitation of malnourished
children.
Treatment and prevention of nutritional
diseases.
3. Water and sanitation-an adequate supply of
safe and basic sanitation.
4. Prevention and treatment of locally endemic
disease and injuries.
5. Maternal and Child Health (MCH) and
Family Planning (FP). Main functions are:

44. Antenatal care
Delivery care
Postnatal care
Child care
Family planning
6. Provision of essential drugs
7. Health Education
For promoting health
For prevention of disease
For maintenance of health
Education to deal with the disease.

45. 8. Control of communicable diseases
9. Mental health
10. Dental health
11. Control of ARI
12. Controls of HIV/AIDS and other STDs.
The 1985 review of PHC implementation
attempts in Ethiopia revealed the following
achievements.

46. Expansion of health services to the broad
masses especially by establishing new
health station and health posts.
Expansion of immunization program against
six major communicable diseases.
Increasing number of medical and paramedical
personnel
Increased health propaganda attempts to
improve health consciousness of the
population by building the promotion of
health information to the people.

47. • Problems encountered in PHC
implementation in Ethiopia
– Nature of community involvement (poor
community participation)
– Political and social organization
– Political and bureaucratic unwillingness
– Structure and tradition of formal health system
– Lack of resource planning and management.

48. – difference of vision between community and
health professionals
– Misunderstandings:
– PHC is community based care
– It is only for poor people in developing countries
– It is for rural area
– PHC is cheap, etc.

49. • 1.2.3. Sector wide Approach Period
(199…….)
• The government of Derge is overthrown by
EPRDF in 1991 and transitional government
was established for 1991-1995. During this
period health policy and strategy were
developed.
• Currently the Ethiopian government is
following a twenty-year health development
implementation strategy, known as the
Health Sector Development Program
(HSDP), with a series of five-year
investment programs.

50. • HSDP proposes a sector-wide approach to
achieve the government’s objectives.
• The Health Sector Development Program,
launched by the government in 1998, was
devised after studying the kind of health
problems that affect Ethiopia and
researching their root causes. It also took
into consideration emerging serious health
issues such as HIV/AIDS and put a strong
emphasis on the needs of the rural Ethiopia,
where overwhelming majority of the
country’s citizens live.

51. Sector wide approach-based health care
delivery system is owned by the state, but its
implementation is firmly based on strong
partnership between the Central
Government, the Regional Government, the
Health Development Partners, the Private
and NGO sectors. The focus of health
delivery system is expansion and
improvement in the quality of care and is
guided by the eight components of the
Health Sector Strategic Plan (HSDP) at all
levels.

52. The eight components of HSDP are:
1) Health service Delivery and Quality of care.
2) Health facility Rehabilitation and Expansion.
3) Human Resource Development.
4) Strengthening Pharmaceutical Services.
5) Information, Education and Communication.
6) Health Management Information Systems.
7) Healthcare Financing.
8) Monitoring and Evaluation.

53. 1.2.4. The Traditional Medicine Practice in
Ethiopia
Long before the advent of modern medicine,
Ethiopia had its own method for combating
disease. These methods are usually referred
to as Ethiopian traditional medicine. Not only
was a traditional medicine structure operation
prior to the advent of modern medicine, but it
can be said that even today the rural
populations depend on it.
Ethiopian traditional practitioners practiced not
only curative but also preventive medicine,
and the first

54. “Cordon Sanitaire” was established in Gondar
as early as 1830 G.C. Similar actions were
taken in the whole country in 1918 G.C.
during the notorious influenza pandemic
variolization was very widespread as a
means of preventing small pox, and in certain
times in the 18th century the variolization was
even compulsory.

55. The traditional Ethiopian pharmacopoeia
comprised items from the animal and
vegetable kingdoms. And even some
minerals (e.g. floss from iron melting).
Counter-irritants (burning of the skin over the
diseased part of the body), bleeding and
cupping were other routinely used
procedures. Several surgical procedures,
including trepanation and Cesarean section,
have been repeatedly reported, but probably
the greatest skills were observed in bone-
setting (‘Wegesha’), including even
operations and insertions of sheep’s bone.

56. In connection with traditional medical
practices, one has to mention some harmful
procedures that have been widely practiced
in the country, such as female circumcision,
removal of tonsils by means of a nail, uvula
cutting, and pulling healthy children’s teeth.
In recent times the Ministry of Health has been
making an effort to integrate traditional
medicine into the general network of health
services, particularly since the skills of
certain healers are known to be effective.

57. Among the most prominent practitioners, bone-
setters (wogeshas), herbalist’s (kitel betash),
traditional birth attendants and particularly
different types of “spiritual healers” can be
useful in general, and the people appreciate
their services.
Formal recognition to traditional medicine in
Ethiopia was given in 1942 (Proclamation
27), where legitimacy of the practice was
acknowledged as long as it does not have
negative consequence on health.

58. Despite the relatively rapid expansion of
modern medicine, traditional medicine (TM)
is still the predominanthealth care resource
in Ethiopia. World Health Organization
estimated that 80% of the population in
developingcountries and as many as 90% of
the Ethiopians use TM for their illnesses

59. UNIT II: THE CURRENT ETHIOPIAN
HEALTH POLICY
Introduction
In the first unit of the module we have seen the
historical development of health care delivery
system in
Ethiopia period by period from early exposure
of medical practice to the current sector wide
approach.
In this unit we will see the general policy,
priories of policy and general strategies of
the policy in Ethiopia context.

60. Objectives
On completion of this unit students should be
able to:
State the ten points on general policy
Identify the general strategies of health policy
State the eight health policy priorities
2.1: General Policy
– Democratization and decentralization of the
health service system.
– Development of preventive and promotive
components of health care.

61. – Development of an equitable and acceptable standard of
health service system that will reach all segments of the
population within the limits of resources.
– Promoting and strengthening of intersectoral activities.
– Promotion of attitudes and practices conducive to the
strengthening of national self-reliance in health
development by mobilizing and maximally utilizing
internal and external resources.
– Assurance of accessibility of health care for all segments
of the population.
– Working closely with neighboring countries, regional and
international organizations to share information and
strengthen collaboration in all activities contributory to
health development including the control of factors
detrimental to health.

62. – Development of appropriate capacity building
based on assessed needs.
– Provision of health care for the population on a
scheme of payment according to ability with
special assistance mechanisms for those who
cannot afford to pay.
– Promotion of the participation of the private
sector and nongovernmental organizations in
health care.

63. 2.2: Priorities of the Policy
Information, Education and Communication (I.E.C) of health shall
be given appropriate prominence to enhance health awareness
and to propagate the important concepts and practices of self-
responsibility in health
Emphasis shall be given to:
The control of communicable diseases, epidemics
and diseases related to malnutrition and poor living
conditions;
The promotion of occupational health and safety;
The development of environmental health;
The rehabilitation of the health infrastructure
The development of an appropriate health service
management system;

64. – Appropriate support shall be given to the curative
and rehabilitative components of health including
mental health.
– Due attention shall be given to the development
of the beneficial aspects of Traditional Medicine
including related research and its gradual
integration into Modern Medicine.
– Applied health research addressing the major
health problems shall be emphasized.
– Provision of essential medicines, medical
supplies and equipment shall be strengthened.
– Development of human resources with emphasis
on expansion of the number of frontline and
middle level oriented training shall be
undertaken.

