Module 3 Applying HIS Principles For HSD and AdmissionDischarge - LearnerModule Nov

Applying Health Information System
Principles for Service Delivery and

Hospital Admission/ Discharge
Procedures
Outcome-Based Learning Module for HIT level IV

Health Information system Principles for Service Delivery and Hospital Admission/ Discharge Procedures Learner module
Acknowledgments
This learner module would not have been possible without the support of many organizations
and experts. The Ethiopian federal ministry of health and Tulane international would like to
express their gratitude to the regional Health Science Colleges for their participation in the
development of the draft materials for this learner module. We also would like to gratefully
acknowledge Harar health Science College for all kinds of support provided during the initial
draft development workshop held at the College. Finally, an honorable mention goes to
FMOH and Tulane International experts for their invaluable contributions during the
processes of the HIT occupational standard revision, new curriculum development and lastly
this learning material preparation.
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Contents
Introduction ........................................................................................................................................... 6
Topic 1: Healthcare Delivery System ........................................................................................... 13
1.1 Introduction ........................................................................................................................... 13
1.2 Learning Objectives .............................................................................................................. 13
1.3 Basics of health care delivery system ................................................................................... 14
1.4 Principles and characteristics of health care delivery system ............................................... 18
1.5 Major Components of Ethiopian Health System .................................................................. 21
1.6 Organization of the Ethiopian Healthcare Delivery System ................................................. 22
1.7 Health Services and facilities ................................................................................................ 31
1.8 Health Information Flow ....................................................................................................... 33
Self- check Assessment..................................................................................................................... 35
Topic 2: Ethiopian Health Service Program and Regulations ................................................... 37
2.1 Introduction ........................................................................................................................... 37
2.2 Learning objectives ............................................................................................................... 37
2.3 Ethiopian health policy ......................................................................................................... 38
2.4 Health Service Development Program .................................................................................. 45
2.5 Major Health Related Legislations in Ethiopia ..................................................................... 56
2.6 Healthcare Regulation System .............................................................................................. 58
2.7 Regulating Ethiopian Healthcare Facilities operational procedures ..................................... 61
Self-check Assessment...................................................................................................................... 69
Topic 3: Health Service Planning ................................................................................................. 71
3.1 Introduction ........................................................................................................................... 71
3.3 Basics of Health Service Planning ........................................................................................ 72
3.4 Planning steps ....................................................................................................................... 74
3.5 Planning Approaches ............................................................................................................ 79
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3.6 Features of planning .............................................................................................................. 80
Self-check Assessment...................................................................................................................... 82
Topic 4: Fundamentals of Monitoring and Evaluation System ................................................. 83
4.1 Introduction ........................................................................................................................... 83
4.2 Learning Objectives .............................................................................................................. 83
4.3 Monitoring and Evaluation Concepts.................................................................................... 84
4.4 Commonly used terms in Monitoring &Evaluation .............................................................. 86
4.5 Monitoring and Evaluation plan ........................................................................................... 88
4.6 Monitoring and Evaluation Framework ................................................................................ 90
4.7 Monitoring and evaluation tools ........................................................................................... 90
4.8 Monitoring and Evaluation Activities ................................................................................... 92
Self -check Assessment..................................................................................................................... 97
Topic 5: Ethics and Laws in Medical Record Handling ............................................................. 99
5.1 Introduction ........................................................................................................................... 99
5.3 Ethics and Health Related Laws ......................................................................................... 100
5.4 Major ethical principles and standards of ethics in health information management ......... 101
5.5 Professional Obligations ..................................................................................................... 103
5.6 Law and Health Related Laws ............................................................................................ 107
5.7 Medical Record as a Legal Document ................................................................................ 111
5.8 Application of Ethics and The law in HIT .......................................................................... 114
Self-check Assessment.................................................................................................................... 116
Topic 6: Patient Privacy and confidentiality of Health Information....................................... 118
6.1. Introduction ......................................................................................................................... 118
6.2. Learning Objectives ............................................................................................................ 118
6.3. Privacy and Confidentiality ................................................................................................ 119
6.4. Release of Individual Health Information ........................................................................... 119
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6.5. Ethical standards related to Patient Privacy Right .............................................................. 121
6.6. General Medico legal principles ......................................................................................... 122
Topic 7: Security and Access to Health Information ................................................................ 126
7.1. Introduction ......................................................................................................................... 126
7.2. Learning Objectives ............................................................................................................ 126
7.3. Security Measures to Patient/Client Medical Record ......................................................... 127
7.4. Patient access to their health information ........................................................................... 131
7.5. Record Keeping during Refusal of treatment by Patients ................................................... 132
Topic 8: Hospital Admission and Discharge .............................................................................. 135
8.1 Introduction ......................................................................................................................... 135
8.2 Learning Objectives ............................................................................................................ 135
8.3 Hospital Admission ............................................................................................................. 136
8.4 Admission /Discharge recording tools ................................................................................ 137
8.5 Information Recorded while Admitting a patient ............................................................... 141
8.6 Monitoring and Updating Patient Information during patients hospital stay ..................... 142
8.7 Basic hospital statistics for inpatient services ..................................................................... 143
8.8 Discharge and clearance procedures ................................................................................... 146
8.9 Verifying Medical Records for Completeness for discharged patient ............................... 149
Self Check Assessment ................................................................................................................... 151
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Introduction
This learner module is developed in line with the national competency standard in the Health
Information Technique (HIT) Training Package HLT HIT4( code nationally given to health
information technique level four) for the clustered units of competence of Applying
Principles of Health Information System for Service Delivery and Implementing
Admission/Discharge Procedure (HLT HIT4 03 0112). These clustered units of competence
are:
• Applying principles of health information for health Service delivery (HLT HIT4 06
0611)
• Implement and monitor admission /discharge filing procedure ( HLT HIT4 06 0611)
This learner module contains information on health information for health service delivery
system and implementing admission/ discharge filing related to:
• Ethiopian Healthcare Delivery Systems

• Ethiopian Health Service Program and Regulations
• Health Service Planning
• Fundamentals of Monitoring and Evaluation System
• Ethical Guidelines Related to Patients’ Medical Record Handling
• Patient/Client Privacy and Confidentiality Rights
• Security and Access to Health Information
• Hospital Admission/ Discharge procedure
• Patients’ Medical Record management During Hospital Stay
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Completion of this learner module can help you to understand the Ethiopian healthcare
delivery system, develop the skills necessary to work in the healthcare system and to collect,
and properly manage data related to hospital admission and discharge procedure. After you
have completed this module, you are required to have the following essential knowledge and
skills.
Essential Knowledge of:
• Principles of health care delivery system and health information flow.

• Ethiopian Health Service Programs and Health Care system Regulations
• Health Information System Policies and Procedures in Relation to Healthcare Delivery
System.
• Basics of Health Services Planning, Health Service Planning Approaches, Woreda
health Planning and Healthcare Facility Planning.
• Concepts of Monitoring and Evaluation, Monitoring and Evaluation plan, tools and its
program.
• Ethics and Law related to health.
• General Medico-Legal Principles in relation to patient medical records.
• Security Measures to Patient/Client Medical Record.
• Patient Access to their Medical Records.
• Admitting procedure and recording tools.
• Updating Patient Information during admission.
• Patient’s Discharge and clearance procedures.
Essential skill on:

• Applying basic principles of healthcare delivery
• Demonstrate Admission/Discharge procedure’s data management
• Calculate patient Length of stay at hospital, bed occupancy rate, morbidity and
mortality rates
• Demonstrates Recording and documentation of health information
• Organize and conduct training on privacy and confidentiality of patient information
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• Implement Ethical standards related to patient’s privacy rights are implemented.

• Manage Patients who are not able to communicate in case of emergency or other
conditions in relation to patient’s information.
• Prepare relevant data/information for healthcare planning.
• Implement how to use monitoring and evaluation tools.
Learning Outcome Summary

On completion of this learner module, you should be able to:
• Identify basic principles of healthcare delivery system
• Apply principles of healthcare delivery system in managing healthcare data
• Produce quality data for health service planning
• Apply monitoring and evaluation systems
• Apply ethical principles and guidelines related to patients’ medical record handling
during admission.
• Promote patients’ privacy and confidentiality rights.
• Protect individual medical records from unauthorized access and disclosure.
• Implement admission/ discharge and clearance procedure’s data management
• Record and compile patients’ information during hospital stay.
Assessment criteria
The set of competences (knowledge, attitudes and skills) you have developed at the
completion of this module should allow you to demonstrate certain level of performance in
the work world. These may be assessed by the following assessment criteria.
1. Healthcare delivery system principles are applied to each level of healthcare
delivery system.
2. Utilization of basic principles of health care delivery system is ensured in relation
to health information.
3. Health information flow is identified and monitored in the health system.
4. Health information needs are identified.
5. Healthcare organization structure and operational regulations are identified.
6. Regulations applicable to health service organization level are followed.
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7. Data that are helpful for Health service planning is generated and reported
annually.
8. The application of monitoring and evaluation tools is ensured.
9. Proper evaluation system for implementation process is maintained.
10. Ethical standards related to patient’s privacy rights are implemented.
11. Patient’s rights to access care, transfer and continuity of care are respected.
12. Policies and procedures for access and disclosure of personal health information
are implemented.
13. Record keeping during acceptance and refusal of treatment by the patient are
monitored.
14. Ethical standards related to patient privacy rights are demonstrated.
15. Assessments are conducted and solutions on privacy issues/problems
recommended.
16. Disclosure of patient’s information to another person without patient’s consent.
17. Patient-specific data is released only for authorized user.
18. Proper patients’ admission is conducted.
19. Admitted patients’ record is delivered to the appropriate destination.
20. Admission/ discharge reports are compiled.
21. Discharge summaries are completed according to the guidelines.
22. Location of admitted patient is recorded.
23. Length of stay and bed occupancy rates are calculated and reported.
24. Information from discharge summary is recorded for scheduling follow up
appointment.
25. Patient’s records are verified for completeness before returning to Medical Record
Unit.
26. Completeness of all required clearance processes is ensured
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How to use the learner module
• This learner module is prepared for the clustered units of competence that defines
the set of knowledge, attitudes and skills required to work in the health institutions/
facilities by applying principles of healthcare delivery system with health
information technologies; and implementing appropriate procedures during patient
admission, hospital stay and discharge. It contains learning materials and activities
relevant to the aforementioned clustered units of competence of level IV HIT
program.
• You are required to go through a series of learning activities in order to complete
each of the topics in the module. In each topics and sub-topics, there are
Information and activities. Use the information and carry out those activities on
your own at the end of each lesson. Each topics or sub-topics may have more than
one learning activity.
• This module will be the source of information that will enable you to acquire the
knowledge and the skills independently at your own pace or with minimum
supervision or help from your instructor.
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Resource
Topics Resource/Learning materials

Healthcare Delivery Systems HMIS National documents(
Ethiopian Health Service Program technical area 1,2,3, and 4;
and Regulations HSDP IV; Other National
Health Service Planning Health related documents;
Practical visits to Health
Fundamentals of Monitoring and
Facilities and Institutions
Evaluation System
Ethical Guidelines Related to

Patients’ Medical Record Handling
Patient/Client Privacy and
Confidentiality Rights
Security and Access to Health
Information
Hospital Admission
Patients’ Medical Record During
Hospital Stay
Hospital Discharge
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References
Topics Resource/Learning materials

Healthcare Delivery • FMOH. (2010). Health Sector Development Program IV. Addis Ababa.
Systems • FMOH. (2005). Essential Health service package (1st ed.). Addis Ababa.
Ethiopian Health • FMO. (2010). Ethiopian Hospital Reform Implementation Addis Ababa.
• FMOH. (2011). Guideline for Building Health Sector and Annual Plan
Service Program and
Using Balanced Score card. Addis Ababa: FMOH.
Regulations
• Challi Jira, A. F. (November 2204). Health Planning and Management for
Health Service Health Extension Workers (1st ed.). Addis Ababa: Addis Ababa
Planning Unversity.
• Chaplowe, S. G. (2008). Monitoring and Evlaution planning- Guidlines
Fundamentals of
and Tool. (G. S. (CRS), Ed.) Washington, DC 20006- USA.
Monitoring and
• UN. (2012, April 09). programming –essentials - monitoring- evaluation.
Evaluation System Retrieved May 26, 2012, from http: //www.endvawnow.org en: html
• UNAID. (2008). Basic Terminology and Frameworks for Monitoring and
Ethical Guidelines
Evaluation. (B. Michel Caraël (Free University Brussels, Ed.) Geneva::
Related to Patients’
Greet Peersman (Payson Center for International Development, Tulane
Medical Record
University, USA),Deborah Rugg.
Handling • UNDP. (2009). Handbook on planning,monitoring and evaluating for
Patient/Client development results (1st ed.). New york- USA: A.K.Office Supplies (NY).
Privacy and • World Health Organization (WHO) 2006, Medical Record Manual a guide
Confidentiality for developing Countries, Manila, Philippines.

• Huffman, (1990) Medical Record Management, 9th edition, Berwyn,
Rights
Illinois.
Security and Access
• Penny Duquenoy, Carlisle George and Kai Kimppa, (2008) Ethical, Legal,
to Health and Social Issues in Medical Informatics, United States of America.
Information • National Audit Office NHS Executive (2000) Inpatient Admissions and
Hospital Bed Management in NHS acute hospitals.
Admission/Discharge • Michelle A. Green, et al, (2005) Essentials of Health Information

Management: Principles and Practices, USA.
• World Health Organization, (2004), Developing Health Management
Information Systems. A Practical Guide for Developing Countries.
• Federal Democratic Republic of Ethiopia (March 2010) Ministry of Health
Ethiopian Hospital Reform Implementation Guidelines, version 1.
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Topic 1: Healthcare Delivery System
1.1 Introduction
Health care is one of the essential components of basic social services that have a direct
linkage to the growth and development of a country as well as to the wellbeing of a society.
This topic discusses the overall structure of the Ethiopian healthcare system, the principles,
its components, actors, the current three tier (level) healthcare delivery system and
information flow in the country’s health system. In addition, the services offered at each level
of healthcare facilities are presented in detail.
1.2 Learning Objectives

At the end of this topic, you should be able to:
• Define health care delivery system and other related terms

• Identify principles of health care delivery system
• Describe components of health care delivery system
• Distinguish health care facilities and their services
• Explain health information flow in the health system
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1.3 Basics of health care delivery system

Health care delivery system may vary from country to country. Ethiopian healthcare delivery
system has been designed based on the health need of its population. Its structure and
organization will be discussed in consecutive topics and sub-topics. However, before we
discuss in detail, you need to be familiarized with some terms that are commonly used to
describe a country’s healthcare delivery system. These are:
Health care: The prevention, treatment, and management of illness and the preservation of
mental and physical well-being through the services offered by the medical and allied health
professions. According to the World Health Organization (WHO), health care includes all the
goods and services designed to promote health, including preventive, curative and palliative
interventions, whether directed to individuals or to populations.
Health services: are specific activities within the larger domain of health care undertaken to
maintain or improve health or to prevent decrements of health. Good health services are those
which deliver effective, safe, quality personal and non personal health interventions to those
that need them, when and where needed, with minimum waste resources.
Health service organizations: are entities that provide the organizational structure within
which the delivery of health services is made directly to consumers (Clients), whether the
purpose of the services is preventive, curative, restorative or palliative.
Health system: is the sum total of all the organizations, institutions and resources whose
primary purpose is to improve health. A health system needs to provide services that are
responsive and financially fair, while treating people decently. The health system delivers
preventive, promotive, curative and rehabilitative interventions through a combination of
public health actions and the pyramid of health care facilities that deliver personal health care
by both government and non-government actors.
Health care delivery system: is an institutional arrangement organized for the delivery of
preventive, promotive and personalized curative care through a network of health facilities
that may be connected to each other by some form of referral mechanisms. Or a term without
specific definition, referring to all the facilities and services, along with methods for
financing them, through which health care is provided to the population.
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Access: the comprehensive measurement of access requires a systematic assessment of the

physical, economic, and socio-psychological aspects of people’s ability to make use of health
services.
Availability: is an aspect of comprehensiveness and refers to the physical presence or

delivery of services that meet a minimum standard.
Utilization: is often defined as the quantity of health care services used.
Coverage: of interventions is defined as the proportion of people who receive a specific

intervention or service among those who need it.
Key Components of health system
Any health system of a country should function to respond the population’s health need and
expectation by improving the health status of the individuals, families and communities;
defending the population against what threatens its health status; providing equitable(fair)
access to people centered healthcare; and allowing the people to participate in decisions
affecting their health and health system. Health system has six components which are also
known as the building blocks of a health system.
a. Leadership and governance: A health system should have good governance and
leadership that ensure health authorities take responsibility for leading the entire health
sector dealing with the current and future health challenges of the country. It also defines
the national health policies, strategy and plan that set clear direction for the health sector
development with:
• A formulation of the country’s high level policy goals such as people

centeredness, health equity, sound public health policy and effective and
accountable governance.
• A Strategy for translating theses policy goals into its implications for
financing, human resources, pharmaceuticals, technology, infrastructure
and service delivery with relevant guidelines, plan and targets
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• Effective regulation through a combination of guidelines, mandates, and

incentives, backed-up by legal measures and enforcement mechanisms
• Mechanisms for accountability and adaption to evolving needs
• Mechanisms and institutional arrangements to channel donor funding and
align it to country priorities.
b. Health information system: Good information system on the broader environment in

which the health system operates, and on the performance of the system is one of the key
components of the health system. The information system should provide timely
intelligence or information on:
• Access to healthcare and on the quality of health services provided

