Transforming health care in Ethiopia (Zoë Mullan)

Dec 22 2015

(Zoë Mullan – The Lancet Global Health)

To judge from recent news stories, 2015 has not been a good year for Ethiopia. It has seen the country’s worst drought since the dark days of 1984–85; 8·2 million people are currently in urgent need of food aid. And the government was widely criticized in June when the ruling People’s Revolutionary Democratic Front party won an unlikely 100% of parliamentary seats in the general election. Yet at the INDEPTH Scientific Conference in Addis Ababa last month, the mood was upbeat. The conference showcases research carried out within the INDEPTH Network’s 53 Health and Demographic Surveillance Systems (HDSS). Ethiopia has more HDSS sites than any other country in the Network. It has also just embarked on an ambitious Health Sector Transformation Plan (HSTP). What can Ethiopians expect from their Health Ministry over the next 5 years?

Most notably, the HSTP will build on Ethiopia’s highly successful health extension programme, which has seen the training and deployment of an all-female army of 38 000 community health workers across remote areas since 2003. These health extension workers (HEWs)—in teams of two per kebele (neighbourhood or ward)—look after about 500 households each, focusing mainly on family planning, antenatal care, and childhood vaccination, but also advising on household hygiene and prevention of HIV, tuberculosis, and malaria. Since 2003 the neonatal mortality rate has fallen by 38%—from 44·4 to 27·7 per 1000 livebirths—and the maternal mortality ratio by 43%—from 740 to 420 per 100 000 livebirths. A World Report published in The Lancet on Dec 5 outlines some of the country’s successes in tuberculosis control. The HSTP’s aim, in line with the Sustainable Development Goals, is to reduce the neonatal mortality rate to 20 per 1000 livebirths and the maternal mortality ratio to 199 per 100 000 livebirths over the next 5 years. Targets for HIV, tuberculosis, and malaria are similarly ambitious.

Photo - Health worker visit in a rural community near Dessie, Ethiopia

An outreach worker arrives for a home visit in a rural community near Dessie, Ethiopia [I-TECH/Julia Sherburne]

In trying to achieve these lofty targets, the HSTP is putting particular emphasis on transforming health services at the district (woreda) level, starting with the selection of directors of primary health-care units who can establish “a culture of quality management, focus, and data-driven achievement”. These units will be subject to performance contracts and citizen scorecards, and community members will be invited to join their governing boards. Mechanisms for turning around underperforming health centres will be put in place. Community members will also be strongly encouraged to take ownership of their own health: previously households who adhered to health extension programme standards were designated “model families”. The HSTP extends the concept to the kebele level and is designed to address issues that require social, rather than individual, transformation, such as open defecation. Health Minister Kesetebirhan Admasu and colleagues outline this “model kebele” concept in a Comment. It’s a novel idea, which one could imagine would raise the heckles of western communities. Yet community engagement is essential in populations with low levels of health literacy such as Ethiopia, where, despite recent progress, health, health-care access, and quality of care vary widely by socioeconomic status, education, location, and sex.

Leadership is again key to addressing issues of inequity, according to the plan. Managers will be trained so as to have “a rich understanding of the causes of disparities and the vision to implement solutions and transform the health system to deliver high-value health care”. Additionally, a regional-level equity analysis will be performed every year, documenting access to health care and health service uptake.

Finally, as Admasu announced at the INDEPTH conference, the Plan heralds a dual data revolution: a digital revolution, whereby data collection becomes more scientific, systematic, and joined-up—there are plans to digitise all 18 million paper-based family health records over the next 5 years—and a mindset revolution, whereby those collecting the data are doing so with the intent to drive decision making rather than just reporting up the chain. The ambition is to create a demand in society for informatics of better quality, building awareness in communities and putting equity at the heart of transformation.

Ethiopia’s HSTP is both deep and broad, embracing leadership, data for decision making, empowerment, accountability, equity, quality, respect, and compassion. It’s hard to find anything not to like. The world will be watching its progress with great interest and expectation.

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* Originally published on The Lancet Global Health, Dec. 22, 2015

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