65. – Special attention shall be given to the health
needs of:
The family particularly women and children;
Those in the forefront of productivity;
Those hitherto most neglected regions and
segments of population including the majority
of the rural population, pastoralists, the
urban poor and national minorities,
Victims of man-made and natural disasters.

66. 2.3: General Strategies
Democratization within the system shall be
implemented by establishing health councils with
strong community representation at all levels and
health committees at grass-root levels to participate
in identifying major health problems, budgeting,
planning, implementation, monitoring and
evaluating health activities.
Decentralization shall be realized through transfer of
the major parts of decision-making, health care
organization, capacity building, planning,
implementation and monitoring to the regions with
clear definition of roles.
Intersectoral collaboration shall be emphasized
particularly in:

67. – Enriching the concept and intensifying the
practice of family planning for optimal family
health and planned population dynamics.
– Formulating and implementing an appropriate
food and nutrition policy.
– Acceleration the provision of safe and adequate
water for urban and rural populations.
– Developing safe disposal of human, household,
agricultural, and industrial wastes, and
encouragement of recycling.
– Developing measures to improve the quality of
housing and work premises for health.

68. – Participation in the development of community
based facilities for the care of the physically and
mentally disabled, the abandoned, street
children and the aged.
– Participating in the development of day-care
centers in factories and enterprises, school
health and nutrition programmes.
– Undertakings in disaster management,
agriculture, education, communication,
transportation, expansion of employment
opportunities and development of other social
services.
– Developing facilities for workers’ health and
safety in production sectors.

69. • Health Education shall be strengthened
generally and for specific target populations
through the mass media, community leaders,
religious and cultural leaders, professional
associations, schools and other social
organizations for:
– Inculcating attitudes of responsibility for self-care
in health and assurance of safe environment.
– Encouraging the awareness and development of
health promotive life-styles and attention to
personal hygiene and healthy environment.
– Enhancing awareness of common
communicable and nutritional diseases and the
means for their prevention.

70. – Inculcating attitudes of participation in community
health development.
– Identifying and discouraging harmful traditional
practices while encouraging their beneficial
aspects.
– Discouraging the acquisition of harmful habits
such as cigarette smoking, alcohol consumption,
drug abuse and irresponsible sexual behavior.
– Creating awareness in the population about the
rational use of drugs.

71. • Promotive and Preventive activities shall address:
– Control of common endemic and epidemic communicable
and nutritional diseases using appropriate general and
specific measures.
– Prevention of diseases related to affluence and ageing from
emerging as major health problems.
• Prevention of environmental pollution with
hazardous chemical wastes

72. • Human Resource Development shall focus on:
• Developing of the team approach to health care.
• Training of community based task-oriented frontline and
middle level health workers of appropriate professional
standards: and recruitment and training of these
categories at regional and local levels.
• Training of trainers, managerial and supportive categories
with appropriate orientation to the health service
objectives.
• Developing of appropriate continuing education for all
categories of workers in the health sector.
• Developing workers within their respective systems of
employment.

73. • Availability of Drugs, supplies and Equipment shall be
assured by:
• Preparing lists of essential and standard drugs and
equipment for all levels of the health service system and
continuously updating such lists.
• Encouraging national production capability of drugs,
vaccines, supplies and equipment by giving appropriate
incentives to firms, which are engaged in manufacture,
research and development
• Developing a standardized and efficient system for
procurement, distribution, storage and utilization of the
products.
• Developing quality control capability to assure efficacy
and safety of products.
• Developing maintenance and repair facilities for
equipment.

74. • Traditional Medicine shall be accorded appropriate attention by:
• Identifying and encouraging utilization of its
beneficial aspects.
• Coordinating and encouraging research including its
linkage with modern medicine.
• Developing appropriate regulation and registration
for its practice.
– Health systems Research shall be given due emphasis by:
• Identifying priority areas for research in health.
• Expanding applied research on major health problems and health
service systems.
• Strengthening the research capabilities of national institutions and
scientists in collaboration with the responsible agencies.
• Developing appropriate measures to assure strict observance of
ethical principles in research.

75. – Family Health Services shall be promoted by:
• Assuring adequate maternal health care and referral
facilities for high risk pregnancies.
• Intensifying family planning for the optimal health of the
mother, child and family.
• Inculcating principles of appropriate maternal nutrition.
• Maintaining breast-feeding and advocating home-made
preparation, production and availability of weaning foods
at affordable prices.
• Expanding and strengthening immunization services,
optimization of access and utilization.
• Encouraging early utilization of available health care
facilities for management of common childhood diseases
particularly diarrhoeal diseases and acute respiratory
infections.
• Addressing the special health problems and related
needs of adolescents.
• Encouraging paternal involvement in family health.
• Identifying and discouraging harmful traditional practices
while encouraging their beneficial aspects.

76. • Referral System shall be developed by:
• Optimizing utilization of health care facilities at all levels.
• Improving accessibility of care according to needs
• Assuring continuity and improved quality of care at all
level.
• Rationalizing costs for health care seeders and providers
for optimal utilization of health care facilities at all levels
• Strengthening the communication within the health care
system.

77. • Diagnostic and Supportive Services for health care shall
be developed by:
• Strengthening the scientific and technical bases of health
care.
• Facilitating prompt diagnosis and treatment.
• Providing guidance in continuing care.
• Health Management information system shall
be organized by:
– Making the system appropriate and relevant for
decision making, planning, implementing,
monitoring and evaluation.
– Maximizing the utilization of information at all
levels
– Developing central and regional information
documentation centers.

78. • Health Legislations shall be revised by.
• Up-dating existing public health laws and
regulations.
• Developing new rules and regulations to help
in the implementation of the current policy
and addressing new health issues
• Strengthening mechanisms for
implementation of health laws and
regulations

79. – Health Service Organization shall be
systematized and rationalized by:
• Standardizing the human resource, physical
facilities and operational systems of the
health units at all levels.
• Defining and instituting the catchments areas
of health units and referral systems based on
assessment of pertinent factors.
• Regulating private health care and
professional development by appropriate
licensing.

80. – Administration and Management of the health
system shall be strengthened and made more
effective and efficient by:
• Restructuring and organizing at all levels in line with
the present policy of decentralization and
democratization of decision-making and management.
• Combining departments and services which are
closely related and rationalizing the utilization of
human and material resources.
• Studying the possibility of designating under
secretaries to ensure continuity of service.
• Creating management boards for national hospitals,
institutions and organizations.
• Allowing health institutions to utilize their income to
improve their services.
• Ensuring placement of appropriately qualified and
motivated personnel at all levels.

81. – Financing the Health services shall be through public, private
and international sources and the following options shall be
considered and evaluated.
• Raising taxes and revenues.
• Formal contribution or insurance by public employees.
• Legislative requirements of a contributory health fund for
employee of the private sector.
• Individual or group health insurance.
• Voluntary contributions.

82. UNIT III: STRUCTURE OF HEALTHCARE
SERVICE ORGANIZATION
UNIT OUTLINE
1. Structure of the healthcare service
organization
• Federal
• Regional
• District/Woreda

83. 2. The roles of various agencies in health
promotion
• Government
• Multi-laterals (e.g. WHO [world Health
Organization ])
• Bi-laterals (e.g. USAID [United States
Agency for International Development ])
• NGOs (e.g. AMREF [African Medical and
Research Foundation])
• Private providers (PO’s)

84. 3.1: Structure of the Healthcare Service
Organization
3.1.1. Introduction
• The mechanism through which health services are
organized and delivered in Ethiopia function as a
complex system, in which providers, consumers and
regulators of the health service interact. The system
responds to changes in the external environment
which include changes in:
• Medical knowledge and technology,
• Political and economic situation of the country,
• Social norms and values
• Population health and disease processes.