• Progress in meeting health goals and social objectives such as equity(
fair distribution of health resources)
• Health financing and barriers to health services for the poor and
vulnerable.
• Trends and needs for HRH(human resource for health);on consumption
of and access to pharmaceuticals; on appropriateness and cost of
technology; on distribution and adequacy of infrastructure
The health information system requires a variety of institutional mechanisms including a

national monitoring and evaluation plan that specifies core indictors (with targets),data
collection and management, analysis and communication and use and arrangements to make
information accessible to all involved, including communities, civil society, health
professionals and politicians.
c. Human resources for health: it is another building block of health system that should
be well performing to respond for the country’s health need and expectations. The main
concerns of this health system component are improving recruitment, education, training
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and distribution; enhancing productivity and performance; and improving retention of

human resource.
d. Service Delivery: Service delivery component of the health system depend on the
networks of the primary health care and specialized hospital services responsible for a
defined population; provision of comprehensive and integrated range of clinical and
public health interventions that respond to health problems; standards and guidance to
ensure access and essential dimensions of quality such as safety, effectiveness, continuity
and people-centeredness.
e. Essential medical products and technologies: Universal access to healthcare is heavily

depending on access to affordable essential medicines, vaccines, diagnostic and
technologies. This building block of a health system should have: a medical product
regulatory system; national list of essential medical products, diagnostic and treatment
protocols and standardized equipment; supply and distribution system to ensure access to
essential medical products and health technologies; national medical product availability
and price monitoring system.
f. Health financing: The primary objective of this component is improving health and
reduces health inequalities to achieve universal coverage by removing financial barriers
to access and preventing financial hardship.
Next to this general description of health system components, we will examine the Ethiopians
health system in terms of these components in the subsequent topics and subtopics.
Health care delivery system in Ethiopia
The Ethiopian health care delivery system has historically been unable to respond
quantitatively or qualitatively to the health needs of the people. It was highly centralized. Its
services were delivered in a fragmented way with a reliance on vertical programs and there
was little collaboration between public and private sectors. As a result, the Ethiopian
Transitional Federal Governments have initiated political, economic and social changes
resulting in the formulation of the 1993 Health Policy and Strategy. The federal government
and the regional authorities seek to reorganize health services into a more cost-effective and
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efficient system, better able to contribute to the overall socio-economic development effort of
the country.
The government has been realizing its health development objectives through a twenty-year
health Sector development strategy that is divided into four phases which each phase
comprises of five years time period. The first Health Sector Development Program (HSDP-I)
was implemented in the period from 1997/98-2001/02 G.C. More description about HSDP
will be shown in the subsequent topics.
1.4 Principles and characteristics of health care delivery system

Principle is a law or rule that has to be, or usually is to be followed, or can be desirably
followed, or is an inevitable consequence of something, such as the laws observed in nature
or the way that a system is constructed.
The principles or philosophy of health care delivery approach is characterized by a holistic

understanding of health as wellbeing, rather than the absence of disease. It actually forms an
integral part of both the country's health system (which is the central function and main
focus) and the overall social & economic development of the community.
In general, the main function of health care delivery system is to increase the coverage and
quality of promoting preventive and curative activities. If a better performing health system is
to be attained, adequate and motivated personnel, availability of medical supplies and
sustainable financial resources are conditions to be fulfilled.
The basic principles of health care delivery system are:
a. Inter-Sectoral Collaboration: A joint concern and responsibility of sectors

responsible for development in identifying problems, programs, and undertaking tasks
that have an important bearing on human well being. Earlier, health-care services seen
to be the sole responsibility of the health-care system with no links to other sectors and
focusing on individual person presenting for care. However, this focus should be shift
to better integration with other sectors that impact on health such as education, labor,
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justice, social services focusing on population and linking between health and health
determinants.
b. Community participation: One of the fundamental principles of healthcare delivery

is the participation of the community at all stages. Individuals and families assume
responsibility for the community and contribute to their health and the community’s
development. For communities to be involved, they need to have easy access to the
right kind of information concerning their health situation and how they themselves
can help to improve it. The information given should be neither over sophisticated nor
condescending but should be in a language people can understand.
c. Appropriate technology: Using the most appropriate and cost-effective methods and
equipment for the level of care in the community. The healthcare delivery requires the
development, adaptation, and application of appropriate health technology that the
people can use and afford, Technology can refer to the structure and delivery of health
services, human resources, medical equipment, pharmaceutical agents or new
interventions and techniques. There is a need to ensure that interventions and
technologies used in health care are proven to be effective and affordable including an
adequate supply of low-cost with good quality essential drugs, vaccines and other
supplies and equipment.
d. Equity: Services should be physically, socially, and financially accessible to

everyone. People with similar needs should have equal access to similar health
services
e. Focus on prevention and health promotion: This is related to the importance
adopting where possible or preventive approach to health problems. The health focus
is shifted to wellness, competence and coping in addition to illness/treatment. In the
service delivery, the care shall be increasingly community based but with
maintenance or enhancement of high quality secondary and tertiary facility based
care. Clients are also meaningfully involved in care decisions.
f. Decentralization: Is the way of bringing decisions making closer to the communities.
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Key characteristics of good Service Delivery
As mentioned earlier, health service delivery is a crucial element of any health system.
Service delivery is a fundamental input to population health status. The organization and
content of health services may differ from one country to another. However, service
delivery of any well-functioning health system should have the following key
characteristics.
• Comprehensiveness: A health service delivery should provide a comprehensive

range of health services that are appropriate to the needs of the target population,
including preventative, curative, palliative and rehabilitative services and health
promotion activities.
• Accessibility: Health services should be directly and permanently accessible with
no unjustified barriers of cost, language, culture, or geography. Health services
should be close to the people at primary care level (May not at the specialist or
hospital level). Services may be provided at home, in the community or health
facilities as appropriate.
• Coverage: Service delivery should be designed so that all people in a defined
target population are covered, i.e. the sick and the healthy, all income groups and
all social groups.
• Continuity: Service delivery should be organized to provide an individual with
continuity of care across the network of services, health conditions, levels of care,
and over the life-cycle.
• Quality: Health services should be of high quality, i.e. they are effective, safe,
centered on the patient’s needs and given in a timely fashion.
• Person-centeredness: Services are organized around the person, not the disease or
the financing. Users perceive health services to be responsive and acceptable to
them. There is participation from the target population in service delivery design
and assessment. People are partners in their own health care.
• Coordination: Local health service organizations should be actively coordinated,
across types of provider, types of care, levels of service delivery, and for both
routine and emergency preparedness. The patient’s primary care provider
facilitates the route through the needed services, and works in collaboration with
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other levels and types of provider. Coordination also takes place with other
sectors (e.g. social services) and partners (e.g. community organizations).
• Accountability and efficiency: Health services are well managed so as to achieve
the core elements described above with a minimum wastage of resources.
Managers are allocated the necessary authority to achieve planned objectives and
held accountable for overall performance and results. Assessment includes
appropriate mechanisms for the participation of the target population and civil
society.
1.5 Major Components of Ethiopian Health System

As it is discussed earlier any health system has six components or building blocks. Basically,
the Ethiopian health system has also six integrated building blocks. These are:
I. Service Delivery
II. Health workforce
III. Information
IV. Medical products, vaccines and technologies
V. Financing
VI. Leadership and governance
These building blocks of the health system are summarized as follows.
Service Delivery: the backbone of “service delivery” in Ethiopia is the Health Extension
Program that provides integrated preventive, promotive and basic curative services at
community level. Furthermore, at all levels, programs are integrated at the point of service
delivery.
Health workforce: With regard to this building block of the health system, the focus is on
the production of key categories of health workers in short supply (i.e., new cadres, such as
integrated emergency surgery officers), integration in skill mix (combinations of activities or
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skills needed for each job within the organization), task shifting, public-private partnership,
and cost-effectiveness in staff retention and motivation.
Health information system, Finance, Leadership and Governance: Integration has been
ensured for “information”, “financing” and “leadership and governance” building blocks of
the health system with the principle of harmonization “One-Plan, One-Budget and One-
Report”. In particular, different data sources have been integrated for evidence-based
decision making, as well as an integrated reporting system has been implemented for
performance monitoring and accountability purposes. Monitoring the performance of the
health sector is based on a core set of sector-wide indicators that provide a comprehensive
picture of the performance of the health sector.
Medical products, vaccines and technologies: Concerning “medical products, vaccines and
technologies”, the implementation of the integrated pharmaceutical logistic system is under
way while health insurance has started implementation.
Progress have been made towards the integration of building blocks; however, huge
challenges have still to be addressed to speed the current pace of change into significantly
faster progress to achieve MDGs by 2015. In the subsequent subtopics, we will describe the
organization of health system and health service delivery in Ethiopia.
1.6 Organization of the Ethiopian Healthcare Delivery System

The healthcare delivery system is organized into three interrelated components: people in
need of health care services called health care consumers; people who deliver health care
services: the professionals and practitioners called health care providers; and the systematic
arrangements for delivering health care: the public and private agencies that organize, plan,
regulate, finance, and coordinate services called the institutions or organizations of the health
care system.
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Business Process Reengineering (BPR) is the fundamental reconsideration (reassessment)

and radical redesign of organizational processes in order to achieve drastic improvement of
current performance in cost, services and speed (Hammer, 1990). This in short is interpreted
as “the present system does not add value to customers and need to be removed and
redesigned in a way that can maximize customer value (satisfaction), and minimize
consumption of resources required to render the service”.
Based on this management tool, the Federal ministry of Health (FMOH) has undergone
Health Sector Reform Program (HSRP) since 2009. According to the new HSRP three main
pillars are identified as key role players (actors) of the healthcare systems of the country
namely Provider, Purchaser, and Regulator. The roles and responsibilities of each actor will
be discussed below.
1.6.1. Provider
Provider in the healthcare system is the actor which directly or indirectly has the role and
responsibility to render quality healthcare services to the public at large. The provider
includes:
1. Federal ministry of health
The Federal Ministry of Health (FMOH) is a central actor in terms of holding health care
providers accountable, and being accountable to other branches of government, and indirectly
to citizens. It is responsible to control the public sector health care providers at various levels
(central, regional, and local); private sector health care providers through regulatory
monitoring and enforcement; policy, planning, regulatory, and quality assurance functions,
etc. The FMOH has been given the following powers and duties under the proclamation
number 471/2005:
1. Coordinate and direct the country's health sector development program

2. Devise strategies for preventing and eradicating communicable and non-
communicable diseases
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3. Devise strategies for preventing malnutrition and food contamination; certify and
supervise the safety of food stuffs
4. Undertake the necessary quarantine at the main entry and exit points of the
country to safeguard public health
5. Undertake appropriate measures in the events of disasters and other situations that
threaten public health, and coordinate measures to be taken by other bodies
6. Ensure the availability and proper utilization of essential drugs and medical
equipment in the country
7. Create conducive conditions for research, registration and utilization of traditional
medicines; and give the necessary support to practitioners to register and practice
their profession
8. Establish and administer health research centers
9. Set and supervise the enforcement of health service standards
10. Determine the qualification requirement, of professionals desiring to engage in
public health service at various levels, and issue certificates of competence to
them
11. Ensure the execution of drug administration and control activities
Although these all are the responsibilities and duties of the FMOH, it has been give the power
to delegate its responsibilities (partly or in full) to regional health' bureaus or other
government organs as deemed necessary.
A. Pharmaceuticals Fund and Supply Agency (PFSA)
• This agency is established by law with core objective of supplying quality

assured essential pharmaceuticals at affordable prices in a sustainable manner
to the public. The powers and duties given to this agency under the
proclamation number 553/2007 are: Establish and implement efficient and
effective procurement and distribution systems to deliver services by using the
Drug Fund and focusing on the country's major health problems.
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• Provide adequate and proper pharmaceutical storage facilities to ensure

uninterrupted supply through establishing a modern storage management
system.
• Expand and strengthen storage and distribution outlets based on equity and
effectiveness.
• Supply essential pharmaceutical of quality, safety and efficacy approved by
the appropriate body to all public health institutions; where appropriate and in
accordance with directives of the Board, supply to private and
nongovernmental health institutions selected pharmaceuticals which are not
adequately available.
• Deliver pharmaceutical directly to districts, hospitals and selected health
centers through establishing an effective transport network system.
• Establish a logistics management information system compatible with the
overall pharmaceuticals logistics system.
• Prepare and implement short, medium and long-term plan for procurement,
storage and distribution, and monitor its implementation.
• Provide consultancy and training services in its field of operation.
B. HIV/AIDS Prevention and Control Office (HAPCO)
This office is established by law with core objective of controlling the spread of HIV/AIDS.
It is accountable to HIV/AIDS prevention and control council. The office is mandated to
execute the following powers and duties that are given under proclamation number 276/2002:
• Serve as the secretariat of the HIV/AIDS Prevention and Control Council

• Submit a national HIV /AIDS prevention and control plan prepared on the basis of
the recommendations of the Council for the approval by the Government.
• Coordinate the activities of federal and regional HIV/AIDS prevention and control
program and non-governmental organizations engaged in HIV/AIDS prevention
and control activities.
• Organize local and international meetings and workshops for enhancing the
awareness of the society about HIV/AIDS.
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• Collect and compile information on the general status of HIV/AIDS in the country
and disseminate to all concerned bodies, as necessary.
• Participate in national and international conferences on prevention and control of
HIV/AIDS.
C. Ethiopian Health, Nutrition and Research Institution (EHNRI)
This institute is established under the proclamation number 26/1996 with a core objective to
conduct research on the causes and spread of diseases, nutrition, traditional medicines and
medical practices and modem drugs and thereby support the activities for the improvement of
health in the country. The institute’s core responsibilities include:
1. Research and technology transfer with regard to:

• Infectious and non-infectious diseases
• Nutrition and food science research
• Traditional and modern medicine
• Vaccine and diagnostic production
• Technology transfer and research translation
• Health system research
2. Public Health Emergency management
• This includes disease surveillance and emergency preparedness, early
warning, response and recovery
3. Regional laboratory capacity building
2. Regional/State Health Bureaus
In a country which follows decentralized governance systems, local authorities often have a
number of responsibilities for health services, either direct service provision, financing, or
both. Health bureaus are government structures established at each regional state to deliver
health services to the public. They are autonomous to develop and implement their own
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contextual healthcare plan that goes in line with the Health Sector Development Program
prepared at national level. They are accountable to their respective regional state councils and
to the public. They are key mediators between the central government and local communities.
3. Private Health Institutions
These are institutions established by individuals or share companies to provide health

services for the public. The core value of these institutions is profit. They get their license to
practice from the government. Their license can be suspended or revoked if they are found
violating the laws or standards set by the government. They are accountable to the
government and to the public.
4. Non-governmental Health Institutions
These are not-for-profit making institutions that are established by missionaries, charities,
individuals or interested others to render health services for the public. They get their license
to practice from the government. Their license can be suspended or revoked if they are found
violating the laws and standards set by the government. They are accountable to the
government and to the public.
1.6.2. Regulator
In the above subtopics, we have discussed about the different health service providers and the
duties and responsibilities of each provider, in this subtopic, topics like healthcare actor, and
the regulator which has been established to ensure quality of the health service will be
discussed with adequate details. Before the establishment of the current healthcare regulator,
the Ethiopian Food, Medicine and Healthcare Administration and Control Authority
(EFMHACA), healthcare regulation was being undertaken fragmentally by different actors:
the Federal Ministry of health was responsible to regulate health service institutions, health
professionals, and control communicable diseases at the port of entry and exit of the country,
the Drug Administration and Control Authority (DACA) was responsible to regulate
pharmaceuticals products through licensing of producers, importers and retailers. However,
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currently all the fragmented regulatory activities have come together and are being done by
EFMHACA. This authority is mandated to regulate the following 4Ps:
1. Product (Food and Medicine)

2. Premises …. Institutions (importers, exporters, wholesalers, etc)
3. Professionals …issue, suspend or revoke license
4. Practice of both professionals and health institutions

The authority is given the following powers and duties under the proclamation number
661/2009 to accomplish its mandates efficiently and effectively:
1. Prepare regulatory standards for regulating food, medicine, health facilities and
health professionals
2. Issue, renew, suspend or revoke certificate of competence for health and health
related institutions
3. Initiate policies and legislation to strengthen the quality of food and medicines,
health institution and professional regulation.
4. Serves as healthcare regulatory information center
5. Organize quality control laboratories as needed
6. prepare pharmacopoeia(a book describing drugs, chemicals, and medicinal
preparations) for the country, structure the medicines included in the
pharmacopoeia into different categories,
7. Evaluate and register medicines on the basis of registration requirements,
8. Undertake and coordinate post marketing surveillance in order to ensure the
safety, quality and efficacy of medicine and food
9. Authorizing individual researchers to conduct clinical trial,
10. Regulate the production, transport, storage and distribution of tobacco and tobacco
products
11. Inspect planes entering the country to ensure the protection of health and control
of communicable diseases
12. Control communicable diseases at port of entry and exit on international travelers,
prohibit or quarantine as necessary.
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13. Ensure proper disposal of expired medicine, chemicals and foods and their raw
materials;
14. Ensure that disposed solid and liquid wastes are not harmful to public health;
15. Ensure the safety and quality of trans-regional water supply for the public
16. Ensure availability of necessary hygienic requirements in controllable health
related institutions under the federal government;
17. Provide support to state regulatory bodies and harmonize the Federal and
Regional regulatory system.
1.6.3. Purchaser (Social Health Insurance Agency)
Before we proceed to discussing about the roles and responsibilities of the purchasers of the
Ethiopian health system (actors), it is advisable to discuss on the definitions and concepts of
Social Health Insurance. Social Health Insurance (SHI) Scheme is a type of health
insurance provided by the government to its citizens, especially to low and middle income
population.
The main objectives of SHI are:
• Providing health care that avoids large out of pocket expenditure

• Increase appropriate utilization of health services
• improving health status
The Social Health Insurance Agency of Ethiopia (EHIA) is established by law with core objective
of providing quality and sustainable universal health care coverage to the beneficiary through
pooling of risks and reducing financial barriers at the point of service delivery. The Agency
pays service fee for health services rendered to each citizen regardless of its social status (rich
or poor), this means there is no citizen who will be devoid of medical services because of
financial constraints. However, there are services that are not covered by the social health
insurance scheme for instance:
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• Health services that will be given outside Ethiopia.

