2013年-世界发展银行全球_The_Health_Extension_Program_in_Ethiopia_34页_1mb

Summary of the Health Extension Program in Ethiopia

Core Content

The Health Extension Program (HEP) in Ethiopia is a flagship initiative launched in 2003 by the Federal Ministry of Health, aimed at achieving universal primary health care coverage in a resource-constrained setting. It has played a significant role in improving health outcomes, reducing financial risks, and increasing equity in Ethiopia's health system. The program is fully integrated into the Health Sector Development Program IV (HSDP IV) and operates as a community-based model, focusing on preventive, promotive, and basic curative services.

Main Objectives

• To improve health outcomes by targeting households and communities.
• To expand access to basic health services through the development of health infrastructure and local human resources.
• To enhance the quality and efficiency of health services.
• To ensure equitable distribution of health services, especially for the poor and vulnerable.
• To align financing mechanisms with the needs of the health sector.

Key Components of the HEP

• Health Extension Workers (HEWs): Female, 10th-grade graduates recruited and trained by the community. They are deployed to serve 3,000 to 5,000 people, with two HEWs per health post.
• Service Delivery: The HEP provides 16 packages of essential health services, including:
  • Childhood vaccinations
  • Family planning
  • Prevention and treatment of malaria
  • Management of diarrhea and pneumonia
  • Promotion of hygiene and sanitation
• Infrastructure Development: Over 15,668 health posts and 2,999 health centers have been constructed and equipped as part of the program.
• Community Participation: The program emphasizes community involvement in recruitment, identification, and targeting of beneficiaries.
• Financing: The HEP is financed through a combination of government budgets, external assistance, and out-of-pocket expenditures, with a focus on free services for the poorest populations.

Implementation and Outcomes

Outcomes (2005–2011)

• Under-five mortality rate decreased by 28% (from 123 to 88 per 1,000 live births).
• Contraceptive prevalence rate increased by 83% (from 15% to 27.5%).
• Stunting in under-five children declined by 14% (from 51% to 44%).
• Anemia prevalence among women decreased by 37% (from 27% to 17%).
• Total fertility rate dropped by 11% (from 5.4 to 4.8).
• Use of insecticide-treated nets increased dramatically from 1.3% to 42%.

Challenges

• Service Quality: Ensuring the quality of services provided at all levels of the health system remains a challenge.
• HEW Performance: Enhancing the skills and performance of HEWs, particularly in maternal health, is critical.
• Sustainability: Sustaining the program requires an appropriate carrier structure for HEWs.
• Equity and Access: Despite progress, maternal mortality and reproductive health services remain underdeveloped.
• Financing Gaps: Some exempted services are not fully funded, leading to charging of fees by health facilities.

Health System Structure

Ethiopia's health system follows a three-tier structure:

1. Primary Care Level: Includes health posts, health centers, and primary hospitals.
2. Secondary Care Level: Comprises general hospitals.
3. Tertiary Care Level: Includes specialized hospitals.

The HEP is a key component of the primary care system, providing basic and essential services to households and communities.

Health Financing

• Total Health Expenditure (THE) in Ethiopia increased from US$5.6 to US$16.09 per capita between 1999/00 and 2007/08.
• Public spending on health increased faster than private spending, mainly due to donor funding.
• Out-of-pocket expenditure remains a major source of health financing, accounting for 37% of THE.
• External assistance constitutes 39% of THE, while government budget accounts for 21%.
• The HEP is financed through block grants, external funding, and refresher training for HEWs.

Institutional Arrangements

• The HEP is fully integrated into the primary health care unit structure.
• Decentralization has been implemented from the national to regional and woreda levels.
• The Sector Wide Approach (SWAp) ensures coordination and harmonization of health policies and services.
• Community-based health insurance is being studied in 13 woredas, with plans for national scale-up.

Conclusion

The HEP has been instrumental in improving health outcomes and expanding primary health care coverage in Ethiopia. It has been a model for resource-constrained countries aiming to achieve universal health coverage (UHC). However, challenges in service quality, HEW performance, and financial sustainability remain, which need to be addressed to ensure the program's long-term success. The HEP's community-centric approach, integration into the health system, and focus on essential services make it a valuable case study for the World Bank's UNICO Studies Series.