85. • Understanding the work of the major players
within the national health system and the
many ways in which they interact provides a
basis for managing the system to improve
accessibility, quality and cost of the
services .The health care delivery system in
Ethiopia is a universal national system and in
order to understand the system the major
actors within the system must be identified,
the resources on which these actors depend
must be identified and the external
environment which affects these actors must
also be identified. The major actors are:

86. • the healthcare providers
• the healthcare consumers
• the policymakers and regulators
• The resources used by these actors include:
• funding
• facility
• personnel
• technology
• Information
• The various components are organized into
the following structures:

87. 3.1.2. Administrative Structure of the
Healthcare System Organizations
• The health service organization and
management used to be centralized with
very little community participation.
• This had an undesirable impact on efficiency,
resource allocation, human resource
development, and utilizationof health
services.

88. • A decentralized system was put into place
when in 1990, under the transitional
government , Ethiopia became a Federal
Democratic Republic composed of 9 National
Regional States (NRS) which are; Tigray,
Afar, Amhara , Oromia, Somalia,
Benishangul-Gumuz, Southern Nations
Nationalities and Peoples Region
(SNNPR),Gambella, and Harari,
Administrative states (Addis Ababa city
administration and Dire Dawa council).

89. • The national regional states as well as the
two cities administrative councils are further
divided into six hundred eleven woredas and
around 15,000 kebeles (5,000 Urban and
10,000 Rural).
• Arguably, the most significant policy
influencing the Health Sector Development
Program (HSDP) design and implementation
is the policy on decentralization. This is well
articulated within the constitution and in a
number of major and supplementary
proclamations, and provides the
administrative context in which health sector
activities take place.

90. • Important steps have been taken in the
decentralization of the health care system.
Decision-making processes in the development and
implementation of the health system are shared
between the Federal Ministry of Health (FMOH),
the Regional Health Bureaus (RHBs) and the
Woreda Health Offices (WHO). As a result of recent
policy measures taken by the Government, the
FMoH and the RHBs are made to function more on
policy matters and technical support, while the
woreda health offices have been made to play the
pivotal roles of managing and coordinating the
operation of the primary health care services at the
woreda levels.

91. • The powers and duties of the Ministry of
Health (MOH) according to proclamation 4/87
are to:
– Cause the expansion of health services
• Establish and administer referral hospitals as
well as study and research centers
• Determine standards to be maintained by
health services; except insofar as such power
is expressly given by law to another organ,
issue licenses to and supervise hospitals and
health services established by foreign
organizations and investors

92. • Determine qualifications of professionals required
for engaging in public health services at various
levels; issue certificates of competence to same
• Cause the study of traditional medicines; organize
research and experimental centers for same
• Cause research to be undertaken on traditional
medicines and, for this purpose, organize centers
for research and experiment
• Devise and follow up the implementation of ways
and means of preventing and eradicating
communicable diseases
• Undertake the necessary quarantine controls to
protect public health

93. – Structure of the Ethiopian Health System
I. Structure of Federal Ministry of Health
(FMoH)
• The FMOH is responsible for setting the
health policy and giving technical support.
The organogram below represents the
administrative structure of the FMOH.

94. • organogram of the federal ministry of health
• Minister of Health
• Vice Minister
• Legal and Medico-legal Service
• Public Relation Service
• Plan and Program Department
• Pharmaceutical Supply and Administration Service
• Disease Prevention and control Dept.
• Malaria and vector borne disease prevention team
• HIV/AIDS and other STD prevention and control
team
• TB and leprosy prevention and control

95. • Other diseases prevention and control team
• Hygiene and Env’tal Health Dept
• Water quality and sanitary control team
• Food, drink and herbal preservation control Team
• Quarantine service team
• Industrial and other institution health control system
• Family Health Dept
• Health and Nutrition Research Institute
• Health Service team
• Specialized hospitals
• Health psychosocial educator and training team
• Health Educator Center
• Panel of assessors
• Babies, children and yo

96. • Family planning team
• Women’s healthcare team
• Health Service and Training Dept
• Audit Service
• Organization and Management Service
• Women’s Affairs Department
• Administrator and Finance Service
• Service Delivery Administrative Population

97. – Ethiopian health facilities, their administrative
bodies and the population served by them
• Health Centers (PHCU) Woreda Health
Office 25,000
• District Hospitals Zonal health department
250.000
• Zonal Hospitals Regional health bureaus
1,000,000
• Specialized Hospitals Ministry of health
5,000,000

98. • II. Structure of Regional Health Bureau (RHB)
• Organogram of regional health bureaus
• Bureau Head
• Advisor
• Regional Laboratory Auditing service
• Administration and Logistics Planning and
Programming service
• Hospital Desk Assistance
• Disease prevention and Health programs
Department
• Surveillance team
• Child Health Team
• Pharmacy and Traditional med. Team

99. • Health workers Training School
• Maternal and Reproductive Health team
• Health service organization and Expansion team
• Training Team
• Health sanitation
• Coding and Processing Team
• TB and HIV/AIDS and STI prevention Team
• Family Health Department
• Health service organization and Expansion
Department
• Training Health coding and Guideline Head
• Public relation
• Deputy Bureau Head
• Regional Laboratory

100. III. Structure of District/Woreda Health Office
(WrHO)
Organogram of district/woreda health offices
• Woreda health office Head
• Deputy Woreda health office Head
• Maternal and child health team
• Communicable disease and surveillance team
• HIV control team
• Environmental health team
• Malaria control team
• Health extension program
• Logistics and pharmacy unit
• Planning and program unit

101. 3.2: Contributors of Health Care Provision in
Ethiopia
Introduction
• The main healthcare providers in Ethiopia are:
• the Government
• Private providers
• Non-government
• International Health Agencies:
– Multilateral Agencies
– Bilateral Agencies

102. 3.2.1 The Government
• For many countries, especially in the developing
countries, it is very likely that the government
remain the
• largest single provider of health care giving an
impression of dominating health care provision.
3.2.2 Private Providers
• Private providers work for profit and increasingly
the private providers are getting involved in the
delivery of health services. Nearly all pharmacies
(drug stores) are privately owned. The role of
private hospital and clinics and medical services is
growing especially in urban areas and those who
afford can be managed there and help in reducing
load at government facilities.

103. 3.2.3 Nongovernmental Agencies (NGO’s)
• NGO’s are sometimes known “people to people” aid;
their activities are sometimes very specific, for
example targeting Trachoma and cataracts. Where
as some have more general agendas, for example
aid for orphans.
• They are usually funded by voluntary donations
although some act under contract to governments
and other agencies. The largest and NGO is the
international Red Cross which has national offices
within most countries.
• Other well known NGO’s are USAID, CDC, Oxford
Famine Relief (OXFAM), Care international, save
the children.