• Health problems caused due to accidents, natural disasters, and epidemics.
• Health problems due to drug addiction.
• Plastic surgery.
• Transplantation, etc.
The agency’s source income includes:
• Contributions from government and government employees

• Employers contribution
• Government contribution
• Pensioned citizens
1.6.4. Others
In the above consecutive sessions you have learnt about the three key actors of the health care
services: provider, regulator and purchaser, in this session we will learn on healthcare actors
who directly or indirectly influence the key healthcare actors: this includes the parliament,
development partners and professional associations.
1. Parliament (the House of People’s Representatives)
The parliament (the House of People’s Representatives) is an organ, which is duly elected
representative of the Ethiopian people. This organ is the highest organ in the country which
passes decisions, ratify regulations, endorse the country’s development plan and budget,
monitors and evaluates the performance of each sector, and so on. Likewise the parliament
has decisive role in the healthcare system, it endorses the Health Sector Development
Program of the country, it ratifies different health related regulations, it evaluates
performance of the health sector and give directions for correcting deficiencies, and so on.
The parliament evaluates the performance of the sector through the normal reporting
mechanism and oversight visit. The parliament is accountable to the country’s constitution
and the citizenry (electorate).
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2. Development partners
Development partners support health system reform efforts by directly providing fund,
material resources or recruiting technical assistants who can enhance the endeavors of the
government.
3. Professional Associations
Professional Associations have an important role in quality assurance and performance

improvement purposes. Work in collaboration with the health service actors in developing
laws, standards, guidelines etc. related to their respective profession. They advise the
government in issuance of license to health professionals.
1.7 Health Services and facilities

The Ethiopian healthcare delivery system is restructured into three levels that are commonly
known as three tier system. These levels are:
• Primary Healthcare Unit : First level

• General Hospital: Second level
• Specialized Hospital: Third/tertiary level
a. Primary level: Primary Health Care Unit
This level is characterized by first level of a Woreda/District health system comprising a

primary hospital (with population coverage of 60,000--100,000 people), Health Centers (HC)
(1:15,000-25,000 population) and their satellite Health Posts (1:3,000-5,000 population) that
are connected to each other by a referral system. A health center in urban areas is expected to
serve to a population size of 40,000.
A primary hospital, health center and health posts form a Primary Health Care Unit (PHCU).
Each health center has five satellite health posts.
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The Health Post (HP) is staffed with two Health Extension Workers (HEWs). The HEWs are
expected to spend less than 20% of their time in health posts, and more than 80% of their
time is spent on community outreach programs visiting households and household members
especially mothers and children. They provide training to household members on the selected
packages of health extension programs (HEP) and follow the practices to help the households
for winning certification and labeled as a graduated household. HEWs provide family
planning, immunization, Outpatient therapeutic program (OTP), clean delivery and essential
newborn care services; moreover, they diagnose and treat malaria, pneumonia and
dehydration.
A Health Center (HC) is staffed with an average of 20 healthcare providers. It provides both
preventive and curative services. It serves as a referral center and practical training institution
for HEWs. A HC has inpatient service with capacity of five beds.
Figure 1.1: Ethiopian three tier health System. (Source: HSDP IV)
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A primary hospital provides inpatient and ambulatory services to an average population of

100,000. In addition to what a HC can provide, a primary hospital provides an emergency
surgery service including cesarean section and gives access to blood transfusion service. It
also serves as a referral center for HCs under its catchment areas and a practical training
center for nurses and other paramedical health professionals. A primary hospital has an
inpatient capacity of 25-50 beds. It is staffed by a minimum of 53 healthcare providers.
b. Secondary Level: General Hospital
The second level in the health tier is a General Hospital. It provides inpatient and ambulatory
services to an average of 1,000,000 people. It is staffed by a minimum of 234 professionals
and serves as a referral center for primary hospitals. It has an inpatient capacity and serves as
a training center for health officers, nurses and emergency surgeon’s categories of health
workers.
c. Tertiary level: Specialized hospital
This level includes a specialized hospital that serves an average of five million people. It
serves as a referral general hospitals, has an inpatient service capacity and serves as teaching
medical center.
1.8 Health Information Flow

The Health Management Information System (HMIS) is health information recording and
reporting system that allows important health information to flow from the source to the next
higher level in the health system. The data sources are health facilities (public and private),
woreda health offices, zonal health departments, regional health bureaus and the federal
ministry of health. Based on the type of the health institution, it generates data/information on
the health services provided or the health problems identified or both. The healthcare services
provided and the data that are generated by each health facility varies from level to level:
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• Health Posts: Provide community-based services, primarily preventive and

promotive, along with simple curative care.
• Health Centers: Usually provide primary care services and may have few beds
for inpatient services.
• Hospitals: It is at least equipped with basic laboratory, X-ray and basic treatment
facilities and provides a wide range of curative services, including inpatient
service.
Health facilities usually aggregate the service and health problem data by age group and
sex. Whereas the health administrative level that receives data from facilities aggregates the
data by facility type and ownership.
In case of public health emergency conditions, particularly for the purpose of outbreak
detection and control, the data channel has a fast track system. The immediately notifiable
diseases are reported via a yellow envelope (or electronic channel when available) directly
to the designated disease prevention and control expert at each level. This expert notifies
the next disease prevention and control expert in the reporting chain. You will learn the
detail description of the Ethiopian HMIS in learner module six.
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Self- check Assessment

Activity: 1
1. Provide definition for the following terms by your own words.

a. Healthcare
___________________________________________________________________
___________________________________________________________________
b. Health service
___________________________________________________________________
___________________________________________________________________
c. Health Service organization
___________________________________________________________________
___________________________________________________________________
d. Health care delivery System
Activity: 2
What are the basic principles of health care delivery system?
Activity: 3
List down the major Ethiopian healthsystem components.
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Activity: 4
List down and describe the Major actors of the Ethiopian health system.
Activity: 5
Write down the levels of the three tiers health system and describe each level with
your own words.
Activity: 6
Explain the health information flow and its sources in Ethiopia heath care delivery
system.
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Topic 2: Ethiopian Health Service Program and Regulations
2.1 Introduction
The development and provision of equitable and acceptable standard of health services to all
segments of the population of Ethiopia has been a major objective of the National Health
Policy. The national health policy to be realized, strategies have to be designed and
implemented. These strategies in turn, may need to develop various intervention programs
and regulations. Ethiopia has developed and implemented health policy that guides the
strategies, health programs and regulation. This topic provides you information on the
Ethiopian health policy, health service programs and regulations.
2.2 Learning objectives
At the end of this topic, the learner should be able to:
• Understand the Ethiopian health policy

• Describe health service program of the country
• Identify health care system regulations
• Explain health information system policies and procedures
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2.3 Ethiopian health policy
Before describing the country’s health policy, we need to familiarize you with some of the
terminologies which are relevant to this topic.
Policy: The set of basic principles and associated guidelines, formulated and enforced by the
governing body of an organization, to direct and limit its actions in pursuit of long-term goals
(management definition).
Health Policies: According to world health organization (WHO), health policy is defined as
decisions, plans, and actions that are undertaken to achieve specific health care goals within a
society. An explicit health policy can achieve several things. These are:
• Defining a vision for the future which in turn helps to establish targets and
points of reference for the short and medium term.
• Outlining priorities and the expected roles of different groups.
• Building consensus and inform people.
Strategies: A method or plan chosen to bring about a desired future, such as achievement of
a goal or solution to a problem.
Regulation: A legal provision that creates, limits, or constrains a right; creates or limits a
duty, or allocates a responsibility.
Guideline: A guideline is a statement by which to determine a course of action. A guideline

aims to streamline particular processes according to a set routine or sound practice.
Guidelines may be issued by and used by any organization (governmental or private) to make
the actions of its employees or divisions more predictable, and of higher quality actions.
Rule: Rule and ruling usually refers to standards for activities.
Procedure: A procedure is a document written to support a policy. It is designed to describe

Who, What, Where, When, and Why by means of establishing organization accountability in
support of the implementation of a policy.
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Apart from the physical/geographical and cultural barriers that affect health services
utilization by the Ethiopian peoples, the pattern of resources allocation has left most of the
rural population without appropriate health services. Following the change of government in
1991(G.C), a number of political and socio-economic reform measures were put in place.
Two of these were the development and introduction of a new National Health Policy in 1993
and, in 1997, the formulation of a comprehensive rolling 20-year Health Sector Development
Plan (HSDP). Both are the result of the critical assessment and analysis of the nature and
causes of the country’s health problems. The formulation of this health policy is based on the
recognition of facts discussed below with prime aim of improving the health status of the
population.
Facts Considered during Ethiopian Health Policy Development
The government of federal democratic republic of Ethiopia has taken into consideration the
following facts during the development of the country’s health policy.
• Life expectancy at birth is estimated 53 years due to very high premature

mortality. Despite this, the population is expected to double in the next two
decades leading to considerable pressure on social services including health.
• Parasitic and infectious diseases account for high mortality and morbidity. The
health of children and mothers are affected by harmful traditional practices
besides diseases.
• Malnutrition is prevalent particularly among children and mothers. It ranks third

among the top ten causes of morbidity and mortality.
• While workers in different production sectors are exposed to accident and illness
due to the nature of their occupation, efforts to establish occupational health
standards and services are very minimal.
• Environmental health problems attribute to the occurrence of the great proportion

of communicable diseases in the country. The access to safe and adequate water
supply is far below the needs of the population. The bulk of the people lack
39
adequate sanitary facilities. The method used to dispose human excreta poses a
threat to public health.
• Modern health care delivery systems are inadequate and remote to the wider
population. They are characterized by in-effective organization, poor logistics and
technological support and infrastructure.
• Since the pharmaceutical sector is not well developed, access to modern

pharmaceutics is very limited. Thus the public will continue to depend on
traditional medicines and technologies.
• Indigenous health technologies have been widely used in Ethiopia. It is important

to look into these technologies in order to upgrade those that are useful,
accessible, and applicable.
• The development of health in a country needs to be supported by the development

of Health Science and Technology (HST), because HST enables people to apply
solutions that are already available, and to generate new knowledge for tackling
emerging health problems. HST encompasses the scientific capability to undertake
studies in relevant fields such as Biomedical, Public Health, Pharmaceutical,
Clinical and Traditional Medicine.
• Moreover, the small number of health activities has been uncoordinated resulting
in unnecessary duplication of efforts and wastage of insufficient resources.
• HST undertakings suffer from lack of adequate infrastructure, limited access to

scientific and technological information and shortage of trained manpower. The
negative effects of these problems are augmented by inadequate funding and
incentives as well as absence of career development structure in HST institutions.
Therefore, a comprehensive health policy was necessary in order to improve the health status
of the population in a sustainable way. The national health policy focuses on a
comprehensive health service delivery system to address mainly the following public health
problems.
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• Communicable diseases
• Malnutrition
• Improving maternal and child health
The national health policy of the government of Ethiopia incorporates the following basic
components.
I. General policy
In 1992 the Task Force for the preparation of the new health policy was mandated to
evaluate the current status of health services, identify the major health problems and develop
a health policy within the frame work of the overall governmental policy of good governance
and decentralization. In September 1993, Government approved Ethiopian's National Health
Policy. The main focus areas of the policy were:
• Democratization and decentralization of the health service system.

• Development of the preventive and promotive components of health care.
• Development of an equitable and acceptable standard of health service system that
will reach all segments of the population within the limits of recourses.
• 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.
• 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.
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II. Priorities of the policy
Following critical examination of the nature, magnitude and root causes of the existing
problems of the country, the government has defined a set of priorities of the national health
policy. Here are some of the policy priorities.
• 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 minorities and poor living conditions
• 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 health professionals with community based, task-oriented
training shall be undertaken.
• Special attention shall be given to the health needs of family (particularly women and
children), those in the forefront of productivity, those most neglected regions and
segments of the population including the majority of the rural population, pastoralists,
the urban poor and national minorities, and Victims of man-made and natural disasters.
III. General strategies
As it is defined earlier, health policy strategies are methods approaches chosen to bring about
a desired future. Therefore, the government has formulated a twenty year health sector
development strategy, which will be implemented through a series of five year investment
program to implement the polices and hence improve the health of the population. In the next
42
topic we will see this health sector development program with enough detail. However, the
major strategies that are set as one of the basic component of the country’s health policy are
described below.
• 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: 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; accelerating 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;
participating 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 the day-care centers in factories and
enterprises, school health and nutrition programs; undertakings in disaster
management, agriculture, education, communication, transportation, expansion of
employment opportunities and development of other social services; and
developing facilities for workers’ health and safety in production sectors.
• 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.
• 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 aging from
emerging as major health problems; and prevention of environmental pollution
with hazardous chemical wastes.
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• 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 or 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; and Developing an attractive career
structure, remuneration and incentives for all categories of workers within their
respective systems of employment.
• 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; and Developing maintenance and repair
facilities for equipment.
• 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; and 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; and
Developing appropriate measures to assure strict observance of ethical principles
in research.
• Referral System shall be developed by: Optimizing utilization of health care
facilities at all levels; improving accessibility of care according to need; assuring
continuity and improved quality of care at all levels; rationalizing costs for health
44
care seekers and providers for optimal utilization of health care facilities at all
levels; and strengthening the communication within the health care system.
• 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 of all levels;
and developing central and regional information documentation centers.
• Financing the Health Services shall be through public, private and international
sources and the following options shall be considered and evaluated.
o Raising taxes and revenues

o Formal contributions of insurance by public employees
o Legislative requirements of a contributory health fund for
employees of the private sector
o Individual or group health insurance
o Voluntary contributions
2.4 Health Service Development Program
As it has been mentioned above in the discussion of health policy and strategies, Ethiopia has
developed health sector development program after formulating health policy that has been
described above. Here, we will see the major components of the health sector development
program (HSDP) with particular emphasis to the fourth phase of its implementation plan.
The components of the health sector development program may slightly vary from phase to
phase. Some of the strategic initiatives may have been implemented since the first phase of
HSDP and others might be relatively the new one like the health extension program that has
been included since the second phase of HSDP.
In General, the HSDP is considered as a policy implementation strategic document that

guides the development of sub national plans and sets the rule of engagement in the health
sector. It responds to a number of problems identified in the health service coverage and
quality, and some of the major objectives of the HSDP –I, II and III were:
45
• Increase access and coverage to health care, along with utilization

• Improve service quality through training and an improved supply of necessary
inputs
• Strengthen management of health services at Federal and Regional levels
In terms of progresses in the implementation of priority health programs including prevention

and control of infectious communicable diseases such as HIV/AIDS, Malaria and TB, the
recorded achievement showed notable sign of improvements during these periods. Similarly
in all the building blocks of the national health system, significant progresses were achieved
and documented on the three HSDP phases. Here we will see the details of HSDP IV as it is
currently being implemented and serves as an input for the national development and
transformation plan (DTP) that the government is implementing widely for the coming five
years.
HSDP phase IV
Unlike the previous phases of HSDP, the government developed the strategic plan for HSDP
IV with balanced scorecard framework together with the previous approach known as
Marginal Budgeting for Bottleneck (MBB) approach. This approach (MBB) enables you to
systematically look into the health system bottlenecks, high impact interventions, different
scenarios and associated costs of achieving results that were planned under HSDP IV.
The Balanced scorecard framework will be described with more detail in the next topic. Here,
we will see the key components of the method used to develop the HSDP IV. These are:
1. Policy framework
2. Health sector strategic assessment
3. Strategy of HSDP
4. Strategic Objectives
5. Performance Measures and Strategic Initiatives of HSDP IV
6. Costing & Financing of HSDP-IV
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1. Policy framework
The Ethiopian health sector has set objectives for the effective health interventions with the
aim of reaching every section of population and meeting the health related Millennium
Development Goal (MDG) and targets by the year 2015 G.C.
The development of HSDP IV has taken into account certain policy framework. This
framework includes the national health policy and other national health related policies such
as policy for HIV/AIDs prevention and control, national drug policy, population policy,
national policy on women, national development and transformation plan and rural
development policy and strategies. In addition, the international commitments like the MDG
goals and targets that are directly or indirectly related to health have been taken into
considerations. HSDP IV is also considered as the expression of the Government of Ethiopia
(GOE) renewed its commitment to the achievement of MDGS. From the MDGs that are
listed below (see figure 2.1), goals number 1, 4, 5, 6,7and 8 are directly linked to the health
sector. Out of these six health related goals, three of them (goals 5, 6 and 7) are particularly
falling under the domain of the health sector. Each goal will be achieved through pre-
determined targets.
MDG 1: Eradicate extreme poverty and hunger
MDG 2: Achieve universal primary education
MDG 3: Promote gender equality and empower women
MDG 4: Reduce child mortality
MDG 5: Improve maternal health
MDG 6: Combat HIV/AIDS, malaria and other diseases
MDG 7: Ensure environmental sustainability
MDG 8: Develop a global partnership for development
Figure2.1 Millennium development goals
47
These targets are listed below as seen in figure 2.2.
Box 2. Target for MDGs 1, 4, 5, 6,7and 8
Target1. Halve, between 1990 and 2015, the proportion

of people whose income is less than one dollar a day.
Target 2. Halve, between 1990 and 2015, the proportion

of people who suffer from Hunger
Target 4. Eliminate gender disparity in primary and

secondary education
Target5. Reduce by two thirds, between 1990 and 2015,

the under-five mortality rate
Target 6. Reduce by three quarters, between 1990 and

2015, the maternal mortality ratio.
Target 7. Have halted by 2015 and begun to reverse the

spread of HIV/AIDS.
Target 8. Have halted by 2015 and begun to reverse the

incidence of malaria and other major diseases.
Target 9. Integrate the principles of sustainable

development into country policies and programs and
reverse the loss of environmental resources.
Target 10. Halve by 2015 the proportion of people

without sustainable access to safe drinking water.
Target 18. In cooperation with the private sector, make

available the benefits of new technologies, especially
information and communications.
Figure 2.2 Targets for health related MDG
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2. Health sector strategic assessment
As part of the health sector assessment, the mandates of the health sector organizations were
assessed to have clear picture on the power and duties of each organization in the health
sector. Mandates are formally defined in the Ethiopian laws and regulations for public
organizations such as the FMOH and RHB by the legislative body. Some of the roles of
administrative health institutions are:
Role of Federal ministry of Health:
• Initiate policies and laws, prepare plans and budget, and upon approval implement
same.
• Causing the expansion of health services.
• Establishing and administering referral hospitals as well as study and research centers.
• Determining the qualifications of professionals required to be engaged in public
health services at various levels, provide certificates of competence for same.
• Undertaking the necessary quarantine control to protect public health.
• Determining standards to be maintained by health services.
• Devising strategies, means and ways for the implementation of prevention, control
and eradication of communicable diseases.
Role of Regional health bureau:

• Prepare, on the basis of the health policy of the country, the health care plan and
program for the people of the region, and to implement same when approved.
• Organize and administer hospitals, research and training institutions that are
established by the regional government.
• Issue license to health centers, clinics, laboratories and pharmacies to be established
by NGOs and private investors and supervise them.
• Cause the provision of vaccinations, and take other measures, to prevent and eradicate
communicable diseases.
• Participate in quarantine control for the protection of public health.
• Ascertain the nutritional value of foods.
49
Role of woreda health office:
The mandate of woreda health offices is to manage and coordinate the operation of the
primary health care services at woreda levels. They are responsible for planning, financing,
monitoring and evaluating of all health programs and service deliveries in the woreda.
In addition to FMOH, and the line institutions at sub national level, the regional, zonal and
district administrative council will play crucial roles in the implementation of HSDP IV.
Some of these include:
• Providing political leadership for health.

