41262 Findings G In oo fo d br Pr ief ac tic e Africa Region · Number 141 · October 2007 Findings Infobriefs reports on Good Practice in ongoing operational, economic and sector work carried out by the World Bank and its member governments in the Africa Region. It is published monthly by the Knowledge and Learning Center on behalf of the Region. The views expressed in Findings are those of the author/s and should not be attributed to the World Bank Group. Ethiopia Health Sector Development Program The Health Sector Development Program Project for Ethiopia aims to develop a health sys- tem that provides comprehensive and integrated primary care services, primarily based at community health level facilities. It focuses on communicable diseases, common nutritional disorders, environmental health and hygiene, reproductive health care, immunization, the treatment and control of basic infectious diseases like upper respiratory tract infections, the control of epidemic diseases like malaria, and the control of sexually transmitted dis- eases especially HIV/AIDS. The project has eight components. (1) expand primary health care access; (2) improve the tech- nical quality of primary health care service provision; (3) expand the supply and productivity of health personnel; (4) ensure a regular and safe supply of effective, safe, and affordable high- quality drugs while improving prescribing behavior by health providers; (5) improve awareness about personal and environmental hygiene and basic knowledge of common diseases and their causes as well as promote political and community support for health services; (6) transform the health system into a four-tiered system that is linked, equitably distributed, and managed in a decentralized, participatory, and efficient manner; (7) monitor improvements in service delivery, quality, and financial performance and evaluate the impact, effectiveness, and cost-effective- ness of the project’s components; and (8) improve financial sustainability. The initial implementation period of the program was July 1997–June 2002 but latter on ex- tended to June 2006. The program was estimated to cost $US737.8 million of which govern- ment, other donors, IDA user fees are expected to finance 55.3% 28.9%, 13.6% and 2.1 percent respectively. The amount of loan from IDA was US$100 million. Indicators Key indicators of progress in health status and health services for the first five years included: ƒ Increase life expectancy at birth from 52 years in 1997 to 55–60 years in 2002; for males from 49.7 years in 1997 to 56.2 years in 2002 and for females from 52.4 years in 1997 to 59.2 years in 2002. The “Good Practice Infobrief” series is edited by Lawrence Mastri, AFTRL, World Bank, 1818 H Street NW, Washington D.C., 20433. Tel. (202) 473-3308; e-mail: lmastri@worldbank.org 41262 ƒ Decrease the infant mortality rate from 110–128 per 1,000 live births in 1997 to 90–95 in 2002 and 50 in 2017. ƒ Decrease maternal mortality rates from 500–700 per 100,000 live births in 1997 to 450– 500 in 2002 and 300 in 2017. ƒ Expand PHC coverage from 45% in 1997 to 55–60% in 2002 and 90% in 2017. ƒ Increase health facilities by 2002 in the forms of: (a) construction of new facilities—216 primary health care units (PHCUs), 12 district hospitals, 5 zonal hospitals, and 2 special- ized hospitals; and (b) renovation of 150 health centers, 50 district hospitals, 10 zonal hospitals, and 5 specialized hospitals. ƒ Increase immunization coverage (DPT3) from 67% in 1997 to 70-80% in 2002 and 90% in 2017. ƒ Increase the contraceptive prevalence rate from 8% in 1997 to 15-20% in 2002 and 40% in 2017. Results on the ground The performance of the Health, Nutrition and Population sector has improved under HSDP. ƒ Between 1997/98 and 2004/05, the infant mortality rate has decreased by about 30% from 110 to 77 per thousand live births. ƒ Between 2000 and 2005, the child mortality rate has decreased by about 35% from 77 to 50, and the under-five mortality rate has decreased by about 26% from 166 to 123 deaths per thousand live births. ƒ During the program period the Federal Ministry and the Regional Heath Bureaus have undertaken extensive work in the expansion and rehabilitation of health infrastructure. The number of hospitals has increased from 87 in EFY 1989 to 139 in EFY 1998. The number of health centers has grown from 257 to 635, while a total of 5943 health posts have been constructed. Potential health coverage has grown from 48% to 76.8% during the same period. ƒ As part of HSDP-II the Health Service Extension Program was launched. HSEP is an innova- tive community-based health care delivery system intended to create a healthy environ- ment as well as healthful living. Pilot implementation was launched in 5 regions in 2002/ 03, and encouraging results were seen in terms of community’s acceptance and demand for services provided through HSEP. ƒ Improvements were seen in construction and utilization of latrines, use of contraceptives and vaccination services in areas where the program has been implemented so far. Problems encountered Some of the problems encountered during the implementation of HSDP included: ƒ Understaffing and high turnover of both technical and managerial staff at all levels ƒ Inadequate follow-up and supportive supervision ƒ Inadequate community participation ƒ Prolonged process of international procurements and the recruitment of consultants ƒ Poor program coordination, especially at regional and woreda level as well as in coordinat- ing the activities of various development partners ƒ Inadequate implementation capacity in undertaking civil works. Lessons learned ƒ The infrastructure, human resource, and support systems within the accelerated expan- sion of Primary Health Care (PHC) have to be synchronized. ƒ Regions should rehabilitate and make fully operational existing health facilities (hospitals, health centers and health posts), and provide trained health workers, equipment and medicines. 41262 ƒ Central human resources development must be strengthened, and it is urgent to estab- lish incentive schemes (in addition to the standard civil-service provisions) to retain staff, especially at outlying stations, and to ensure continuing service delivery for disadvantaged populations. ƒ Improvements are needed in procurement and distribution, human resource availability, rational drug use, budget allocation, and logistics to ensure the regular supply of quality, affordable drugs to all levels. ƒ The efficacy of investment should not be contingent upon the involvement of other donors. This brief has been excerpted from World Bank Implementation Complete Report No. 383, from which detailed information can be obtained. Persons accessing the Bank’s external and internal website can get more information on Health, Nutrition and Population by clicking on Topics.