104. 3.2.4 International Health Agencies
• International Health agencies play an auxiliary role. They
are funded by member governments.
• A) Multilateral Agencies
• The leader among such agencies is the World Health
Organization (WHO), which began its work in 1948
• in Geneva under the United Nation (UN) .Its headquarters,
is in Geneva. It has six regional offices and
• representatives in most of its 200 member countries. Its
tasks are:
• to review and approve policies and program initiatives
• to coordinate and promote technical cooperation among
countries
• facilitate training and technical assistance
• assimilate, analyze and disseminate health related data

105. • A good example of its achievement is the
way it leads in the eradication of smallpox in
1979.
• Other such multilateral agencies are:
• UNICEF – a program concerned with the
healthcare of infants and children
• United Nation Development Program (UNDP)
• World Bank (WB)
• UNAIDS – is a program for HIV/AIDS
• Food and Agriculture Organization (FAO)
• United Fund for Population Activities
(UNFPA)

106. B) Bilateral Agencies
• The most industrialized nations provide aid on a
country to country basis, attempting to match the
recipients need with the donor’s objectives and
capacity to assist, usually subjects to political
considerations. The United States links aid to
democratic reforms and human rights.
• In 2004 only five countries met the United Nations
target of contributing 0.7% of gross national product
in official development assistance. These countries
are Norway, Denmark, the Netherlands,
Luxembourg, and Sweden. In contrast to the United
States provided only 0.16% and the UK 0.36%.

107. • Donor countries often rely on their own
expertise through competitive bidding to
design, implement, and
• monitor projects funded under bilateral
agreements, sometimes requiring that the
donors own products and services be used.
It is critical that such development assistance
is effectively placed, and fairly counted, so
as to help build sustainable capacities for all
the people of the world.

108. UNIT IV: COMPONENTS OF THE
HEALTHCARE DELIVERY SYSTEM
Introduction
• The universal goal of any health systems is to
ensure access to high-quality services to all
members of its society for as little cost as possible.
The decentralized health policy has different levels
of health care delivery systems (Primary health
care unit, district hospital, zonal hospital and
referral hospital). In this unit we will deal with the
components of health care delivery system level by
level and see the activities carried out in each level.

109. 4.1: Components of Healthcare Delivery
System
4.1.1. Introduction
• The universal goal of any health systems is
to ensure access to high-quality services to
all members of its society for as little cost as
possible. This involves three key areas:
• accessibility
• quality and,
• cost efficiency

110. • Efforts to increase access to care within the
system may lead to higher costs, while
efforts to limit health-care costs may have
adverse effects on access. In order to
address gaps in the accessibility and quality
of healthcare services new strategies have
been implemented by replacing the old six
tier system in to the new four tier system.
There are efforts to reorganize the 4 tier
system into 3 tiers, but this has not been
finalized.

111. 4.1.2. The Current 4 Tiers System
• The current 4 tiers system is organized as:
• First tier: Primary Healthcare Unit (which is made
up of 1 health center and 5 health posts, serving
25,000 people)
• Second tier: District Hospital (serving 250,000
people
• Third tier: Zonal hospital (serving 1 million people)
• Fourth tier: Referral Hospital.
• Health care tier system with their basic parameters
– Zonal/Regional Hospital (ref) 1,000,000 population
– District Hospital 250,000 populations
– Primary health care unit (PHCU) With 5 CHPs 25,000
population
– Referral Hospital 5,000,000 population

112. • Main Issues Addressed by the Pyramid
• The above figure depicts the basic parameters and
levels of health care interactions within the pyramid
and out of the pyramid. It illustrates the referral
linkages and administrative supervisory linkage
pathways with the population served at each level
of health care unit.
• The base of the pyramid is formed by primary
health care unit that consists of a single health
center with five health posts and supervised by
Woreda Health Office (WrHO) and expected to
report to the supervising woreda. Also the referral
system linkage in the primary health care unit is
arranged in such a way that all the five health posts
refer their patients/cases to the Health Centers
(HC) for better management and cases that need
referral from HC are referred to District Hospital.

113. • At the second line of the pyramid is district hospital.
It is accountable to receive referral from HC and
should give feedback to them, and cases that
cannot be managed at district hospital level are
referred to Zonal hospital and the last level of
referral system within the country will last at the
level of specialized hospital Administrative
accountability is shown by a broken line arrow at
the right side of the pyramid. Regarding to the
supervision and administrative support in the
hierarchy of FMOH, FMoH supervises RHB, and
RHB supervises WrHO through delegated actor
known as zonal Health Departments (ZHD). And
the ZHDs supervise WrHO and woreda Health
office supervise PHCU

114. 4.1.3. Major Components and Actors of
Healthcare Delivery System
• The major components and actors of the healthcare
delivery system are:
• The health facilities
• Health Posts
• Health Centers
• • Beds=10
• • Ts+13+15
• • NTs=12
• District Hospitals (Primary Hospitals)
• • Beds=50
• • Ts=33
• • NTs=35

115. • Zonal Hospitals (Regional Hospitals)
• Beds=100
• Ts= 60
• NTs=50
• Specialized Hospitals (Referral Hospitals)
• 250 beds
• Ts= 120
• NTS= 50
• Note: Ts = Technical staff; NTs= Non-
technical staff

116. • The health workforce/personnel
• Medical staff: Are the personnel consisting of
physician who have received extensive training and
granted to give clinical service.
• Administrative staff: staffs who are involved in
leadership and management like Chief Executive
Officer
• (CEO), Chief Financial Officer, Chief Information
Officer Etc…
• Supportive staff: clinical supports are activities
carried out by pharmaceutical service, food and
nutritionservices, Health Information management,
social work and social service, patient advocacy
service, purchasing central supply and material
supply management services

117. 4.2: The Health Care Facilities and Services
they Provide
• In order to properly implement the
delivery of health services the role of each
type of health facility/institution is
determined. This in turn determines the
professional mix of the staff assigned to each
type of health facility.

118. 4.2.1. The Primary Healthcare Unit (PHCU)
• The PHCU consists of Health Post and
Health center. The Health Sector
Development Program document of the
Ministry of Health (MOH) describes PHCU is
an important component of the Health
System in Ethiopia.

119. • A comprehensive PHCU services is to be
delivered through community-based health
services by the HealthExtension Program
(HEP) at Health Posts (HP) and household
levels, and further through Health
Centers(HC) and p. Basically the PHCU is
the health service delivery organized and
managed at District level withinthe
decentralized system of the Ethiopian
Government at the Woreda Health System
(WHS)

120. A) Health Posts
• The Health Post (HP) represents the first
contact of the health care system and it is
considered the first contact level between the
service provider and the client. The HP
provides mainly preventive and Promotive
services (health education), but also some
limited services of very basic curative care.
Most cases are referred to the next level, the
Health Center, which is still within the first tier
(i.e. within the PHCU). The HP provides its
services to a catchment population of
approximately 3,000-5,000.

121. • All community-based health services
provided at outreach site and house hold
level services and at the HP are
administratively supervised by Woreda
Health Office and Kebele Council and
technically by the Health Centers in the
catchments area. A health post is run by two
Health Extension Workers (HEWs).
Summary of Job accomplished by HEW

122. • Provide health education
• Promote community nutrition
• Provide Antenatal Health Care (ANC)
• Provide Postnatal Care (PNC)
• Promote and provide family planning service
• Implement hygiene and environmental health service
• Provide first aid and basic clinical service
• Provide delivery service
• Implement immunization service
• Collect and maintain population health data

123. B) Health Center
• The Health Center (HC) with its five satellite
Health Posts, is designed to render integrated
promotive, preventive, basic curative and
rehabilitative services. The Health Centre (HC)
represents the first level of the health care system for
curative services, and serves a catchment population
of 25,000. A standard HC has a capacity of 10 beds
and provides 24 hour emergency medical care
services, treatment of common medical problems,
basic obstetric care, basic laboratory and
pharmaceutical services. The medical conditions that
are expected to be managed at this level are
handled by:

124. • Clinical officers/Health Officers
• Nurses and,
• Midwives.
• The function of the Health Center is
organized into five components based on the
Health Service Extension Program.
– Family health service: Family Health Services that are
expected to be provided at this level include:

125. I. Maternal and newborn care services including:
• antenatal care (ANC),
• delivery and newborn care services,
• postnatal care (PNC), and
• family planning (FP)
II. Child health services including:
• Integrated management of childhood illnesses (IMCI)
• Growth monitoring and promotion
• Immunization
• Adolescent reproductive health services (ARH) and
• Promotion of essential nutrition action (ENA).