• Ensuring the community’s demand for health care is properly addressed.
• Planning, resource mobilization and allocation, monitoring and evaluation of health
programs and the delivery of health services.
• Facilitating inter-sectoral collaboration.
• Provide guidance to enhance the partnership with NGOs, CSOs, private sector.
The other outcomes of the assment of the health sector are identifying its mission and visions.
The mission of FMOH is to reduce morbidity, mortality and disability and improve the health
status of the Ethiopian people through providing and regulating a comprehensive package of
promotive, preventive, curative and rehabilitative health services via a decentralized and
democratized health system. And the Federal ministry of health (FMOH) has set ‘seeing
healthy, productive and prosperous Ethiopian’ as a vision.
The health sector also identified community first (customer), commitment, change,
collaboration, trust and continued professional development as core values of any health
sector organization.
Analysis of strengths, weaknesses, opportunities and threats and recognizing those strengths
and opportunities facilitates the planning and implementation of the HSDP. Some of the most
common strengths of the health sector identified were: High coverage of Health Extension
Program, Increased coverage of antiretroviral treatment (ART) service, accelerated training
of health professionals and rapid expansion of health centers and health posts. Whereas,
Inadequate capacity to implement decentralized health system, Low utilization of health
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services and Lack of Health infrastructure maintenance capacity (Building, Medical

equipment, information technology) are some of the weakness recognized.
3. Strategy of HSDP IV
The Strategy HSDP IV has three key elements. These are: Customer’s core values, strategic
themes and prospective. The customer value proposition is the attributes that define services
that the health sector should provide, the principles behind its relationship with the
community and how the health sector wishes to be perceived. The strategic themes are key
areas in which the health sector must excel in order to achieve its mission and vision.
These strategic themes are:
• Excellence in Health Service Delivery and quality of care

• Excellence in Leadership and Governance
• Excellence in Health Infrastructure and Resources
The prospective of HSDP (its focus in relation to) are three: the community perspective that
try to answer the questions of how to enable the community to produce its own health;
Financial prospective that deals with the question of how to mobilize and utilize more
resources effectively and efficiently; and the capacity building prospective to deal with, what
capacities must the health sector to excel in the processes.
4. Strategic Objectives and Map for the Ethiopian Health Sector
About ten strategic objectives are set in the HSDP IV development process. These are:
1. Improve Access to Health Services

• Maternal, neonatal, child and adolescent health
• Nutrition
• Hygiene and Environmental Health
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• Prevention and Control of Major communicable Diseases

- Reduce Incidence and Prevalence of HIV/AIDS
- Reduce Incidence and prevalence of TB and Leprosy
- Reduce Incidence and prevalence of Malaria
- Reduce Incidence and prevalence of other communicable
Disease
• Prevention and Control of Non Communicable Diseases
2. Improve community ownership

3. Maximize resource mobilization and utilization
4. Improve quality of health services
5. Improve Public Health Emergency Preparedness and Reponses
6. Improve Pharmaceutical Supply and Services
7. Improve regulatory system
8. Improve evidence based decision making: harmonization and Alignment
9. Improve Health Infrastructure
10. Improve Human Capital and Leadership
A strategic map is drawn to illustrate the cause and effect relationship of strategic objectives
in the health sector. The map provides an insight how the Health sector is planning to
establish an added value to the community and how the outcome and the customer value
proposition intended results are achieved. See the map in the HSDP-IV document.
5. Performance Measures and Strategic Initiatives of HSDP IV
Strategic objectives are used to break strategic themes into more actionable activities that
lead to strategic results. Strategic initiatives are long term or short term projects or programs
that should be implemented to ensure success of the strategy. They are selected in terms of
their potential to bring significant impact in the sector’s strategy. Sector core performance
indicators and targets are listed below.
52
Strategic Directions for HSDP IV: A number of initiatives and programmatic interventions
were under implementation in HSDP I, II and III.. The majority of the initiatives and
programs will continue to be implemented in HSDP IV as per the agreed strategic directions.
However, there are new strategic directions or major refocuses that should attract more
attention. These are:
• Health Extension Program

• Quality of Healthcare
• Scaling up of Civil service Reform
• Human Resources Development
• Health Infrastructure (Construction and ICT)
• Special Support to Emerging Regions
• Climate Changes and Health
• Gender Mainstreaming
53
Table 2.1 Summarized priorities and targets of HSDP IV (source: HSDP IV)
Priority Impact Outcome Bloodlines

Areas
Maternal and MMR 267/100,000 • CPR= 66% • Health extension
New born • Deliveries program
attended by • Supply chain
Health skilled birth management
attendants=
• Regulatory system
62% • Harmonization and
alignment
Child Health U5MR 68/1000 • Fully
Immunized= • Healthcare financing
IMR 31/1000 care
90%
• Pneumonia • Human resource
treatment 81% development
HIV/AIDS HIV incidence 0.14 • • Health information
ART =484,966
• PMTCT= 77% system
• Continuous quality
TB Mortality due to all TB case detection improvement program
forms • Referral system
75%
of TB= 20/100,000
Malaria Lab confirmed LLIN=39 million
Malaria
incidence <5 per
1000
Nutrition Wasting IRS=77% of
targeted
prevalence 3%
households
Health Extension Program
As mentioned earlier, Health extension program is one of the programs that the HSDP IV has
developed new strategic directions for its implementation. The program has implemented
essential health service packages that are described below.
54
Essential Health Service Packages (EHSP)
Essential health packages (EHSP) which is also known as the Minimum Health Services
Package (MHSP), refers to a set of cost-effective, affordable and acceptable interventions for
addressing conditions, diseases, and associated factors that are responsible for the greater part
of the disease burden. It comprises the core health and health related interventions that are
promotive, preventive, basic curative, and rehabilitative services that are agreed to be
necessary and which people can expect to receive through the various health delivery
mechanisms and points.
The major components of the EHSP for Ethiopia are classified based on the recently
introduced Health Service Extension Program (HSEP). The HSEP is an essential Health
services package for a community level. A category containing basic curative care and
treatment of major chronic conditions introduced starting from the health center. Thus, the
EHSP is organized into the following five components:
1. Family health services

• Maternal and New born care
o Antenatal care
o Delivery services
o Post natal care
• Child health services
o Integrated management of Childhood Illnesses (IMCI)
o Growth Monitoring and Promotion
o Immunization
o Promotion of essential nutritional action (ENA)
• Family planning services
• Adolescent Reproductive Health Services
2. Communicable Disease Prevention and Control Services: Primarily focus on

• Malaria
• Tuberculosis
• HIV/AIDS/STI
• Epidemic diseases
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3. Hygiene and Environmental Health Services: The package covers

• Control of insects, rodents and other stinging animals
• Ensuring water safety and availability
• Proper housing
• Food sanitation
• Waste disposal including proper latrine usage
4. Basic Curative care and Treatment of major chronic conditions
• First aid for common Injuries and emergency condition
• Treatment of major Chronic Conditions and Mental disorders
• Treatment of Common Infections and complications
5. Health Education and Communication Services
Information, education and communication activities, a key component of EHSP, will be

delivered at all levels integrated with all other components of EHSP. The focus of the
component and the issues to be addressed will be those indicated in the various sections of
the EHSP.
6. Costing and Financing of HSDP-IV
Evidences so far strongly point out that the primary obstacles against fast and sustainable
targeted health gains through implementation of the proven high impact interventions are lack
of resources and weak implementation capacity. There is also low level utilization of existing
proven effective interventions by the community which would require working more on
community education and mobilization aimed at substantially increasing the demand and the
timely utilization of the available health care services at each level of the health care system.
2.5 Major Health Related Legislations in Ethiopia
The history of health and health related legislation in Ethiopia dates back as far as the early
19th century. The first health decrees were vaccination against smallpox by Emperors
56
Yohannes and Menelik II, during the smallpox epidemic in 1886. However, modern medical
legislation could be traced back to the coronation of Emperor Haileselassie I in 1930. On July
18, 1930 a law was passed to regulate the practice of doctors, dentists, pharmacists, midwives
and veterinarians. The law specified that no one could practice these professions without a
relevant Diploma. In 1942 (proc. 27), traditional medicine was given a formal recognition.
This was reaffirmed in 1943 and 1948 (proc. 100) as part of the medical registration
proclamation. Between 1941and present time, some 27 Public Health enactments were made
available, some of them were:
• Public Health Proclamation (NG 91, 1947, 66-68)

• Medical Practitioners Registration Proclamation (NG 100, 1948, 1-3)
• Establishment of Ethiopian Pharmaceutical Manufacturing Factory NG
167/1994
• Council of Minister of regulation established regulation no (NG 174/1994)
to provide for licensing and supervision of Health service Institution.
• Establishment of the Pharmaceutical and Medical supplies import and
wholesome sale enterprise (NG 176/1994)
• Nutrition Research Institute Established under council of ministry of
regulation( NG 4/1996)
• Establishment of Health Education Center NG 40/1998
• Establishment of Ethiopian Health Professional Council (NG 76/2002)
• Establishment of FMHACA ( Regulation No 661/2009)
• Currently, there are more health regulation initiatives on the pipeline under
the newly reorganized Food, medicine and Health Administration and
Control Authority (FMHACA).
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2.6 Healthcare Regulation System

Regulation usually intends to ensure that providers are able to deliver quality care by
ensuring the quality of the physical facility, medical personnel, equipment, and supplies. It
was mainly answers to frequently asked questions do providers have the capability to produce
quality care? Recent development shows that customers are shifted from asking “Do
providers have the capability to produce quality care?” to asking, “Are they actually
providing quality care?” this means that customers started to bother not only about getting
treatment but also about their health outcomes. Quality is ensured basically by regulating
health practitioners and health service providers through the following three approaches:
1. Licensing
2. Certification
3. Accreditation
1. Licensing
It is a mechanism by which an executive organ or authority gives permission to an individual

practitioner to engage in an occupation or to a healthcare institutions to operate and deliver
health services. This mechanism helps governments to ensure public health and safety by
controlling the entry of healthcare practitioners and service provider facilities into the
country’s healthcare market and by establishing standards of conduct for maintaining that
status.
A. Facility Licensing
Facility licensing is the process of judging a health care facility or practice against a set of
standards that specify the minimum structure that must be fulfilled in order for the facility to
operate. Licensing standards specify the equipment, staff, and physical facilities that are
essential for delivering medical care. If the facility meets these standards it is granted a
license to open and provide healthcare to clients. If it lacks any of these requirements it is not
58
allowed to open and provide care to clients. Licensing of health care facilities is mandatory.
The goal of licensing is not to define desirable quality but to define the minimum acceptable
level of capability to deliver service (see figure 2.3).
Standards define Inspection Issuance of license to

Minimum confirms presence begin service
requirement of minimum
standard
Figure 2.3Licensing concept of health facilities
B. Health practitioners licensing
Health practitioners’ licensing is the process by which a regulatory body based on preset
standard requirements issues permission to an individual to practice his or her respective
profession. Licensing is mostly mandatory. A license is usually granted on the basis of
examination or proof of education, or both, rather than on measurement of actual
performance. The regulatory body by issuing a license certifies that those licensed have
attained the minimal degree of competency necessary to ensure reasonable protection of
public health, safety, and welfare. Regulatory body can be a Government or Professional
Associations, independent Council or Board.
The regulatory body is accountable to do the following activities:
1. Set standardized requirements for licensing health practitioners

2. Examine applicants’ credentials to determine whether their education, experience, and
moral fitness meet the preset legal and administrative requirement
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3. Administration of examinations to test the academic and practical qualifications of

medical graduates against preset standards (this may vary from one country to
another)
4. Granting of licenses on the basis of reciprocity or endorsement
5. Investigation of charges of violation of standards established by law and appropriate
regulatory measures: suspension or revocation for violators.
2. Certification
Certification is a process by which a recognized authority—either a governmental agency or

nongovernmental organization—evaluates and recognizes an individual provider or an
organization as having met pre-determined requirements, usually to demonstrate competence
in a specialty area. Unlike licensing certification programs are usually voluntary, and give
certified persons special recognition or authorization to use a particular title or official
designation. Certification makes practitioner feel he or she is the best qualified to do
particular work, which should result in a professional attitude and motivation to improve
competence. Certification also enables the public to identify practitioners who have met a
standard of training and experience set above the level required for licensure.
3. Accreditation
Accreditation is the formal process by which a recognized accrediting body assesses and
recognizes that a healthcare organization meets pre-established performance standards.
Accreditation standards are usually regarded as optimal yet achievable and are designed to
encourage continuous improvement efforts within accredited organizations. The standards
used to assess performance for accreditation are commonly developed by expert committees
working with the accrediting body and revised periodically to reflect advances in technology
or policy changes. By focusing on optimal rather than minimum standards of care,
accreditation instills a strong performance improvement orientation, stimulating healthcare
organizations to pursue increasingly higher levels of quality. Unlike licensing accreditation is
voluntary.
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2.7 Regulating Ethiopian Healthcare Facilities operational

procedures
In the previous session you learned the concept of three approaches of healthcare quality
ensuring mechanisms: licensing, certification and accreditation, in this study session you will
learn Ethiopian healthcare facilities (hospitals) operational regulations.
Operational Standards for Patient Flow
1. Procedures are established to ensure efficient patient flow; such procedures are
specific to emergency, outpatient, and inpatient settings and seek to reduce patient
crowding.
2. The health facility (hospital) has an Emergency Triage, staffed with appropriately
trained personnel and equipped with necessary equipment and supplies.
3. The health facility (hospital) has a Central Triage, staffed with appropriately trained
personnel and equipped with necessary equipment and supplies.
4. All patients (except laboring mothers, patients with an appointment for an outpatient
clinic or admission and private wing patients) undergo triage.
5. Outpatient appointment systems are in place for all disciplines provided by the health
facility (hospital.)
6. Appointment systems are in place for elective inpatient admissions in all disciplines
that are provided by the health facility (hospital)
7. Hospital has a Liaison and Referral Service that:
a. Manages bed occupancy,
b. Facilitates emergency and non-emergency (elective) admissions, and
c. Receives referrals from, and makes referrals to, other facilities in the referral
network.
8. Health facility (hospital) has a written protocol for the admission and discharge of
patients that is known, and adhered to, by all relevant staff.
9. Health facility (hospital) has a Referrals Service Directory, listing facilities which the
hospital may refer patients to or receive patients from, categorized by the type of
clinical services they provide.
10. Criteria for the referral of patients from the hospital to other health facilities are
established, including standardized referral and feedback forms and necessary clinical
61
documents to accompany referred patients, in accordance with the national referral

implementation guidelines.
11. Health facility (hospital) has a standardized method for managing referrals.
12. Health facility staff members are familiar with the referral systems including relevant
referral protocols and forms.
13. Health facility (hospital) promotes and publicizes the referral system throughout the
community in order to ensure that all constituents are aware of the applicable service
pathway.
Patient flow can be improved by an appropriate arrangement of services (hospital layout)

supported by well-placed signs to indicate all service areas. Services should be organized in
such a way that:
• Minimizes patient travel time between services; and

• Reduces the likelihood of patients getting lost when going from place to place.
A site map should be displayed at the hospital entrance. Signboards can be used throughout
the facility to direct patients, caregivers and visitors to the appropriate service areas.
Emergency Services
The Emergency Services should be organized so that the Emergency Service’s entrance can
be easily accessed by ambulances and patients. This means that the entrance to the
Emergency services should be clearly labeled in a way that is visible from the street.
Emergency Triage
Patients entering the hospital through the separate Emergency Department entrance, from the
reception desk or those referred to the Emergency Department from Central Triage should
undergo Emergency Triage. If further investigations and/or treatments are required following
triage, these should be provided by the Emergency Case Team. Patients that are not classified
as emergency cases should be referred to Central Triage.
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Central Triage
Patients will be directed to Central Triage from the reception service (or Emergency
Department). Within Central Triage, the patient will undergo a triage assessment and all
relevant administrative processes (registration, medical record retrieval, payment etc) will be
conducted. The triage assessment will assign each patient to an appropriate case team
(outpatient case team or emergency case team). The patient will then be directed to the
relevant case team with his/her medical record delivered by a Runner.
Outpatient Case Management
Outpatient services should be organized as Case Teams. There should be General Case
Teams and Specialist Case Teams for all specialist services provided by a hospital. Patients
enter the Outpatient case management pathway from Central Triage or directly from the
reception service, if they have a pre-booked appointment. Appropriate care is then initiated
by the Case Team. And in accordance with the findings, the patient would be admitted, sent
home as outpatient (with or without a further appointment) or referred.
Inpatient Services
Patient wards should be located in close proximity to the emergency and outpatient
departments and should be easily accessible from elevators, ramps or stairways. Each ward
should have a functioning set of toilets, sinks and showers. There should be sufficient seating
for caregivers and visitors. If mixed-sex wards are used, there should be separate areas/rooms
for male and female patients. Similarly, if adult and pediatric cases are mixed there should be
separate areas/rooms for pediatrics. Case Teams should be comprised of specialists, general
practitioners, health officers, nurses, runners, cleaners etc. Each Case Team should be led by
a Case Team Leader. Pharmacy and laboratory personnel should also form part of inpatient
services.
Admission process
The hospital should have a written protocol for the admission of patients that includes all
steps to be taken in the admission process including how to arrange admission, and the
activities to be undertaken when the patient arrives on the ward. This should be known by,
and adhered to by all relevant staff.
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The patient should be assessed by a medical doctor upon arrival on the ward and a History
and Physical Examination Assessment should be completed. This should include the
immediate management plan for the patient. Additionally, a Nursing Assessment should be
completed within 24 hours of admission and a Nursing Care Plan developed.
Discharge Process
The hospital should establish a written protocol for the discharge of patients stating all the
steps to be followed when arranging discharge, including preparation of a discharge summary
and handling of the medical record after discharge. In particular, when a patient is ready for
discharge he/she should be counseled by a member of the Case Team.
Patient death
If a patient dies in the hospital, the death should be confirmed by a physician. A death
summary should be completed and should be documented in the patient’s medical record. If it
is necessary to confirm the cause of death, a post mortem examination form should be
completed and the body should be transferred to the pathology case team for post mortem
examination.
Maternity/Delivery Services
The Labor/Delivery Service is comprised of the antenatal and postnatal ward(s), delivery
suite (labor and delivery rooms) and the neonatal unit. An operating room(s) should be
readily accessible. Ideally, there should be a specific operating theatre(s) for the delivery
suite but if this is not possible the general operating theatre should be located nearby and
obstetric cases should be given priority over other surgical cases to minimize delay and
prevent avoidable maternal and perinatal deaths.
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Liaison and Referral Service

Each hospital should establish a Liaison and Referral Service that is responsible to:
1. Manage hospital bed occupancy (bed management)
2. Facilitate emergency and non-emergency (elective) admissions
3. Provide social service support to the Emergency, Inpatient and Outpatient Case
Teams
4. Manage the referral service, specifically:
o Coordinate the overall referral activities within the health facility
o Record and report the referral activities to facility management
o Compile, analyze and interpret data to improve the referral service
o Take part in the quality assurance programs of the referral system by
participating in regular review meetings within and outside the health
facility
o Ensure feedback is sent back to the referring health facility
The Liaison and Referral Service is staffed by Liaison Officers. Each hospital should
determine the number of Liaison Officers required based on the work load. Additionally, the
Liaison and Referral Service should include at least one social worker. Social work
assessment, advice and any necessary follow up is particularly important for emergency and
pediatric cases, and should also be provided for any patient where social work assessment is
requested by the relevant clinical case team.
2.8 Health Information System Policies and Procedures
HIS Policies and Procedures
Legal, regulatory and planning context of health information is a key resource for effective
Health Information System (HIS). It enables the establishment of mechanisms to ensure data
availability, exchange and quality. Legal and policy guidance is needed to elaborate
specifications for health information access and to protect confidentiality, etc.
65
Ethiopia has established a functional central HIS unit under the Federal Ministry of Health
which plays a significant role in coordinating, strengthening and maintaining the national
HIS, including the already implemented health management information system (HMIS).
However, it lacks to develop and implement clear policies and procedures related to
capturing, storing processing, and transmitting and communicating/disseminating health
information in the country. This doesn’t include the HMIS four technical areas discussed in
module one and six that has focused on selected national health indicators and standardized
data, recording and reporting tools with the procedures that apply to the HMIS only.
Health Information Related Initiatives
The HIS related initiatives are best understood in light of the overall objectives of the Health
Management Information System, which are:
• Develop and implement a comprehensive and standardized national HMIS and ensure
the use of information for evidence based planning and management of health
services.
• To review and strengthen the existing HMIS at federal, regional, woreda, health
facility and community levels and ensure use of health information for decision-
making at all levels.
• To achieve 80% completeness and timely submission of routine health and
administrative reports.
• Achieve 100% of evidence based planning at woreda health office and hospital level.
The strategy for implementation of HMIS objectives are:
• Institutionalize HMIS at all levels.

• Build capacity of health workers to analyze, interpret and use health information
for making decisions.
• Introduce appropriate HMIS technology at all levels of the health system in
collaboration with the concerned bodies such as the National Information, and
communication technology (ICT) Authority.
66
• Define the minimum standard of inputs required for HMIS at different levels of
the health system.
• Initiate and sustain regular program review and feedback system.
The breakdown of the plan is detailed according to what activities are carried out by the
various levels in the healthcare system. These are:
A. The key activities at the Woreda Health Offices level are:

• Establishment of HMIS posts and assignment of appropriate personnel in
the organizational structure of woreda health office and health institutions
as per the national standard.
• Determination of the qualification requirements, job descriptions, career
path, and incentive package standards for personnel working on HMIS.
• Ensure the proper reporting and feedback mechanism is laid out beginning
from the health extension workers to the HMIS personnel at woreda level.
• Provide the necessary health and administrative reports to the Regional
Health Bureau (RHBs) as per the guideline.
• Allocate funds for HMIS and provide the necessary facilities for the HMIS
units/personnel.
• Implement and monitor HMIS in collaboration with the RHBs.
• Collaborate on the expansion of the geographic information system and
woreda connectivity.
B. Key Activities at the Regional Health Bureaus Level:

• Adapt and implement qualification requirements, job descriptions, career
path, and incentive packages for personnel working on HMIS at different
levels of the health system.
• Adapt and implement National HMIS Strategy, manuals and standards
developed at national level.
• Conduct regular on-the-job training to HMIS focal personnel, program
managers and health workers.
67
• Equip HMIS units at all levels.

• Implement HMIS in collaboration with the FMOH.
• Collaborate on the establishment of electronic network from federal to
woreda level as part of implementation of HMIS.
• Initiate and sustain the development of Health and Health Related
Indicators in the regions.
• Advocate the allocation of adequate funds for implementation of National
HMIS in woredas.
C. Key Activities at the Federal Ministry of Health Level are:
• Assign a multidisciplinary team at Planning and Programming Department
/MOH and provide the necessary facility so that it will be able to
spearhead the development and implementation of HMIS at national level.
• Develop and popularize the National HMIS Strategy and user-friendly
manuals.
• Develop and popularize qualification requirements, job descriptions, and
career path and incentive packages for personnel working on HMIS at
different levels of the health system.
• Standardize HMIS indicators; harmonize the reporting system and collect
gender, age and facility type disaggregated data.
• Develop, adapt and implement HMIS user-friendly guidelines and revise
International Classification of Disease (ICD) coding system.
• Initiate pre-service training on HMIS in health professional training
institutions.
• Implement HMIS on pilot basis before nationwide replication.
• Conduct system analysis for the application of Information and
Communication Technology (ICT) to HMIS, pre test and implement the
application and expand geographic information system.
• Mobilize funds for implementation of National HMIS.
• Monitor the implementation of program review and research
recommendations through HMIS.
• Publish Health and Health Related Indictors bulletin annually.
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Self-check Assessment
Activity: 1
1. What are the strategies to be followed to achieve HMIS objectives?
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
2. Who is/are responsible for granting college accreditations in Ethiopia?
____________________________________________________
____________________________________________________
3. Describe the essential health service package of Ethiopia
____________________________________________________
____________________________________________________
4. What are the major components of HSDP IV
____________________________________________________
____________________________________________________
Activity: 3
Describe at list two HMIS related activities performed at different level in the health
care system.
Activity: 4
Explain the differences and similarities of Licensing, Certification and Accreditation.

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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Activity: 5
Identify the main core elements of Ethiopian Health policy
__________________________________________________________________
Activity: 6
Visit Woreda health office and or HC and identify activities carried out in HMIS
_________________________________________________________________
_________________________________________________________________
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Topic 3: Health Service Planning
3.1 Introduction
Health Service Planning is one of the primary functions of management and an important
skill for all health practitioners. It precedes all other functions of management. Effective
planning facilitates early achievement of objective, which depend on the efficiency of the
planner. The type of planning, planning steps and approaches are included under this topic.
At the end of this topic you should be able to
• Define planning
• Identify types and features of planning
• Distinguish the different approaches of health service planning
• Assist in Developing, implementing and monitoring health service planning
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3.3 Basics of Health Service Planning
Planning is defined as a systematic process of identifying and specifying desirable future

goals and outlining appropriate courses of action and determining the resources required
achieving them (WHO, district health service planning). Others may define it in a beat
different way as follows.
Planning is:
• Deciding in advance what to do, how to do it, when to do it and who to do it. It
bridges the gap from where we are now to where we want to go.
• Combination of compiling and analyzing, information dreaming up ideas, using logic
and imagination and judgment in order to come to a decision about what should be
done
• A systematic process of identifying and specifying desirable future goals and
outlining appropriate courses of action and determining the resources required to
achieve them.
Why planning?
Planning health service programs in the health sector is essential to meet the following
purposes.
• Protective purpose (eliminates or reduces uncertainty): To minimize risk of failure

(to achieve the goals) by reducing the uncertainty and clarifying consequences of
related management actions.
• Economy in operation: It helps us to select the best alternatives that help us to

achieve the best result at a minimum cost possible. It helps for effective utilization
of resources. It improves the efficiency of the operation, better utilization of
resources.
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• To provide a basis for monitoring and controlling work: To establish a coordinated

effort within the organization (fundamental purpose of planning is to help
organization reach its objectives).
Health services planning may be defined as the process of defining community health
problems, identifying needs and resources, establishing priority health goals, and setting out
the administrative actions needed to achieve those goals.
The primary aim of health planning is to improve the health status of a given population
while safeguarding equity and fairness of access as well as responsiveness of the health
system to the needs of the population. The health plan should achieve this goal through the
provision of efficient and effective health services, taking into account available resources
and the available means and methods of health care delivery.
Depending on the time a plan is prepared for, it can be:

a. Annual plan: health facilities or institutions usually set a plan for one year duration
and such plans are known as annual plan of the health institution.
b. Midterm plan: when the health plan go beyond one year and covers two to three years.
c. Strategic plan: When a health plan covers five years duration. It also known as long
term plan. The HSDP ( each phase comprises of 5 years duration) is good example of
a strategic plan.
Principles of planning
The major principles that need to be considered while planning in the country’s health sector
are: One Plan, One Budget, One report, Evidence based and Flexibility.
• One Plan: “One plan” is the idea that all the major activities happening at various
levels of the health system are included in one joint plan. “One plan” means that all
stakeholders (government (both federal and regional), donor, NGOs and the
community) agree to be part of a broader sectoral plan. The health sector will have
one country-wide shared and agreed strategic plan (HSDP) developed through
extensive consultation. All other regional, zonal, woreda and facility plans will be
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local sub-sets of this strategic plan and should be consistent with the latter. The HSDP
at all levels will have annual plans which are developed in similar consultation
process.
• One Budget: “One budget” ideally means all funding for health activities are pooled
and channeled through government channels. However, there is also a less radical
definition of “one budget” – all funds for health activities reflected in one plan and
one documented budget, but actually disbursed through separate channels.
• One Report: A set of indicators has been identified to monitor progress in achieving
HSDP. Reports should be based on these indicators and the agreed one plan without
duplicating the channels of reporting.
• Evidence Based: Planning in the health sector should be conducted with the help of
concrete, complete and reliable evidence. Based on the evidences root causes of
health problems of the society should be identified and tackled using proven high
impact and low cost interventions. Furthermore, a logical and systematic approach
should be used to define Strategic Objectives and performance measures.
• Flexibility: Plans should have some degree of flexibility in a way that important
revision is possible therefore; plan should be revised as needed. The new planning
process recognized this fact and considered flexibility as principle of planning in the
health sector.
3.4 Planning steps
There are basic steps in the planning process that make a continuous cycle of planning and
we will describe you the major one under this sub topic.
a. Situation analysis
b. Problem analysis and prioritization
c. Setting objectives and targets
d. Developing interventions
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e. Determining resource requirements

f. Preparing plan of action
g. Implementation
h. Monitoring and evaluation
a. Situation analysis
This step involves assessment of the current situation from various perspectives to establish
the actual health situation in terms of needs and priorities. Generally, situation analysis
includes: critical analysis of the previous plan (or plans) as it is an essential early step in the
planning process; reviewing the existing policy guidelines in order to familiarize yourself
with the existing directives and regulations to be followed in the course of preparing a health
plan; and identifying problems with giving consideration to health and health-related
problems based on available data from: HMIS, community surveys, census and your own
experience. The identified problems can be categorized as primary health problems (illness
such as HIV/AIDS, Tuberculosis, and Malaria) or secondary health problems (like inadequate
health resources, poor service coverage).
b.Problem analysis and prioritization
Problem analysis is the art of critical examination of problems against existing health related
conditions of your region or zone or woreda. Once the major problems have been identified,
their causes should be analyzed by asking and finding out why they exist. The analysis can be
done by using tools such as route cause analysis. After you identified the prevailing problems
and their route causes, you need to rank them based on their order of importance and this
process is known as problem prioritization. Prioritization is making decisions on how limited
resources could be best allocated to priority health problems or needs.
c. Setting objectives and targets
An objective is the intended result of a successful activity or program within given inputs and
process. Objectives will be formulated to address the identified priority problems and their
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immediate causes. Objectives should be specific, measurable (or at least observable),

attainable (given resources, environment and management capacity), realistic and time-bound
(SMART). After you set objectives, you need to specify the number and quality of activities
that has to be carried out to realize the objectives. Such determining amount of activities to be
performed is known as setting targets.
d.Developing interventions
Developing interventions is the process of identifying, and deciding between alternative

approaches and measures to address identified and prioritized health problems in the earlier
steps of planning.
Example: Distributing Insecticide treated mosquito net (ITN) to reduce malaria infection
where malaria is identified as priority health problem.
e. Determining resource requirements
This step of health planning allows you to translate all activities of the intervention(s) to
resources such as money, human resource, time and information.
Example: resource requirement to distribute 5000 ITN to a certain rural kebele may need the
following resources to be available.
• Human resource: one driver, 5 daily laborer, 1 malaria expert, 1 cashier

• Money: 20,000 birr for the net, 10,000 for salary/labor cost and 1,000 fuels
• Information; baseline information and information on the progress and effect of
distributing the ITN in that particular kebele.
f.Preparing plan of action
A plan of action is usually prepared in a tabular format and will normally contain the
following items: the problem, objective(s)/interventions, activities, inputs, Responsible
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implementer, activity monitoring indicator, planned output, activity cost and implementation
time frame.
g.Implementation
Once the planning and budgeting has been completed and approved by the appropriate
authority, the success of the plans will depend on how well they have been implemented.
There are three aspects that should be kept in mind while implementing the plan of action.
These are:
• Effectiveness: Effectiveness refers to what extent the particular activity outputs

have been achieved as compared to the targets set. In order to achieve the
objectives set in the plan of action, all activities should be fully implemented,
reaching the set targets and covering all the activity components.
• Efficiency: It relates the output to the resource inputs (human resources, financial
resources, time, and other materials) and refers to the measure of output per unit
resource input.
• Timeliness: While preparing the plan of action, activities are planned to be
implemented within a given period of time. Proper implementation of activities
requires prior preparation in identification of resources needed, allocation of tasks
and setting deadlines. These deadlines and allocated tasks should be made known
to all members of the team involved in the activity. This will ensure timely
completion of activities.
h. Monitoring and evaluation
The key question to be addressed at this stage of the planning cycle is “how will we know
when we get there and what have we achieved?” The details of monitoring and evaluation
will be described to you in the subsequent topic.
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Planning cycle
Planning cycle is a series of steps (that have been discussed earlier) must be followed in
deciding what is to be included in the plan (these steps are well explained in the earlier topic).
The cycle tries to handle the following questions related to each step:
a. Assessment: This step try to answer questions like where we are now, what are we
doing, why are we doing it. Generally, this requires a situational analysis to identify
current health and health-related needs and problems.
Figure 3.1 Planning cycle
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b. Aims and objectives: this step requires the selection of priorities and identification of
objectives and targets to be met in order to improve the health situation and/or service
delivery in a region or zone or woreda where the plan is developed.
c. Actions: this phase of the planning cycle, answer questions like what do we need to
do to get there and the options( alternate course of actions) with details of tasks or
interventions to be carried out, by whom, during what period, at what costs and using
what resources in order to achieve set objectives and targets.
d. Monitoring and evaluation: This step is required to answer how to know when we get
there or meet the defined targets and objectives and better way of getting there by
developing measurable indicators for monitoring progress and evaluating results.
3.5 Planning Approaches
The common methodologies of planning are:

a. Top-down and bottom-up
b. Balanced Score Card framework
b. Top-Down and Bottom-Up Approach
Health sector planning in Ethiopia follows Top-Down and Bottom- Up approach. A top-down
approach means an indicative plan produced at higher level and cascaded to lower levels. At
federal level national indicative plan with disaggregated targets by region is developed in
consultation with RHBs and then will be sent to the lower levels. The indicative plan is
important to give direction and align the plans at all levels with the priorities. Based on the
indicative plan lower level will prepare comprehensive plan that will be finalized jointly with
higher level and aggregated to the upper level. Bottom-up approach hence issues at grass
root level will be reflected at the regional and national levels, the regional and national level
plans will therefore rely on the actual conditions existing on grass root levels.
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Furthermore the strategic and annual plans at all levels should be:
1 Linked with resource mapping process
2 Approved by relevant government authority
3 Linked to each other (strategic- Annual)
4 Comprehensive
c. Balanced Score Card (BSC)
The Balanced score card is a strategic planning and management approach that help everyone
in an organization understand and work towards a shared vision and strategy. The logic of
BSC strategic planning starts at high strategic altitude, mission, vision and core values which
are translated in to desired strategic results. Once the strategic thinking and necessary actions
are determined, annual program plans, projects and service level agreements can be
developed and translated into budget requests.
3.6 Features of planning
Health planning should aim at improving the health status of a given population while
ensuring equity and fairness of access as well as responsiveness of the health system to the
perceived needs of the community. The health plan should achieve this goal through the
provision of efficient and effective health services, taking into account available resources
and the available means and methods of health care.
• Planning is a process rather than behavior at a given point of time. This process
determines the future course of action.
• Planning is future oriented. It is primarily concerned with looking into the future.
It requires forecasting of future situation in which the organization has to function.
Therefore, correct forecasting of future situation leads to correct decisions about
future course of actions.
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• Planning involves selection of suitable course of action. This means that there are
several alternatives for achieving a particular objective or set of objectives.
However, all of them are not equally feasible and suitable for the organization.
• Planning is undertaken at all levels of the organization because all levels of

management are concerned with the determination of future course of action.
Planning methods can be applied to:
o A large program at national level eg. TB control program

o Small one - at village level e.g. Construction of health post
• Planning is flexible as commitment is based on future conditions, which are

always dynamic (changing). Thus, an adjustment may be needed.
• Planning is a continuous managerial function involving complex processes of

perception, analysis, conceptual thought, communication, decision, and action.
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1. What is health service planning?