126. • Communicable Disease Prevention and
Control Services: services provided under
this component are related to the following
major categories:
• Tuberculosis and Leprosy:
– Clinical diagnosis and treatment,
– Management of complications and adverse
drug reactions,
– Training, advice and treatment of leprosy
patients on disability,
– Refer cases to the HP for follow up when
supported by established mechanism of
information and patient flow systems

127. b) HIV/AIDS and STI: the services provided at the
HC level are:
– IEC on transmission and prevention of HIV/AIDS and STI,
– Support and guidance to families on home-based care,
– Condom promotion and distribution,
– VCT and PMTCT services,
– Treatment of common opportunistic infections such as
TB, PCP, toxoplasmosis, and candidiasis in diagnosed
HIV/AIDS cases
– Identification and referral of patients eligible for ART,
– Follow up of ART patients with no complications,
– Provide Syndromic management of STI

128. c) Epidemic diseases: Ensure adequate and
timely preparedness, Investigate, confirm
and provide free treatment to cases of
epidemics of all the reportable epidemic
prone disease.
• Epidemic prone diseases
– Cholera
– Diarrhea with blood (Shigella)
– Measles
– Meningitis
– Plague
– Viral hemorrhagic fevers
– Yellow fever

129. • Diseases targeted for elimination/eradication
• Acute flaccid paralysis(AFP/Polio)
• Measles
• Neonatal Tetanus
• Leprosy
• Dracunculiasis (Guinea worm)
• Other diseases of public health importance
• Pneumonia in children less than 5 yrs of age
• Diarrhea in children less than 5 yrs of age
• New AIDS cases
• Malaria
• Onchocerciasis
• Sexually transmitted infections(STIs)
• Trypanosomiasis
• Tuberculosis

130. d) Rabies:
• Provision of full course of anti rabies vaccination,
• Refer clinical cases of Rabies
• Basic Curative Care and Treatment of Major
Chronic Conditions and injuries: Under this
category the major services that are expected are:
– First Aid for common injuries and emergency conditions,
– Treatment of major chronic condition,
– Treatment of mental disorders and
– Treatment of common infections and complications
4. Hygiene and Environmental Health Services:
activities under this component are mainly related
to giving technical assistance and supportive
supervision to HEW on various environmental
health service issues including:

131. • School health education,
• Prison health service,
• Control of rodents and insects,
• Provision of water quality control,
• Personal hygiene and others.
• 5. Health Education and Communication:
Similar to the previous component, the major
activities under this component is to provide
technical assistance and supportive
supervision to HP in the provision of IEC
materials

132. 4.2.2. District Hospital and Services Provided
• The district hospital represents the third level within
the PHCU, of the health system and has the
capacity of 30-50 beds and provides 24 hour
emergency service for a population of 250,000. It
serves as a referral center for the five Health
Centers under its catchments and will have the
capacity of providing treatment of basic acute and
chronic medical problems, Comprehensive
Emergency Obstetric Care (CEOC), basic
emergency surgical interventions, dental and
mental health services. These hospitals will also
serve as a training site for clinical officers and mid
level health workers.

133. • In addition to the following services, District
Hospital provides all of the essential health
services that are provided by the Health Center.
• Comprehensive Essential Obstetric Care
– Provision of basic emergency obstetric care services
– Provision of obstetric and gynecologic procedures
including (minor and major procedures)
2) Emergency Surgical Procedures:
– Basic life saving procedures
– emergency major procedures and minor procedures)
3) Emergency Medicine, like:
• Diabetic ketoacidosis (DKA)
• Acute poisoning
• Severe and complicated malaria
• Status asthmatics
• Seizure disorders and others

134. 4) Laboratory and pharmacy services
4.2.3. Zonal/Regional Hospitals and Services
Provided
• Generally these hospitals have the capacity of 150-
200 beds and provides 24 hours service. It will have
the four major departments:
• Internal Medicine
• General Surgery
• Paediatrics and
• Gynaecology and Obstetrics
• Additional specialities such as Ophthalmology,
Radiology, Orthopaedics, Dentistry and Psychiatry.
• These hospitals serve as a training site for medical
doctors and other healthcare workers. The major
services at this level include:

135. a. Management of Childhood Illnesses
• The Hospital provides outpatient and in-patient
management of infant and child health, in
accordance with. National Standard Treatment
Guidelines at Hospital Level. This includes
preventive, curative (assessing, classifying and
treating) promotive, and rehabilitative care.
b. Adult Medical Service
• The Hospital provides outpatient and in-patient
management of adults in all life stages in
accordance with the Standard Treatment Guidelines
for hospital care. This includes the provision of
preventive, curative, promotive, and rehabilitative
care.

136. • As much health care as possible is provided
in ambulatory basis;
• Patients are admitted and kept in hospital
only when this is absolutely essential, for
physical, medical, mental or social reasons.
• The hospital provides the second level of
inpatient admissions for hospitalized care.
• Ongoing management of patients referred to
or from the health centers and Primary
Hospitals are provided.

137. • c. Women’s Medical Service
• The Hospital provides that part of the
comprehensive package of promotive,
preventive, curative and rehabilitative
reproductive health services for women who
requires medical and special resources not found
in health centers or clinics. The hospital provides
a 24-hour service for acute gynecological and
obstetric problems and deliveries of most high-
risk pregnancies. The focus of the outpatient
clinic is on taking referrals from health centers
and clinics and referring patients back with
information and advice

138. • d. Trauma and Emergency Surgical Service
• The hospital provides:
• A 24 hour emergency, resuscitation service,
advanced trauma and cardiac life support
• Treatment and observation of medical and surgical
and emergencies
• Treatment and reporting of accidents, gunshots,
and physical abuse
• Referral of patients to specialized hospitals.
• Arrangements to deal with disaster situations.
• Surgery for minor and serious conditions
• Common major elective surgeries

139. • e. Pharmaceutical service
• The pharmaceutical service supplies and
dispenses essential drugs and medical
supplies. It selects drugs and medical
supplies, purchases these from an identified
supplier to maintain adequate quantities,
receives, records, stores them and ensures
appropriate controls are in place. It
dispenses prescribed drugs, encouraging
rational use by the prescribers as well as
patient compliance and appropriate use.