_______________________________________________________
_______________________________________________________
2. Explain the different features of planning
_______________________________________________________
_______________________________________________________
3. Discuss the different types of planning
_______________________________________________________
_______________________________________________________
4. Describe the steps of planning

_______________________________________________________
_______________________________________________________
5. Explain purposes of health service planning
_______________________________________________________
_______________________________________________________
6. Discuss principles of planning
_______________________________________________________
_______________________________________________________
7. Describe the common health service planning approaches
_______________________________________________________
_______________________________________________________
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Topic 4: Fundamentals of Monitoring and Evaluation

System
4.1 Introduction
Monitoring and evaluation are key management functions of an organization. Together, they
serve to support informed decisions, the best use of resources, and an objective assessment of
the extent to which an organization’s services and other activities have led to a desired result.
Monitoring is the systematic and continuous assessment of the progress of a piece of work or
an activity over time. An evaluation is systematic assessment of actions in order to improve
planning or implementation of current and future activities. It also assesses the extent to
which the stated objectives have been achieved. In this topic you will learn the fundamental
concepts and frameworks of monitoring and evaluation in detail.
• Define Monitoring and Evaluation

• Identify Monitoring and Evaluation tools
• Apply Monitoring technique for health intervention program
• Perform monitoring of health intervention program
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4.3 Monitoring and Evaluation Concepts
Monitoring
• Is the ongoing routine collection and analysis of information that are recorded
as the activities are progressing? Using monitoring, one should be able to
check whether activities are being carried out as planned and whether they are
effective or not.
• Will help to keep the work on track, and can let to know when things are
going wrong. If things are going wrong, it will be possible to take action to
correct any problems.
• Enables to determine whether the resources that is available are sufficient and
are being well used and whether the capacity is sufficient and appropriate.
• Can take place at any time during the implementation process, on a regular or
periodic basis.
Monitoring asks:
• What are we doing?

• How does the situation change over time?
What monitoring will not answer?
• Why did a program fail to implement its activities?

• What were the reasons for success?
• What was the reason behind reduction in the prevalence or
incidence of a health problem?
• What was the contribution of a specific program or component of a
program for observed changes?
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Evaluation
• Is the systematic collection, analysis and reporting of information about the

activities.
• It is a critical assessment of the good and bad points of interventions, and how
they could be improved.
• Is the process of assessing whether the specified objectives have been achieved,
in other words how successful have been. (Simply means looking at the
achievements from the planned activities in a more structured way).
With evaluation, one should be able to look into the process he/she have used and identify the
strengths and the weaknesses, before possibly taking corrective measures and he/she judge
his/her achievement and then use those judgments to improve his/her activities. Evaluation
can help you to determine how effective you are in achieving the objectives.
Effectiveness: refers to the extent to which you have achieved your goals and objectives.
While planning activities, you should have set down certain objectives. And by using the
process of evaluation you will be able to assess whether you have achieved these objectives.
Efficiency: means the extent to which you have achieved your objectives with the available
amount of resources. In other words, it refers to the proper utilization of resources when
achieving your objectives.
Evaluation Asks:
• What have we achieved and how?

• How relevant were components of a program in addressing societal needs?
• What were the reasons behind observed levels of performance?
• What is the contribution of a specific intervention for observed achievements?
• How efficient is a program?
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Table 4.1: Differences between Monitoring and Evaluation
Monitoring Evaluation
Frequency Continuous Episodic or periodic
Objective Describing Explaining
Method Follows trends, Compares actual Compares achievements with

performance with expected counterfactual
Performed by Mostly internal Internal and External
Uses Alerts when to take action Provides detailed

information on what types of
actions to take
4.4 Commonly used terms in Monitoring &Evaluation
Inputs: These include financial, human or material resources/ Resources going into
conducting and carrying out the project or program/ or resources used in a program
Examples:
• Health workers
• Drugs
• Laboratory reagents
• IEC materials
Activities: are program procedures that are implemented to obtain desired effects
Examples:
o Training health workers for counseling and testing
o Screening patients for opportunistic infections
o Conducting supervision
o Educating women
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Outputs: are the immediate consequences of the inputs utilized and program activities
conducted/ Immediate results obtained by the program through the execution of activities
(e.g., number of commodities distributed, number of staff trained, number of people reached,
or number of people served). They are measured within the setup of service provision,
usually using routine program records.
Examples:
• Number of patients treated
• Number of clients counseled
• Number of condoms distributed
• Number of HIV tests carried out
Outcomes: are short-term or intermediate results obtained by the program through the
execution of activities. They are also known as effects upon the target population that can
lead to the intended “ultimate goal” of a program.
Examples:
• Increase of condom use
• Improvement of quality of healthcare
• Reduction of risky sexual behaviors
Impacts: the longer range, cumulative effect of programs over time on what they ultimately
aim to change. Often, this effect will be a population-level health outcome, such as a change
in HIV/AIDS infection, morbidity, and mortality.
Impacts are rarely, if ever, attributable to a single program, but a program may, with other
programs, contribute to impacts on a population. Impact can also be used in the context of a
specific program.
In this case, it implies a much closer link to attribution of the program and a conceptual
model underlying it.
This can be through special studies with wide district, regional, or national coverage.
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Examples:
• Reduction in incidence of HIV infection
• Reduction of HIV/AIDS mortality
• Improvement in quality of life of patients
4.5 Monitoring and Evaluation plan
Monitoring and evaluation plans should be created at the end of the planning phase and
before the design phase of a program or an intervention. Monitoring and evaluation play
critical roles in realizing the results envisaged in this development plan. Planning for
monitoring and evaluation should be part of the overall planning process. It is concerned in
setting up the system and processes necessary to ensure the intended results are achieved as
planned.
In the absence of effective monitoring and evaluation, it would be difficult to know whether
the intended results are being achieved as planned, what corrective action may be needed to
ensure delivery of the intended results, and whether initiatives are making positive
contributions towards human development.
Monitoring and evaluation always relate to pre-identified results in the development plan.
They are driven by the need to account for the achievement of intended results and provide a
fact base to inform corrective decision making. It is very difficult to evaluate a program that
is not well designed and that does not systematically monitor its progress.
Good planning and designs alone do not ensure results. Progress towards achieving results
needs to be monitored. Equally, no amount of good monitoring alone will correct poor
program designs, plans and results. The plan should include information on how the program
or intervention will be examined and assessed. Generally, the plan should outline:
• The underlying assumptions on which the achievement of program goals depend

• The anticipated relationships between activities, outputs, and outcomes (the
framework)
• Well-defined conceptual measures and definitions, along with baseline data
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• The monitoring schedule

• A list of data sources to be used
• Cost estimates for the monitoring and evaluation activities
• A list of the partnerships and collaborations that will help achieve the desired
results
• Plan for the dissemination and utilization of the information gained
The key questions that monitoring seeks to answer includes the following:
• Are the pre identified outputs being produced efficiently as planned?

• What are the issues, risks and challenges that we face or foresee that need to be
taken into account to ensure the achievement of results?
• What decisions need to be made concerning changes to the already planned work
at subsequent stages?
• Will the planned and delivered outputs continue to be relevant for the achievement
of the envisioned outcomes?
• Are the outcomes we predicted remaining relevant and effective for achieving the
overall national priorities, goals and impacts?
• What are we learning?
While monitoring provides real-time information on ongoing program or project

implementation required by management, evaluation provides more in-depth assessments.
The monitoring process can generate questions to be answered by evaluation. Planning for
monitoring must be done with evaluation in mind as the availability of a clearly defined
results or outcome model and monitoring data, among other things, determine the
‘evaluability’ of the subject to be evaluated.
Monitoring and evaluation plan includes:

• The stated theory of change
• A monitoring and evaluation framework
• Evaluation questions and tools
• Baseline tools and indicators
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• A description of the monitoring activities and key moments

• A timeline
• A budget and explanation of the needed resources – money and personnel,
capacity development, infrastructure, etc.
4.6 Monitoring and Evaluation Framework
A clear framework, agreed among the key stakeholders at the end of the planning stage, is
essential in order to carry out monitoring and evaluation systematically. This framework
serves as a plan for monitoring and evaluation, and should clarify:
• What is to be monitored and evaluated?

• The activities needed to monitor and evaluate.
• Who is responsible for monitoring and evaluation activities?
• When monitoring and evaluation activities are planned (timing).
• How are monitoring and evaluation carried out (methods)?
• What resources are required and where they are committed. In addition,
relevant risks and assumptions in carrying out planned monitoring and
evaluation activities should be seriously considered, anticipated and included
in the M&E framework.
4.7 Monitoring and evaluation tools
Monitoring and evaluation tool refers to the instrument used to record the information that
will be gathered through a particular method. Some common quantitative and qualitative
M&E tools include:
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• Sign-in (registration) logs

• Registration (enrollment, intake) forms; checklists
• Program activity forms
• Logs and tally sheets
• Patient charts
• Structured questionnaires
• Focus group discussion guide
• Direct observation checklist
• In-depth interview guide
One of the critical steps in designing and conducting M&E activities is selecting the most
appropriate indicators. Indicators should always be directly related to the project or program
objective, so the process of selecting indicators can be fairly straightforward if the program
objectives have been presented clearly.
Type of indicators
Based on their relationship with the subject of interest, indicators can be:
• Direct indicators
• Indirect indicators (proxy-indicators)
Direct indicators: Are indicators directly related to the subject intended to be measured.
What is wanted to be measured is directly pinpointed by the indicator. Most of the time, it is
not realistic to measure direct indicators and whenever possible it will be very expensive.
Example: In an HIV clinic, the Anti Retro Viral therapy (ART) team may want to know if all
eligible patients are prescribed with Co-trimoxazole prophylaxis Therapy (CPT). “The
proportion of eligible patients receiving prescription for CPT” is a direct indicator.
Indirect indicators: Also called proxy-indicator, they speak about a subject of interest only
indirectly. Interpretation of measures is required to understand about the subject of interest
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Example: Monthly expenses of patients could be used to estimate their monthly income.
Target: The target (objective) of the indicator that needs to be achieved must be specified.
This can show the range within which the indicator would be considered as normal. This
enables comparison of actual result with the expectation or target, facilitating the use of the
indicator as tool for management.
Threshold: The threshold showing the minimum or maximum value of the indicator that
should trigger an action should be determined.
Required Action: What should be the nature of the action (decision) once the indicator
reaches the threshold, it should be clearly defined. Action will vary according to the
information provided.
4.8 Monitoring and Evaluation Activities

A. Monitoring Activities
Monitoring activities can be input/output, process or outcome monitoring. Input/ Output

Monitoring follow up of information about inputs or resources and outputs results from
program activities.
• Input monitoring involves checking whether the various resources required in order to
carry out activities are in place, and whether they are going into the intended activities.
• Output is the achievement obtained through utilizing resources. It is the extent to

which you have delivered the planned services, for example the number of people who
have received the service. Output monitoring involves checking whether the resources
that you have utilized for the activities have brought about the desired results. It
answers questions such as:
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o Which services were provided?

o Which resources were used?
o How many people used services?
Examples:
o Follow up of the number of condoms acquired every quarter by a program
o Follow up of the number of patients enrolled to HIV clinics
• Process monitoring tells you if you are doing the right thing to achieve your objectives,
for example whether you have selected appropriate methods, topics, contents,
messages, and so on. If you are not doing the right thing, then process monitoring will
help you take corrective measures.
• Outcome Monitoring follow up of information related to a program’s expected results

on target beneficiaries. It involves multiple outcome level assessments to measure
changes over time. No intention to attribute observed changes to a program rather, it is
usually related to a period of time and answers questions like:
• How is the knowledge of people changing?

• Was there change in behavior?
Example – Behavioral surveillance
The other monitoring activity is impact monitoring i.e. the follow-up of the status of the
social condition that a program is accountable for improving. In health programs, it usually
relates to the follow up of disease trends among targeted populations. It answers questions
such as:
• What effects do all interventions have upon HIV prevalence?

• How does all care, treatment and support activities influence survival of
patients with HIV infection?
Examples: Economic impact of HIV/AIDS in A country.
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B. Evaluation of Health Intervention Programs
Program evaluation is the application of social research methods to systematically investigate

the effectiveness of social intervention programs in ways that are adapted to their political
and organizational environments and are designed to inform social action in ways that
improve social conditions. According to their primary purpose, evaluations could be
classified as:
• Formative
• Summative
Formative evaluation: Is evaluation conducted with the primary purpose of furnishing

information that will guide program improvement. It is a type of evaluation performed during
the entire planning process and program execution to answer evaluation questions important
to modify an intervention. It provides solutions for program improvement by answering
questions such as:
• How can the intervention be modified to achieve its outputs?

• Are there better solutions to beneficiaries needs?
• How do components of a program relate amongst themselves?
Summative evaluations: Are evaluations undertaken to render a summary judgment on

certain critical aspects of a program and are usually performed to provide judgment about the
worth of a program or any of its components. They inform decisions like:
• Is the program effective?

• Should the program be continued?
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Steps in evaluation
Health intervention program evaluation involves the following steps.
Step 1: Involve people to participate in the activities
Begin the evaluation cycle by engaging people who have been taking part in activities. For
example, it will be useful to meet with community members, key informants, NGOs in the
locality, and others who have participated in the activities. Failing to involve them, the
evaluation might not address certain important aspects.
Step 2: Describe the activities to be evaluated
In order to carry out an evaluation, describe the activities being evaluated in detail. This
enables you to determine the objectives, activities, methods and materials and as well as the
content of the messages used in the activities being evaluated. This is important to focus on
what have been planned and what have been achieved.
Step 3: Select methods/tools
In this step, select appropriate evaluation methods to use, (observation or interviews, or use
other methods), depending on what we want to evaluate. Moreover, we need to decide whom
we want to interview, and when to interview them. Prepare all the necessary resources needed
to conduct the evaluation.
Step 4: Collect credible data
The data that are collected in order to conduct an evaluation is the most important step. Use
multiple data collection methods, such as observation, interviewing and discussion, at the
same time. The method we use should be appropriate and sufficient to give us the
information we need to know.
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Step 5: Analyze the data
Once we have collected all the relevant data from various sources, the next step is to analyze
and interpret the data.
Analysis involves presenting the information we have collected in such a way that it gives
meaning. For example, we can convert the raw data to percentages and numbers that will be
relevant to people who need to know about the outcomes of the evaluation.
Step 6: Learn from evaluation
The last step of evaluation deals with judging our achievements. In this step, we look at the
extent to which we have achieved our objectives. If the achievement is encouraging and we
appear to have done the right thing, then it demonstrates that the methods, materials and other
resources we have used have probably worked. So we can learn from this evaluation, and
should be able to replicate these approaches in our future health activities. On the other hand
the evaluation findings may tell us that we have not done so well. This could mean that we
have achieved only a portion of our objectives.
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Self -check Assessment
1. What is the difference between monitoring and evaluation?

______________________________________________________
______________________________________________________
2. What points should be included in monitoring and evaluation plan?
______________________________________________________
______________________________________________________
3. Define health care indicator?
______________________________________________________
______________________________________________________
4. Describe the characteristics of good indicator
______________________________________________________
______________________________________________________
5. Which of the following is an example of output indicator ( Circle your correct answer)
A. Average waiting time to see a doctor
B. The number of physicians providing HIV care in a hospital
C. Number of condom distributed
D. Number of contraceptive pills available in stock
6. A monitoring and evaluation tool was developed to measure contraceptive prevalence in
a specified community. The tool was used before, during and after the implementation of
a family planning program to identify whether contraceptive prevalence rate is
increasing or decreasing over time in that specified target population. Is this process
monitoring or evaluation? Tick in one of the boxes and explain the reason why.
__________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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7. The performance monitoring team in collaboration with a group of researchers and other
stakeholders measured the quality of life of mothers of different age groups on a regular
basis. The data was interpreted to verify whether all types of reproductive health projects
are resulting in improvements in the life of mothers in the locality. Is this process
monitoring or evaluation? And explain the reason why.
_______________________________________________________________________
_______________________________________________________________________
8. The overall situation was examined in the light of different projects underway in the
region to determine to what extent and in what way, each of the projects affected quality
of life among mothers in the locality. Is this process monitoring or evaluation? and
explain the reason why.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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Topic 5: Ethics and Laws in Medical Record Handling
5.1 Introduction
Medical records are essential not only for the present and future care of the patient but also
serves as a legal document to protect patients and Healthcare providers. In order to serve its
purposes, it must be complete, accurate, and available when needed. In addition, handling this
information requires observance of certain ethical principles relating to the health information
profession. This section of the module focuses on fundamental principles of ethics, code of
practice and laws related to the management of health information with particular emphasis
to the Ethiopian situation.
On completion of this topic, you should be able to:
• Define ethics, code of practice and professional obligation of Health Information

Technician(HIT)
• Identify health related laws applicable to HIT
• Identify ethical principles to be followed while handling medical records
• Explain why the knowledge of ethics and law is important to HIT
• Recognize the ethical and legislative environment in relation to HIT in Ethiopia
• Explain the applications of ethics and law to HIT
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5.3 Ethics and Health Related Laws
Ethics is a branch of philosophy dealing with moral principles that may be connected to
beliefs about what may be considered wrong or right. It is the science of moral value. The
word ethics is derived from the Greek word “ethos” meaning “the set of moral principles” or
“a system of moral principles” or “rules of behavior”. An ethical behavior is one that is
considered to be morally correct or acceptable.
There are different kinds of ethics. Ethics can be categorized in accordance with the subject
matters it deals with like medical ethics, bioethics, information ethics, economic ethics,
journalistic ethics, and communication ethics, legal ethics etc. The focus of this topic will be
information ethics.
Professional ethics
Professional ethics is the application of the concept of ethics to a person who belongs to a
learned profession or whose occupation requires a level of training and skill. Therefore, we
can see professional ethics as a guide for members of a profession in their relation with their
clients, colleagues, family, and the society at large. Professionals are capable of making
judgments, applying their skills and reaching informed decisions in situations that the general
public cannot, because they have not received the relevant training. Professional people and
those working in acknowledged professions exercise specialist knowledge and skill. How the
use of this knowledge should be governed when providing a service to the public can be
considered a moral issue and is called professional ethics. Health information technicians,
who are practicing their profession, must act and work within the basic principles and
guidelines for morally acceptable behaviors in relation to their profession.
Code of Ethics
A Code of Ethics, in its formal sense, is an attempt by an organization to codify the values of
the group i.e. a statement of overarching principle telling members what is right and what is
wrong as a guide to all decision making within the organization. Codes of ethics set out
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general principles, often social or moral, that guide rather than dictate behavior. Codes of
professional ethics serve several purposes such as:
• It provides ethical guidance for the professionals themselves

• It furnishes a set of principles against which the conduct of the professionals
may be measured, and
• It provides the public with a clear statement of the ethical considerations that
should shape the behavior of the professionals themselves.
A Code of Ethics for Health Information Technicians (HIT) should therefore be clear and
easily applied in practice. Moreover, since the field of health information is in a state of
constant change, it should be flexible so as to accommodate ongoing changes without
sacrificing the applicability of its basic principles. It is therefore inappropriate for a Code of
Ethics for HITs to deal with the specifics of every possible situation that might arise. Instead,
such a Code should focus on the ethical position of HITs as a professional, and on the
relationships between HITs and the various parties with whom they interact in a professional
capacity. These various parties include (but are not limited to) patients, health care
professionals, administrative personnel, health care institutions and governmental agencies.
5.4 Major ethical principles and standards of ethics in health

information management
Ethical principles are an important tool to protect the privacy and confidentiality in health
information management. This section introduces the subject of ethical principles and their
applications in handling health information. These ethical principles provide a framework for
analyzing and resolving ethical problems. Involvement in the protection of individual health
record requires observance of ethical principles which must not be violated.
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Fundamental Ethical Principles
All social interactions are subject to fundamental ethical principles. HITs function in a social
setting. Consequently, their actions are also subject to these principles. The most important of
these principles are presented below:
a. Principle of Autonomy
All persons have a fundamental right to self-determination. Autonomy implies an individual

is master of himself/herself and he/she can act, make free choices and take decisions without
the involvement of another person. However there are pre-conditions for the application of
autonomy principle, which are:
• Competency of a person i.e. is the capacity to be a moral agent, for example a person
who is 18 years and above in Ethiopia is competent and
• Liberty or freedom.
The principle of autonomy is based on the value of giving due regard to clients view and
respecting their choices. For example, autonomy in health information management would
requires that HIT’s must make sure that the client, not a spouse or third party, is making the
decision regarding access or disclosure to a third party about its private health information.
b. Principle of Equality and Justice
All persons are equal as persons and have a right to be treated accordingly. Justice means
“fairness” which implies giving each person/ client what he or she deserves. Justice requires
you that “equals be treated equally and un-equals unequally”. As a matter of principle all
clients are equal as they all come for health service and therefore need to be treated equally.
However, in some circumstance this principle may not work. For example when there is an
emergency a physician may need immediate access of the clients’ health record, which must
be pulled out ahead of other patients’ who are already waiting in line. In this circumstance,
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this client may be treated differently than those who may be waiting to access their own
health information.
c. Principle of Beneficence and Non-Maleficence
The principles of beneficence and non- maleficence are best considered together, as they are
complementary principles. In simple terms, beneficence means doing good and non-
maleficence means avoiding evil or harm. The first one states that “All persons have a duty to
advance the good of others where the nature of this good is in keeping with the fundamental
and ethically defensible values of the affected party”. The second principle is “All persons
have a duty to prevent harm to other persons in so far as it lies within their power to do so
without undue harm to them”. The principles of beneficence and non- maleficence translate
into the duties to maximize benefits while minimizing harms.
Beneficence would require HIT’s to ensure proper information disclosure. This means the
information is released to individual who need it for something that will benefit the client;
including continuation of care, or for health insurance payment purposes. On the other hand
the principle of non- maleficence would require that a patient’s information is not released to
someone who does not have the legitimate authorization to access it, and who might harm the
client in some way if access were permitted. This may happen for example, when an
employer seeks to use health information for discriminatory purposes in employment.
5.5 Professional Obligations
Ethical and professional obligations in HIT can be categorized into six categories. Each
category demarcates the different domains of the ethical relationships that exist between HITs
and specific stakeholders. These categories are:
• Obligations to client
• Obligations to colleagues in the health care team
• Obligations to the employer
• Obligations to the public
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• Obligations to self
• Obligations to professional association
a. Professional obligation to client and the health care team
In the course of performing ones professional duty, the following major obligations towards
clients and colleagues must be observed:
• With regard to the patient and the health care team, HIT personnel is obliged to provide
the necessary services to those who seek access to client information in accordance with
the applicable rule. Individuals who may request access to client information include
health care professionals or even the client himself or herself. Here you must ensure the
honor of the profession and the health and well-being of client before all personal and
financial interest.
• HIT personnel are expected to protect both the medical and social information of the
client. Clinical information, like diagnoses, procedures, or genetic data must be
protected as well as behavioral information like the use of drug or alcohols, and sexual
habits. Particularly it is increasingly important to protect social information like drug
abuse to avoid discrimination.
• HIT personnel are expected to protect confidential information of the client. This
involves ensuring the information collected and documented in the patient information
system is protected by all members of the health care team and by any other person with
legal access to the information.
• HIT personnel should preserve and secure the health information in their control. This
includes obligation to maintain and protect the place where you stored the record (hard
copy, electronic or imaged) and to secure the information in both manual and
computerized information systems.
• HIT personnel have to promote the quality and advancement of health care in the
institution they are serving. As an important member of the health care team HIT
personnel must provide their valuable expertise in the collection of health information
that will help other healthcare providers to improve the quality of care they are
delivering.
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• HIT personnel need to observe their scope of responsibility to which they are assigned.
They must not make or pass clinical judgments. Sometimes health care data may
indicate a problem with a provider of care, the treatment of diagnosis or some other
problems; in such cases the obligation of the HIT personnel is to provide data not to
pass judgment. The obligation rest with the health care team that reviews the data. The
obligation of the HIT personnel is to report accurate result.
b. Professional obligation to the employer
In relation to the employer, the following major professional obligations must be observed:
• Demonstrate loyalty to employer. This can be done by respecting and following

the rules, policies and regulations of employment. This obligation may include
giving the employer adequate notice when the decision to change employment or
resign is reached.
• Observe all laws, regulations, and policies that govern health information
management. Keep up to date with regional and federal laws; employer policies
and procedures affecting HIT.
• Accept payment only in relation to work responsibilities. HIT personnel must
never accept money illegally by disclosing patient information and trading in
patient secrecy.
c. Professional obligation to the public
With regard to the public, HIT personnel are obliged to observe the following key
obligations:
• Advocate change when patterns or system problem are not in the best interest of
the patient. Protect clients, the health care team, the professional association and
colleagues.
• Refuse to participate in or hide unethical practices. Become accountable for
noticing trends and potential problems with regard to providers of care, diagnosis
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and procedure. Furthermore refuse to conceal illegal, incompetent, or unethical

behaviors.
• Report violation of practice standards to the proper authorities. Avoid sharing
information learned at work with family or friend, and avoid discussing such
information in public places.
d. Professional Obligation to self and professional association

• Being honest about one’s education, credentials and work experience when applying
for a job; being careful to report only academic qualification attained, and submitting
only document which are successfully earned.
• In the HIT profession, personal competency and professional behavior is very
important. HIT personnel must try to ensure that peers and colleagues are proud to
have them in the health information team.
• HIT personnel should set goal/ aim at advancing his/her career. This can be done by
not stopping his/her education when one has earned the professional qualification
one is currently studying. Rather try to continue to attend educational sessions to
keep up to date with changing circumstances.
• Strengthen the health information professional association. This obligation includes
becoming a member of a professional association, actively participating in different
activities of the association, and encouraging others to seek a career in the health
information field.
• Promote and participate in health information research. When problems are
discovered within a health information system, studies must be conducted to clarify
their source and potential solutions.
Despite the fact that HIT professional association not yet established in Ethiopia,
professionals should contribute their faire share to the establishment of their professional
association and obey the abovementioned professional obligations.
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5.6 Law and Health Related Laws
What is Law?
Law is defined as a set of rules or principles dealing with human activities and formally
recognized as binding or enforceable by a controlling authority. Laws are passed by
government to keep society operating smoothly and to control behaviors that could threaten
the public safety. Enforcement of these laws is possible by penalties for violation which are
decided by courts of law. Penalties vary with the severity of the violation. Those persons who
violate the law may be fined, imprisoned or both and professionals who violate laws may also
lose their registration or license to practice their profession.
Basis for a law
The Constitution of the Federal Democratic Republic of Ethiopia divides the power and
responsibilities of the Federal government among:
• The legislature - which is the law maker,
• The executive - which is the law enforcer, and
• The judiciary - which is the interpreter of the law.
The House of Peoples Representatives is the legislative branch which originates

proclamation that becomes federal law. The executive branch of the government (the
Council of Ministers) through delegation from the House of Peoples Representatives can
issue regulation. In addition, administrative offices with delegation from the House of
Peoples Representatives or the Ministers of Council can issue directives. Directives are the
lowest form of laws in the hierarchy of legislation. For example Ministry of Health can issue
a directive on a specific health related issues. In a country having a federal set up like
Ethiopia, regions have also their own legislative, executive and judiciary organs exercising
their powers and duties in the region.
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Health related laws
Health related laws are laws which set rules and principles relating to the health sector
operation and includes a vast range of laws dealing with issues affecting the health and
welfare of the people.
There are many categories of laws having direct or indirect application to the health sector in
general and HIT in particular. While this legislation varies from country to country, health
related laws in general cover legislations related to:
• Disease control and medical care,

• Health professional regulation
• Ethics and patients rights
• Health information and statistics
• Pharmaceuticals and medical devices
• Health institution and services
• Nutrition and food safety
• Occupational health and accident prevention
• Mental health
• Health insurance
• Smoking, alcoholism and drug abuse
• Environmental protection
• Criminal sanctions and human rights.
Among the above mentioned health related laws health information and statistics; ethics and
patients rights; Health professional regulation and human rights document are the major
legislative documents which have direct or indirect application to the HIT profession and
privacy and confidentiality of personal health information in particular. Legislation on health
information and ethics and patients rights in respect to HIT primarily covers issues of the
privacy and confidentially of the same. In addition, professional regulation on the other hand
covers health information technician’s regulation by registration or licensure and various
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mechanisms of disciplining when professionals deviate from privacy and confidentiality

standards and other ethical deviations.
Though HIT involves other professionals and support staffs, the HIT personnel are the
primary custodian of the medical record and bear the primary responsibility in respect to this
record. This is because they are in charge of privacy and confidentiality protection in the
course of handling, security and disclosure of the medical record.
In the Ethiopian context, some of the above mentioned legislative text can be generally found
under the Constitution of the Federal Democratic Republic of Ethiopia and international
human rights documents which Ethiopia endorsed such as the Universal Declaration of
Human Rights and International Covenant on Civil and Political Rights.
Difference between Ethics and Law
Both professional ethics and law share two fundamental goals: the regulation of behavior and
the protection of society at large. Ethics and Law, therefore, share the goal of creating and
maintaining societal good. In respect to the HIT profession, the ethical and legal requirements
aim at primarily the protection of privacy and confidentiality of personal health information
of client/patient. Though both ethical and legislative requirements strive to this end, ethics
and law differ in a range of issues.
Professional ethics is a set of principles and in general require professionals to behave in a

certain manner just because doing something is right or wrong. An illegal act by a
professional is always unethical but unethical act is not necessarily illegal. This follows the
issue of whether ethical standards are enforceable or not. Though moral values are a
beginning to the development of legal rules for social order, an ethics statement which is not
adopted into law is generally unenforceable. However, courts of law may see the ethics
statements or principles of professional associations or regulatory bodies when they interpret
laws affecting that profession. Therefore, ethical standards influence legal standards by
creating professional ethics standards.
In contrast, law sets a general standard of conduct which must be adhered to or civil or
criminal consequences may follow a breach of the standard. These laws are written, approved
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and then enforced by the government body which approved of them. In other words laws go
through a process to get approved, then are written into laws, and then are enforced.
Enforcement of these laws is through penalties decided by courts of law. This may include
fines, civil or criminal penalties, depending on the gravity of the violation.
Legal Framework and enforcement in Health Information Management
Individual health record is known to be an important legal document. This record has to do
with the protection of clients’ legal right of privacy and confidentiality of the information and
it may be used in medical malpractice suit and settlement of health insurance payment. There
are various relevant issues that must be known by HIM personnel in order to fully grasp the
legal implications when managing patients’ health record. HIT professionals need to meet
various legislative requirements in respect to collection, security, right of access, use and
disclosure of the individual health information and ownership and control of the health
record. Therefore, it is very important to become familiar with all the requirements and
standards set collection, security and rights of access to personal health information. In
addition, know and apply requirements on how the information can be used, and under what
circumstances it may be disclosed.
All the above concepts have an important implication in the protection of the right to privacy
and confidentiality of personal health information. In addition, it is important to understand
what the HIM personnel’s role and functions is in the life cycle of specific individual health
information.
In order to know and apply all these legislative requirements effectively, all the relevant
laws and regulations applicable to HIT in Ethiopia must be well understood. These laws
primarily include the Constitution of the Federal Democratic Republic of Ethiopia (FDRE),
international human rights documents which are adopted by Ethiopia and other specific laws
on health information management. Moreover, there are the specific health institution’s
policy and procedure which supports the legislative requirements and other rational
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management of information; these must also be well understood in order to adequately apply
them.
Legal responsibility of professional conduct may be civil liability or criminal liability. Under
civil liability of professional misconduct the person may be required to pay compensation to
the person who suffers any damage by the act or omission which is done by the professional.
In the case of HIT professionals, anyone who discloses the personal health information of the
client/patient in violation of any applicable law may be required by courts of law to pay
compensation to a person whose privacy is unjustly disclosed.
In addition, within the legal procedure anyone who discloses personal health information may
be held accountable for criminal sanction. Where the HIT professional violates the privacy
and confidentiality of personal health information in violation of legal requirements he/she
may be required to suffer court process of criminal liability. Depending on the severity of the
breach, the professionals may be required to be fined or imprisonment.
5.7 Medical Record as a Legal Document

These days in many countries, medical record has become an important legal document. This
may imply that you should be aware that good medical records are essential not only for the
present and future care of the patient but also as a legal document to protect the patient and
the health institution. For both purposes, they must be complete, accurate, and available when
needed. Medical records are legal documents. They must be used and stored according to all
governing laws and also to the policies of the health facility.
Legally, medical records are used to support the patient’s claim in case of injury, for the
protection of the attending doctor against claims of malpractice, and for the protection of the
health institution against criticism and claims for injuries and damages. Medical records are
considered the property of the health institution and are compiled and kept primarily for the
benefit of the patient. The personal data contained in the medical record is considered
confidential and the property of the patient. That is, the information contained in a medical
record belongs to the patient and is a confidential communication between the doctor or other
health professional and the patient.
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Although the physical medical record is considered to be the property of the health institution
and the information in the medical record is the property of the patient, information cannot be
released without the consent of the patient. Exceptions to this rule include the use of the
information:
• By doctors and other health professionals for the continuing care of the patient.
• For medical research where the patient is NOT identified, and
• For the collection of health care statistics when the individual patient is NOT
identified.
Situations in which Medical Records are used as Legal document
Medical records are generally used in court for the following:
a. Worker's Compensation
A person injured in the course of his or her duties and while acting in the scope of his or her
employment is entitled to compensation for bodily injury and disability. The medical record
is used as evidence to show the date of injury, the type and severity of injury, and the
patient’s expected recovery.
b. Personal Injury Claims
A person may claim to have been injured through the fault or neglect of another and sues to
recover damages for injuries sustained. The medical record would be used to show how the
injury happened as recorded in the patient’s words on admission to the hospital. The medical
record would also be used to show the extent of the injuries, treatment given, duration of care
and expected recovery or disability. It is the most frequent situations by which Medical
records are used as evidence.
c. Malpractice Claims
In this type of case the Plaintiff (person suing) claims damages from a doctor, a hospital,
nurse or other health professional for negligence in rendering care or giving improper
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treatment. The medical record would be used to show that there was no negligence and that
treatments rendered were adequate and proper.
d. Will Case
A patient may have made a will during his or her health institution stay. After the death of
the patient, an attempt may be made to set aside the will by seeking to prove that the patient
was not mentally incompetent. The medical record would be used to show the mental state of
the patient at the time of making the will.
e. Criminal Cases
Medical records have been used in many criminal cases and the most frequent use
includes:
• Assault cases: to prove the assault and extent of injuries.

• Violent or unexplained death: to prove death resulted from natural causes,
accident, misadventure or murder.
• Sexual assault cases: to prove the condition of a patient on admission or
attendance at a hospital and the history of the assault related by the patient.
• Mental competency: hospital medical records may also be used as evidence in
proving the mental condition of a patient.
f. Insurance Cases
Used by the patient for proof of injury and/or disability in personal accident cases or by the
insurance company to disclaim responsibility.
In order to treat medical records as legal documents, the following points should be
considered in your daily practice of handling them:
• Use blue or black ink unless you are using a computer.
• Do not use pencil or ink that can be erased.
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• Write so that it can be read clearly, sloppy writing causes errors.

• Date all of your notes.
• Write the time that you took your notes.
• Sign your full name and title.
• Do not use white or any other cover up for mistakes.
• Write only the facts. Never add personal comments or feelings.
• Do not use abbreviation unless they are accepted for use by your health institution.
• Do not allow anyone to touch or look at your medical records unless they are a
healthcare worker assigned to take care of the patient.
• Keep all medical records in a safe and secure place.
• Medical records are confidential. Do not disclose or discuss any facts of the patient
or their care with anyone other than the assigned healthcare staff or the patient
themselves.
5.8 Application of Ethics and The law in HIT
The function of ethics and legal requirements which are applicable to the HIT profession are
critical. The laws and ethics governing the provision and maintenance patients’ privacy
protection and confidentiality have a broad application in the HIT profession. The following
is expected of HIT personnel:
• To bring about honor in the course of professional service to the HIT profession;
• To advance HIT knowledge and practice through continuing education, research and
dissemination;
• To state truthfully and accurately your credentials, professional education and
experiences;
• To facilitate interdisciplinary collaboration in situations supporting health information
practice;
• To respect the inherent dignity and worth of every person and refuse to participate in
all unethical practices or procedures.
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Furthermore, in the course of collection and use of patient’s personal information, ethical
requirements demand the utmost security must be maintained during disclosure of personal
health information in order to ensure privacy and confidentiality of personal health
information. To keep personal health record secure patients’ information must not be
disclosed unless it is relevant or necessary for service provision for the patient/client, for
public use, and where there is valid consent and other justifiable grounds in accordance with
the relevant laws and regulation.
In addition to ethical standards, the importance of law in the HIT is enormous. Like the above
mentioned ethical standards, the application of law in HIT is very broad. Legislation may
require the collection, use, security and disclosure of personal health information in a certain
manner and all health professionals are expected to work in line with these legislative
standards where applicable. The principles applicable to the collection, use, security and
disclosure of this information will be useful for standard service delivery to the patient/client
and protection of confidentiality, research purpose and management of the health system,
including planning, resource allocation, policy development, monitoring and evaluation and
reporting. However, in one way or another, all these rules regarding the collection, use,
security and disclosure of this information have to do with the protection of the right to
privacy and confidentiality of personal health information.
Though we do not currently have separate law governing HIT, the Constitution of the Federal
Democratic Republic of Ethiopia (FDRE) and other international human rights documents to
which Ethiopia is a member and party like the Universal Declaration of Human Rights
(UDHR) of 1948 and the International Covenant of Civil and Political Right (ICCPR) of
1966 provides the right to privacy protection. Since the right of privacy may be violated in
relation to collection, safeguarding and security, disclosure, right of access and transfer of
health record and other related subjects, the rules related to these items can be taken as an
explanation on how you should protect patients/clients privacy in the course of your
professional activities.
Therefore it’s very important to see the positive application of both ethics and the law as vital
in particular for the protection of privacy and confidentiality of personal health information
which is one of the basic rights of patients/clients in our case and recognized under
international human rights documents which Ethiopia guarantees to observe and protect.
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Activity 1: Read carefully and answer the following knowledge and attitude assessment
questions after understanding of the given unit competence.
1. Discuss about four fundamental principles of ethics (Define each term) and give examples for
each.
• Autonomy__________________________
• Beneficence_________________________
• Non-Malfeasance_____________________
• Justice______________________________
2. How can justice as a principle be applied in health information Technician?
___________________________________________________________
___________________________________________________________
3. Mention at least two major differences between ethics and law.
___________________________________________________________
___________________________________________________________
4. The application of ethics and law in the HIT is only for the protection of privacy of
personal health information? Yes / No, give reason for your answer.
___________________________________________________________
___________________________________________________________
5. What will happen if professionals ignore applicable ethical standards?
___________________________________________________________
___________________________________________________________
6. Mention the different kinds of ethical and legal measures against persons who violate
applicable rules of a profession?
___________________________________________________________
___________________________________________________________
7. Discuss various administrative (disciplinary) measures an employer can take against HIT
professionals who violate his/her ethical and legal duty.
___________________________________________________________
___________________________________________________________
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8. Explain the importance to use Codes of ethics?