140. • f. Laboratory Service
• The basic functions include:
• Conducting all the routine tests including quality
control and some tests that the hospital activity
requires
• Taking specimens and sending them
• Helping in training technician assistants with further
technical supervision
• Preparing reagents and recording them
• Keeping equipments in a good status
• Preparing a monthly report about the lab activities
• Taking safety measures in the laboratory

141. • 4.2.4. Referral Hospitals
• In addition to the services in the general
hospital, specialized hospitals have
additional departments like
• Pathology, Anaesthesiology, ENT,
Dermatology and sub-specialities. Such level
of hospitals will also serve as a teaching
centre for medical doctors and different types
of specialists. In Ethiopia we have five
hospitals to such level (Tikur Anbesa, St
Pawlos, Amanuel, St Petros and ALERT)

142. • 4.3.1 Human Resource (healthcare workforce)
Requirement
• The other major component of the healthcare delivery system
is the healthcare work force. They play a crucial role based
on the service delivered at the facilities. Number and type of
personnel required varies depending on the type of facility
they are posted at. The human resource requirement for
each level of care is established based on the expected
services at each level, the workload and service standard by
using the Workload Indicator for Staffing Needs (WISN)
method. The average HRH requirement for each level of care
is summarized in the following Table (look at table 4.1).
However, as the work load may vary across facilities, each
facility need to develop its staffing requirement on case by
case basis.
• The make-up of the healthcare work force can be categorized
as:

143. • Medical staff
• Administrative staff
• Supportive staff
• A) Medical Staff
• Medical staff includes the professional
occupations such as:
• Physicians of all categories: – in Ethiopia there is
shortage of medical doctors, and also concerns
about the distribution of doctors across geographic
areas. There is also misdistribution over rural
verses urban areas.
• Nurses – constitute the largest healthcare
profession. The primary paths to becoming a nurse
are by obtaining a BSc or a diploma in nursing.
Their responsibilities include performing patient
assessments, providing nursing care, and
administer patient care services.

144. • Health Officers – receive their training through a
university-based program, and have expanding
responsibilities with the healthcare delivery system
• 4.1: Average number and professional types
required at different health facility levels
• Other professional components of the health
workforce include dentists, dental hygienists,
social workers, pharmacists, therapists,
nutritionists. The application of medical
technologies and equipment requires additional
technicians with specialized skills, such as
radiology technicians, laboratory technicians, and
pharmacy technicians.

145. • B) Administrative Staff
• The leader of the administrative staff is the medical director,
who is going to be replaced by Hospital CEO’s according to
the new human resource development strategy. The CEO is
responsible for coordinating the health services provided at
that facility. While department staff nurses are accountable
to the head nurse, the head nurses are accountable to the
matron. The matron is in turn accountable to the medical
director of the hospital.
• C) Support Staff
• Support staff provides support services to patients, medical
staff, and employees.
• Clinical support staff
• Food and nutrition services
• Health record services
• Social services
• Central supply services

146. • Professional Category CHP HC District Hospital Regional Hospital
Specialized Hospital
• Specialist 0 0 0 18 51
• GP 0 1 2 20 60
• Clinical Officer 0 2 4 0 0
• Dentist 0 0 1 2 4
• Nurse 0 5 10 87 178
• Midwife 0 2 2 14 21
• Anesthesia Professionals 0 0 2 5 14
• Psychiatry Nurse 0 0 1 4 12
• Other dental professional 0 0 1 2 6
• Laboratory professionals 0 2 3 12 20
• Pharmacy professionals 0 2 3 8 16
• Physiotherapist 0 0 1 4 8
• Radiographer 0 0 2 5 11
• Biomedical Technician 0 0 1 3 4
• Hospital Manager 0 0 1 1 1
• Public Health Officer 0 1 1 2 4

147. • HIT 0 1 2 4 8
• Dietician 0 0 0 2 4
• Social Worker 0 0 0 2 4
• Health Extension Worker 2 0 0 0 0
• 2 16 33 195 426
• Administrative support services
• Registration clerks
• accounting
• Secretaries
• Security personnel
• Cleaner

148. • UNIT V: HEALTH SERVICE PROGRAMS
• Introduction
• The first Health Sector Development Program (HSDP) was launched in
1977 and currently we are on the third HSDP. In this unit we will deal
with health service programs of Ethiopia. A key aspect of health service
program is the Essential Health Service Package (EHSP), which
specifies the basic services that should be available at a certain level of
the health system.
• Unit Outline
• 1. Health policy, plans and strategies
• 2. Essential health service package
• 1. The Health Service Extension Program (HSEP)
• 2. Family health service
• 3. Prevention and control of disease
• 4. Medical Services
• 5. Hygiene and environmental health
• 3. Human resource development
• 4. Pharmaceutical service
• 5. IEC and HMIS
• 6. Monitoring and evaluation and health care financing

149. • 5.1: The Health Policy, Plans and Strategies
• Lesson objectives
• At the end of the lesson the learners should be able
to:
• 1. State major goals of HSDP
• 2. Explain the current Ethiopian health policy
• 5.1.1. Introduction
• As a means of achieving the goals of the health
policy (refer Ethiopian health policy), the
government has formulated a twenty-year health
sector development strategy, which is being
implemented through a series of five-year plans.
The implementation of the first Health Sector
Development Program (HSDP) was launched in
• 1997, and now the third HSDP is under way. (Please
refer to the HSDP III manual.)

150. • 5.1.2. The HSDP-III
• The ultimate goal of HSDP-III is to improve
the health status of the Ethiopian people
through provision of adequate and optimum
quality of promotive, preventive, basic
curative and rehabilitative health services to
all segments of the population. Contributing
to this overall goals, there are 3 sub-goals.
These are:
– To improve maternal health
– To reduce child mortality
• To combat HIV/AIDS, malaria, TB and other
diseases

151. • 5.1: Summary of HSDP III focus areas and outcomes
• Focus areas Outcome Vehicles Bloodlines
• Maternal health
• MMR 871 to 600
• CPR> 60%
• 30,000 HEWs
• Health Officers: 5,000
• Health Posts: 13,635
• Health Center: 3,200
• Train GP’s
• Improve QA
• • HMIS
• • Logistics
• • Human resource
• • Finance harmonization

152. • Child Health
– U5MR 123/1000 to 85/1000
– IMR 77/1000 to 45/1000
– Immunization >85%
• HIV/TB * Maintain prevalence of HIV at 3.5%
• Malaria * 20 million ITNs
• The above table describes nation-wide priorities.
“Priorities” means activities that have been selected
as the most important and urgent for improving the
health of Ethiopians. When resources are in short
supply – money, staff, managers’ time, drugs, etc.
– then they will be allocated first to the priority
activities.

153. • In other words the 5 targets related to family
planning, immunization, HIV/TB, and the distribution
of nets to be used in malaria prevention are the
most important priorities in the Ethiopian healthcare
delivery system.
• These broad sub-goals are then described in more
detail through 8 major objectives:
– To cover all rural kebeles with HEP to achieve universal primary
health care coverage by 2008
– To reduce the MM ratio to 600 per 100,000 live births from 871
– To reduce the under 5 mortality rate from 123 to 85 per 1,000 live
births and the infant mortality rate from 77 to 45 per 1,000 population
– To reduce the total fertility rate from 5.9 to 4
– To reduce the adult incidence of HIV from 0.68 to 0.65 and maintain
the pre-valence of HIV at 3.5%
– To reduce morbidity attributed to malaria from 22% to 10%
– To reduce the case fatality rate of malaria in age groups 5 years and
above from 4.5% to 2% and the case fatality rate in under 5 children
from 5% to 2%
– To reduce mortality attributed to TB from 7% to 4% of all treated
cases

154. • These objectives are then re-structured as 8
implementation components, to reflect the
way in which healthservices are delivered
and financed:
• Health service delivery and quality of care
• Access to services: health facility construction,
expansion and transport
• Human resource development
• Pharmaceutical service
• Information, education and communication (IE&C)
• Health management information system
• Monitoring and Evaluation
• Health care financing.

155. • In effect, components 1 describe the main
health service delivery activities and
components 2 -7 are the inputs and activities
required to provide these services.
• In addition to the HSDP, Ethiopia is in the
process of implementing the Millennium
Development Goals
• (MDGs). The MDGs came out of the UN
Millennium Declaration, assuring the right of
each person on the planet to health,
education, shelter and security. The
important role health plays in achieving the
MDGs is clearly reflected.

156. • The 8 MDG Goals are:
• Eliminate Poverty and hunger
• Ensure primary education for all
• Promote gender equality and
• Reduce juvenile mortality
• Better maternal care
• Combat HIV/AIDs, Malaria and other diseases
• Ensure a sustainable environment
• Build a global partnership for development
• Of the above MDGs, goal 4, 5, and 6 are
addressed by the health sector.

157. • 5.2: Essential Health Service Package
• Lesson Objectives:
• At the end of this lesson the learners should be able to:
• Describe the five components of Essential Health Service Package
(EHSP)
• Identify the components of packages that will be carried out by the
Health extension workers
• State the goal of Family health services
• Mention the goal of medical service
• Identify diseases which are of top priority
• State the priority activities/interventions area in HIV/AIDS and malaria
Prevention and Control Programme
• Explain the need for TB and Leprosy Control Programme (TLCP)
• Identify the role of each facility level in TB leprosy Control program
• Identify the objectives of hygiene and environmental subcomponents
• List the diseases given due emphasis in HSDP II program
• State minimum standard expected in health care delivery at different
levels
• Describe the importance of having base line information on key
indicators like TFR, MMR, U5MR?

158. • 5.2.1. Introduction
• The best way of understanding the healthcare
delivery system is to break down the “Essential
health Service Package” provided at hospitals,
health centers and health posts.
• A key aspect of this component is the Essential
Health Service Package (EHSP), which specifies
the basic services that should be available at a
certain level of the health system. EHSP consists of
an essential package for the community level, plus
basic curative care and the treatment of major
chronic conditions to be provided at health centers.
The EHSP has five components:
• The Health Service Extension Program (HSEP)
• Family health service
• Prevention and control of disease
• Medical Services
• Hygiene and environmental health

159. • 5.2.2. The Health Service Extension Program
(HSEP)
• The HSEP is a community based healthcare
delivery system which focuses on preventive health
service. This basic healthcare coverage is
implemented at the health post level. Each health
post has a catchment of 5000 people, and is staffed
by 2 HEWs. The HSEP has 16 major packages
which fall into the 4 major components:
• Hygiene and environmental sanitation
• Family health services
• Disease prevention and control
• Health education and communication

160. • 5.2.3. Family Health Services (Maternal and
Child Health Care)
• The goal is to reduce deaths and illnesses
associated with pregnancy, childbirth, and early
childhood diseases.
• This is done by educating mothers and community
midwives on birth spacing, contraception, antenatal
care, delivery practices, child health and nutrition.
• Health workers also diagnose and provide basic
clinical treatment for common childhood illnesses
including respiratory infections, measles, malaria,
pneumonia, and diarrhea. Childhood vaccines,
vitamin A, oral rehydration treatment, tetanus
vaccines to pregnant women, and anti-malarial
drugs are provided.

161. • A) Maternal Health
• Nearly half (49.7%) of Ethiopia’s population is
female, of which 47% are in the range 15-49
years of age. Total Fertility Rate (TFR) is
estimated at 5.9. According to data from
health facilities across the country,
pregnancy related problems account for
13.8% of in-patient mortality among women
of child bearing age. The Maternal mortality
Rate (MMR), estimated at 871 per 100,000
live births, is one of the highest in the world.
The major causes of maternal mortality
include delivery, other pregnancy related
complications and abortion.

162. • B) Child Health
• Like in many developing countries, children
less than 15 years of age constitute 44.7%;
of this around 40% are under five years of
age, and 8% are under one years of age.
• In year 2000, the under-five mortality rate
(U5MR) was estimated at 166, while infant
mortality and neonatal mortality rates were
estimated at 97 and 49 per 1000 live births
respectively. Assuming a steady annual
decrease, the U5 MR is currently estimated
at 146.6.

163. • The major causes of under-five mortality have been
pneumonia (28.9%), malaria (21.6%) and diarrhea
(6.7%), all types of pneumonia and malaria are the
major causes of death among infants, with each
accounting for 39.7% and 21.1% of deaths
respectively. High maternal fertility, especially early
first pregnancy and short birth intervals, have also
been strongly associated with increased under-five
mortality.
• Malnutrition has been a major underlying cause of
an estimated 57% of deaths, while HIV/AIDS
underlies 11% of deaths, particularly those due to
pneumonia, according to FMOH documents. Half of
Ethiopia’s children under-five are stunted (52%),
while 11% are estimated to be wasted.

164. • The government has adopted an Integrated Management of
Childhood Illnesses (IMCI) as its key strategy towards
reducing under-five mortality and morbidity, and promoting
healthy growth and development of children. The strategy
focuses on key child survival interventions, proven to be
effective in reducing childhood mortality. These
interventions include:
• Improved birth interval,
• improved antenatal care coverage both for TT2 and
measles
• improved coverage of skilled delivery
• prevention of mother to child transmission of HIV/ AIDS
• promotion of exclusive breast feeding in the first 6 months,
complementary feeding after 6 months and continued
breast feeding
• treatment of fever, ARI and diarrhea
• vitamin A supplementation
• delivery of safe drinking water and sanitation
• provision of insecticide treated nets (ITNs)

165. • Indicator
• HSDP-I HSDP-II
• Baseline Target Achievement Target Achievement
• DPT3 59.3 70-80% 51.5 70 70.1
• CPR 9.8% 15-20% 18.7 24%, 25.2
• ANC 5% - 30 45 41.5
• Assisted delivery 3.5% - 7% 25 12.4
• TT2 for pregnant - - 27 70% 43.3
• TT2 for nonpregnant
• - - 14.8 32 25.8
• PNC coverage 3.5 - 6.8 20 13.6
• C) Steps taken

166. A National Reproductive Health Taskforce with
technical working group for Making
Pregnancy Safer (MPS), family planning,
nutrition, STIs/HIV, logistics and adolescent
RH have been formed to assist the
programme with resource mobilization,
monitoring and development of appropriate
policies and guidelines.

167. Making Pregnancy Safer was launched in 2001 and
implemented in four regions on pilot basis. Health
workers were also trained on basic emergency
maternal and newborn lifesaving obstetric services,
EOC, cesarean section and anesthesia. 10 hospitals
and over 40 HCs were equipped with basic essential
equipment and supplies, and vehicles were procured
and distributed to enhance programme
implementation and the referral system. The review
of the programme conducted in year 2003 revealed
improvement in the quality of service and handling of
obstetric emergencies that stimulated the rapid
scaling up of the programme coverage.

168. • 5.2: Summary of Targets and
Achievements during HSDP-I and II in
Maternal and Child
• Health Services
– With regard to child health, IMCI was adopted nationally in
1997 as a major strategy to reduce childhood mortality and
morbidity and promote childhood development. It has three
components :
– improving the skills of health workers,
– improving health systems,
– Improving family and community practices.
• The main activities under IMCI are
prevention and control of ARI, diarrhea,
malaria, malnutrition, measles and
HIV/AIDS.

169. – Interagency Coordination Committee (ICC) has been
established and meets regularly to address issues on
improving routine EPI, supplementary immunization activities
and disease surveillance. This committee also plays a key
role in resource mobilization for EPI.
– In addition to the scheduled vaccination programs,
supplemental immunization of polio, measles and neonatal
tetanus was introduced in order to reach the remote areas of
the country, strengthen the routine immunization activity and
eradicate/eliminate the 3 vaccine preventable diseases.

170. – Training was given to mid-level managers and cold chain
technicians using Midlevel Managers and Immunization in
Practice Modules. The programme has also replaced the
reusable syringe by AD syringe and all injection vaccines
were given using the disposable syringes and safety boxes.
– Introduction of the Reaching Every District (RED) strategy,
where most woredas have been developing micro-plans.

171. • Major constraints encountered during the
implementation of MCH programmes were:
– understaffing and high turnover of both technical
and managerial staff at all levels
– inadequate follow-up and supportive supervision
– shortage of transportation
– lack of motivation of service providers
– poorly functioning of outreach sites and weak
referral system
– high vaccine wastage rates,
– critical shortage of basic equipment for the
management of emergency obstetrics at facility
level
– Short supply of contraceptives and vaccines.

172. • The following are the future directions towards the
improvement of MCH service.
• Operationalize the harmonization of maternal and child health
programs with the Health Extension Programme.
• Accelerate capacity building at the Regional and District level
for planning, training, follow up and support supervision.
• Building the capacity of training institutions to scale-up IMCI
pre-service training through training of instructors and
provision of financial and material support.
• Involve NGOs and the private sector to scale up maternal
and child health interventions.
• Strengthen the collaboration and integration among relevant
programs like RBM, EPI, Nutrition, MPS, IMCI and HIV/AIDS
etc., to avoid duplication of efforts and maximize the impact.
• Optimally utilize the opportunity of the child survival initiative
to scale up maternal and child health interventions.
• Introduce new vaccines against Hepatitis B and Haemophilus
Influenzae.

173. • 5.2.4. Prevention and Control of Disease
• The health service program gives priority to the
prevention and control of HIV/AIDS, malaria,
tuberculosis, leprosy, blindness and onchocerciasis.
• A) HIV/AIDS Prevention and Control Programme
• It is now more than two decades since the
HIV/AIDS epidemic started in Ethiopia. HIV/AIDS
was recognized as top priority from the very
beginning of HSDP. There is a National HIV/AIDS
Policy supporting disease prevention and case
management (including home-base care),
strengthen IEC/BCC, mobilization of resources and
coordinating multisectoral effort to ensure proper
containment of the spread of the disease and
reduce its adverse socio-economic consequences.

174. • The priority intervention areas are:
• IEC/BCC,
• Condom promotion and distribution,
• Voluntary counseling and testing (VCT),
• Management of sexually transmitted infections
(STIs),
• Blood safety,
• Infection prevention/universal precaution,
• Prevention of mother to child transmission of HIV
(PMTCT),
• Management of opportunistic infections,
• Care and support to the infected and affected,
• Legislation and human rights and surveillance and
research

175. • In order to facilitate the implementation of these
interventions, a number of guidelines, manuals and
other relevant documents have been prepared on
counseling, case management, home-based care
and other areas.
• The policy on supply and use of anti retroviral drugs
has been implemented within the framework of the
existing HIV/AIDS Prevention and Control Policy and
Strategy. In addition, intensive and continuous
advocacy has been conducted leading to the
involvement of more and more NGOs, UN and
Bilateral Organizations, CBOs and the community at
large in the prevention and control of HIV/AIDS.

176. Six strategic issues have been identified in the HIV/AIDS
prevention and control strategic plan, these are:
• Capacity building
• Community mobilization and involvement
• Integration with health programmes
• Leadership and mainstreaming
• Coordination and networking
• targeted response
Challenges faced in the implementation of the program
are:
• Weak coordination and communication at all levels
• Inadequate implementation of blood safety procedures
• Scarcity and insufficient implementation of guidelines related
to HIV/AIDS
• Shortage of supplies required to provide care and support

177. B) Malaria and Other Vector-borne Diseases Prevention
and Control
• Malaria is the leading cause of morbidity and mortality in the
country. Three quarters of the landmass of the country is
malarious and around two-thirds of the population is at risk of
infection. Considerable attention has been given to malaria
in order to reduce the overall burden of the disease. The
prevention and control of malaria is achieved by:
• Distribution of effective drugs to all health facilities, including
health posts
• Distribution of insecticide treated bed nets
• Provide health education to communities to maximize use of
bed nets
• Spraying of DDT as per plan
• Training of health professionals in malaria control and
prevention

178. • C) Tuberculosis and Leprosy Control
Programme (TLCP)
• The general objective of the TLCP is to
reduce the incidence and prevalence of TB
and Leprosy as well as the occurrence of
disability and psychological suffering related
to both diseases and the mortality resulting
from TB to such an extent that both diseases
are no longer public health problems. The
general objective has been specified for the
various TLCP activities as follows:

179. • Case detection: to diagnose TB and Leprosy
patients at an early stage of the disease to the
extent that the case detection rate of new smear
positive pulmonary TB patients is at least 70% of
the estimated incidence and the proportion of
disability grade II among new leprosy patients is
less than 10%.
• Treatment: to achieve and maintain success rate of
at least 85% of newly detected smear positive
pulmonary TB patients (PTB+) and extra pulmonary
TB patients treated with DOTS. For Leprosy,
treatment should achieve a treatment completion
rate of at least 85% and prevention of Leprosy
related disability during chemotherapy should be
below 3%.

180. DOTs/MDT is expanded to all regions. For instance,
86% of woredas in the country and 50% of the
government health facilities are implementing
DOTS/MDT (32% in 2000). The treatment success
rate, which is the main indicator of programme
effectiveness, has reached 76%. The treatment
defaulter rate has also decreased from10% in
1998/99 to 7% in 2000/01 and then to 5% in
2003/04 for patients on short-term chemotherapy.
Additionally, encouraging results were seen in the
areas of integration of DOTs/MDT into the routine
health service delivery. Standardized national
treatment manual and basic microscopy services
are also put in place.

181. • Challenges with regard to implementation of TLCP are:
• Shortage and high turnover of staff
• Inadequacy of on-the-job training and supervision
• Inadequate involvement of communities in the
implementation of DOTS
• Poor communication between the public and private TB care
providers.
• In order to alleviate these problems, there is a need to
strengthen the programme implementation capacity at all
levels of the health system including capacity for the
efficient use of financial resources. There should be proper
planning for staff allocation and regular training. Involvement
of the Health Posts in TLCP implementation and
improvement of community mobilization with the
implementation of the HSEP is expected to enhance the
effectiveness TLCP.

182. • 5.2.5. Medical Services
• Medical Services is one of the components in
essential health service package
• The goal of Medical Services is to:
• improve quality of health service and utilization by
the population through reorganizing the health
service delivery system into 4-tier system
• strengthen the decentralized management to
ensure full community participation
• develop and implement essential health service
package and referral system
• Develop health facility standards and staff and
equip the health facilities accordingly.

183. In line with this, there has been significant
transformation of the old six-tier health delivery
system into the new four-tier system spearheaded
by the establishment of PHCUs (which is being
revised and a proposal to use a 3 tier system is
underway). A complete set of national standards for
health posts, health centers and district hospitals
have been prepared, endorsed, published and
distributed to regions. These standards contain
specifications for the building design, lists of
equipment and furniture, the scope of service,
detailed information on the cadres of staff required,
and drug lists for each level. Essential health
service package document has been finalized and
referral system guideline has been drafted.