___________________________________________________________
___________________________________________________________
Activity 2:
1. Ato Solomon is working in Harar General Hospital as head of the medical record unit. He
has read medical record documents of patient and learnt that the patient is drug/substance
addicted. While chatting somewhere else with friends, a friend has raised an issue about the
personality of that patient. During expressing his opinion about the person, Ato Solomon
disclosed to his friends about patient’s drug addiction. Which professional obligation(s) is
violated by Ato Solomon?
_________________________________________________________________
2. When you have learned that your best friend has disclosed the patient’s social information
illegally to an unauthorized person. What should you do? What dictates you to decide so? Is
it not unethical to expose your best friend’s sin to others?
_________________________________________________________________
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Topic 6: Patient Privacy and confidentiality of Health

Information
6.1. Introduction
The fact that health information is one of the sensitive information an individual could have;
knowledge or concepts related to privacy, confidentiality and release of patient information is
crucial while dealing with such health information. This topic covers concepts and principles
related to privacy, confidentiality of patient information, release of health information, and
medico legal principles important for your practice.
6.2. Learning Objectives

At the end of this section the learner should be able to:
• Explain concepts of patient confidentiality of information.

• Apply patient’s privacy and confidentiality of patient information.
• Identify patient/client right to access of care.
• State ethical standards related to patient privacy right and confidentiality.
• Describe general Medico-Legal principles in relation to patient Medical records
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6.3. Privacy and Confidentiality

The term privacy, confidentiality and security are frequently used when health information or
medical records are discussed. As health information technician, one should have clear
understanding of these interrelated concepts.
Privacy is the right of every person to be left alone and no one can interfere in the personal
life of the individual. No matter that health record is in the possession of the medical record
keeper physically, the information is still the property of the client. Therefore, it is the client
who has a say in his individual health information.
On the other hand, Confidentiality means the responsibility of a health record keeper to limit
disclosure of individual health information unless authorized by the client or specifically
under law. This concept includes the responsibility of professionals to use, disclose or release
such information only with the knowledge and consent of the client. Security includes
physical or electronic protection of the integrity, availability and confidentiality of personal
health information. In addition, this responsibility extends to make sure that the mediums
used to enter, store and communicate this individual health record are safe and secured.
Accordingly the basic responsibilities in HIT are to provide privacy and confidentiality.
Ensure patient’s privacy, maintain confidentiality of information, and ensure data security
measures are used to prevent unauthorized access to the patient’s information. In addition,
HIT personnel are expected to ensure that release policies and procedures of health
institutions are followed properly, and all violations of privacy or confidentiality of
individual health information are reported to the appropriate authority.
6.4. Release of Individual Health Information

Unlike in the past when only few people wanted access to the information contained in a
patient’s medical chart, there are many more stakeholders who want to access this
information. Some of these are:
• Insurance companies who want to determine the extent of the damage caused to the
person eligible for insurance payment, and
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• Someone in a law suit who wants to challenge the health status of his accuser.
In these circumstance the HIT personnel is the one responsible to ensure that access to the
patient’s health record is appropriate and authorized.
The healthcare facility should develop a policy for the release of patient information. It is
important to ensure that all staff, not only in the Medical Record Unit, but also in all other
sections of the health care facility, are aware of the policy and that it is followed.
There are four methods of releasing information:

• Direct access to the medical record;
• Supply abstract
• Verbal release
• Photocopying
Note: Unauthorized person cannot take any or part of a medical record out of file, or read,
copy, or otherwise tamper with them.
If a request is made for the release of information, the request should contain the following:
• Full name of patient, address and date of birth;

• Name of person/persons or institution requesting information;
• Purpose and need of the information;
• Extent and nature of information to be released, including dates; and
• A recently dated authorization, signed by the patient or authorized representative
E.g. parent or guardian of a child
Patient Consent for Release of Records
Unless the patient has given written consent to release information from his or her medical
record, the information contained in it can only be released to a court by subpoena or a court
order. No information concerning a patient should be released to another person without the
written consent of the patient or the patient's legal guardian. If a patient is under the age of 18
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years or otherwise subject to a guardianship order, any consent for access to information
should be given in writing by the patient's parents or legal guardian. If the patient lacks the
capacity to provide genuine consent then the written consent must be obtained from the
person's legal guardian. In the case of a patient who has died, the written consent to access
information from the patient's medical record should be provided by the next of kin shown on
the medical records.
6.5. Ethical standards related to Patient Privacy Right

In terms of health, there are many reasons why the protection of privacy is important.
Among other things health information privacy is vital for the following major reasons:
• First, information privacy is a fundamental human right (with Constitutional

protection which is the supreme law in Ethiopia). It is a right that is essential to
the dignity and integrity of an individual. It should also be noted that the
information is the patient’s property; it does not belong to anybody else.
• Second, if appropriate health information privacy is not guaranteed, the client-
caregiver relationship will suffer negative impacts. This means clients will not
tell the necessary information or will avoid seeking care. Therefore, the
necessity for protection of individual health information is very important.
This right to privacy is understood as an individual right protected under the Constitution,
international human rights documents like the UDHR and ICCPR and other laws. The UDHR
provides that no one shall be subjected to arbitrary or unlawful interference with his privacy,
family, home or correspondence, or to unlawful attack on his honor and reputation.
The right to privacy is found to be very important in examining the protection of individual
health information. One aspect of the right to privacy is defined as: The right to be free from
unlawful intervention of one’s personality, the publicizing of one’s private affair with which
the public has no legitimate concern; or the wrongful intrusion in to one’s private activities.
Everyone has the right to the protection of the law against such interferences. Therefore, HIT
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personnel are duty bound to protect individual health information from any kind of unlawful
interference.
6.6. General Medico legal principles

The Health Information Technician must be familiar with the legal requirements regarding
medical records as per the national policy to be able to cope with medico-legal problems. The
term Medico-legal is defined as something of or pertaining to the intersection between
medicine and law. The Health Information Technician must also be able to identify legitimate
and illegitimate requests for information. Remember that being used for patient care a
medical record is also a legal document and should be treated accordingly.
Major medio-clegal principles
• No information concerning a patient should be released to another person without the

written consent of the patient or the patient's legal guardian.
• If a patient is under the age of 18 years or otherwise subject to a guardianship order,
any consent for access to information should be given in writing by the patient's
parents or legal guardian.
• In the case of a patient who has died, the written consent to access information from
the patient's medical record should be provided by the next of kin shown on the
medical records or by the administrator of the patient's estate.
• If the patient lacks the capacity to provide genuine consent, then the written consent
must be obtained from the person's legal guardian.
• Medical records should be kept under adequate security and only removed from the
hospital or health care center upon receipt of a subpoena, statutory authority, search
warrant, or court order.
• When an original medical record leaves the hospital for legal purposes, a photocopy
of the medical record is made beforehand and kept in the hospital until the original is
returned. The copy is subsequently destroyed.
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The health care facility is NOT legally bound, however, to release information if it affects the
health care facility or the attending health care workers. The information requested is
identified and the attending health care worker asked to write a report. In many health care
facilities a pre-designed form may be used if a discharge summary is already in the medical
record, it is checked and if it includes all the requested information, a copy is made. This will
save the doctor having to write a new report. If the original medical record is needed, the
lawyer must produce a court order or subpoena to enable the release of the medical record.
Example of format for a summary of medical record information for medico-legal case:
Date:______________
To: (name of lawyer or law firm requesting information)____________________________
Dear ___________________
The following is a summary of the medical record of (patient’s name) __________________

Age: _____ living at (address)______________________________________________
________________________________________________________________________
who was admitted to this hospital on (date of admission)_____________________________
and who was discharged (or died) on (date of discharge or death) ___________________
History: _____________________________________________________________
Physical Examination: ______________________________________________
Laboratory Reports: ___________________________________________________
X-Ray Reports: _________________________________________________________
Operation/Procedure: __________________________Findings: ____________
_________________________Pathological Report: ____________________________
______________________________________________________________________
Final Diagnosis: ____________________________________________________
Result On Discharge: ______________________________________________
Signed: ___________________________(Attending doctor)
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Activity: 1
Write the definition of privacy and confidentiality of patient information with your own
words.
Activity: 2
Discuss Ethical standards related to patient/client privacy right and confidentiality of

patient/clients information.
Activity: 3
Sister Askale is a Nurse who works as head of Medical wards in a nearby Hospital. She
wanted the Health Information Technician to tell the diagnosis of Ato Feyissa Hailu who is
the cousin of her husband and treated a month before in the medical outpatient department of
the hospital.
How do you respond to her request?
___________________________________________________________________
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Activity: 4
a. Who do you think is the owner of the medical record and the information within the
medical record?
_________________________________________________________________
__________________________________________________________________
b. It is always prohibited to disclose personal health information without the consent of your
client. True or False? Explain the reasons for your answer.
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Topic 7: Security and Access to Health Information
7.1. Introduction
The patient personal data contained in the medical record is considered confidential
communication and the property of the patient. This information has to be well protected
from unauthorized access. This to happen and ensure the security of patient records while
also complying with requests for release of patient data for medico-legal cases, there must be
security measures in place whether the medical record system is paper-based or electronic
one. This topic contains information on common security measures such as policies and
procedures to Health Information Access (including patient’s access to their health
information) and record keeping or documenting information during refusal of treatment by
patient.
7.2. Learning Objectives
• Identify issues related to the use and disclosure of individual health information
• Identify common information security measures
• Identify the legislative requirements for the collection and security of individual
health information
• Define the right of access to individual health information
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7.3. Security Measures to Patient/Client Medical Record
Medical records may be maintained as paper-based or computer records. Regardless of the

systems, health facility and individual staffs must take reasonable steps to protect the
personal information contained in the medical records from loss, unauthorized access,
modification or disclosure. Staffs, particularly the medical record unit staffs need to protect
medical records against such unauthorized access where those medical records are stored or
transmitted. A breach of the security measures in place should result in disciplinary action
with a range of penalties including dismissals.
Handling Confidential Information
Confidential health information must be stored, transported, transmitted, handled, used, and
disposed of in ways that protect the information from unauthorized access, alteration,
destruction, disclosure, copying, theft, or physical damage. However, such ways of handling
medical records shouldn’t be obstacle to use the medical record for provision of care when
needed. You must have security measures in place to protect work areas and patient-
identifiable information. Some of the security measures for paper-based or electronic medical
records are:
• System access management

• Personnel clearance procedures
• Password protection of computer applications
• Secure disposal of confidential waste
• Sanctions for misuse of systems and data
• Signed confidentiality agreements
• Data backup and disaster recovery procedures
• Assigned responsibility for confidentiality and security of information
• Confidentiality and security awareness training
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Some good practices to meet security requirements are:
• Policies, Physical and administrative safeguards: The medical record unit,

computers and portable devices that contain patient health information should be
physically protected from unauthorized access by means of a security measure such as
having alarm systems or locking with key. Written policies and administrative
measures like designating security officers, training the work force, controlling
information access and periodic security reassessment through staff training and
monthly review of user activities can minimize unauthorized access to patient
information in the health facility.
• Prevent Unauthorized or Inappropriate Access: Issue unique user names and
passwords to everyone who will use the EHR (if accessed this way) to prevent
unauthorized or inappropriate access to patient information and system controls.
• Use Encryption Technology: Whether an EHR is locally installed or accessed over
the Internet, encryption technology can protect patient health information from being
read by unauthorized parties when it is transmitted, or stored on any device, including
mobile devices. Encrypting personal health information puts information in a coded
form that can only be read by an authorized user who has a “key.”
• Backup: To keep information available when and where it is needed, plan for backing
up your EHR system.
Policies and Procedures to Health Information Access and Disclosure
Medical record policy will endeavor to protect the confidentiality and security of its patient
health information against inappropriate access, inappropriate use, tampering,
loss/destruction and inappropriate disclosure through the use of reasonable safeguards. The
purpose of this policy is to set forth the general principles and procedures for maintaining the
confidentiality and security of patient health information.
The medical record service shall be properly equipped to enable its personnel to function in
an effective manner and to maintain medical records so that they are readily accessible and
secure from un-authorized use. The organization policy should address the following areas.
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• The medical record unit shall have written policies and procedures that are reviewed
at least once every three years, revised more frequently as needed, and implemented.
They shall include at least:
1. Procedures for record completion, including chart analysis.

2. Conditions, procedures, and fees for releasing medical information.
3. Procedures for the protection of medical record information against the loss,
alteration, destruction, or unauthorized use.
• All entries in the patient's medical record shall be written legibly in ink, dated, and
signed by the recording person. If computer generated orders with a physician's
electronic signature are used (in case of EMR), the Health care facility shall develop a
procedure to assure the confidentiality of each electronic signature and to prohibit the
improper or unauthorized use of any computer generated signature.
Access and disclosure are usually associated with the concept of ownership and control of
health information or the health record. Access of health information means using the
personal health data internally within a health institution like a hospital or health center,
however, disclosure relates with the manner how health information should be disseminated
externally. In principle, medical records, x-rays, laboratory reports or other physical
documents relating to the delivery of health care service are owned by the specific health
institution. However, this doesn’t mean that the client have no right over the health record.
Rather, the information within the record is the property of the client. It’s out of this concept
that the client is granted the right to take a copy or view or otherwise access his/her health
information or amends the information when it’s found to be proper.
In order to give access to personal health information, it should be understood that all the
rules and regulations applicable to access and disclosure of health information must be
applied. It is part of the obligation of health information technicians to keep clients’ health
information confidential, whether the information is transmitted verbally, on paper, or
electronically. Therefore, you have to obey applicable laws and policies of the health
institutions to which you are working for as HIT.
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All health information is to be kept confidential unless the client authorizes the use and
disclosure of personal information or it is specifically allowed by law. If the client is
considered unable to give authorization, such as in the case of minors, a legal guardian should
give the consent for release of information. When all requirements are fulfilled disclosure of
health information will be limited to the minimum necessary to achieve the purpose of the
disclosure.
Use and disclosure of personal health information other than for the primary purposes can be
possible in two cases. Firstly, personal health information can be disclosed or used when
consent is acquired or collected from the client/patient. The second case or condition where
personal health information disclosed is for his/her legal representative. In the former case,
you may disclose or use individual health record by the consent of the client or to a person
represented by the individual. In the latter case, there must be clear authorization from the
law that you can use or disclose personal health information without the consent of the client.
In addition, use and disclosure may be subject to notice and approval by the client, to a health
professional regulatory body for the purpose of conducting investigations, discipline
proceedings, practice reviews or inspections relating to the members of a health profession or
health discipline. For example a health professional council or other regulatory body may see
the record that is prepared by a doctor to examine its correctness or there may be mal practice
or ethics complaint against this doctor. In this case the professional regulatory body may wish
to examine the record documented by the doctor.
Since the information on the record belongs to the client, in the case of disclosure the
individual has a right to know to whom his/her information is given and for what purpose.
The information recorded shall be retained by the custodian for a period of 10 years
following the date of the disclosure.
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7.4. Patient access to their health information
Clients have right of access to their own health information for different purposes. They may
need to inspect copy or amend the information on the medical record when they believe they
have wrongly provided inaccurate information.
Under the draft regulation of HMIS, clients have the right to access their own health
information. The client may access their records at any time they want in accordance with the
policy of a specific health institution. This right may be exercised through a receipt of a copy
or by viewing the health information in the medical record.
In this case, the client is required to submit their requests in writing. If there is a form
prepared for this purpose, ensure that the person is really the one who is the subject of the
information. Because of the privacy and confidentiality implication of giving access, it should
be done very carefully. This can be ensured by requiring the client to present an identification
card and checking the information that belongs to the client.
In the case of representation (where the client authorize another person to be given access to
health information), if the client has signed a written authority for access to be granted to a
person named in the instrument of agency, the person so named shall be given access to the
health information requested.
On the other hand a client who believes there is an error or omission in his individual health
record may in writing or orally request, depending on the case, the custodian or health
professional to correct or amend the record. Where the error concerns the client’s
demographic data the health information technician may be of help. On the other hand, if the
appropriate custodian or health professional agrees or refuse to make the correction or
amendment in accordance with the relevant guideline, he shall make the correction or
amendment or refuse the same and give notice to the client that the correction or amendment
has been made or refused.
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7.5. Record Keeping during Refusal of treatment by Patients
Patients have the right to refuse treatment and need to be made aware that they may refuse all
or part of any care and treatment proposed and may withdraw previously given consent at any
time.
• Refusal may be written, verbal or by any form of communication possible.

• It is also revocable at any time.
• If there is any concern about the capacity of the patient to give valid consent, it
should be discussed preoperatively with senior staff. Any remaining concerns
should then be discussed with the Director of Medical Services or equivalent.
Before complying with a direction to refuse or withdraw treatment, the health professional is
required to take all steps to ensure that the patient has been provided with all relevant
information; the patient has understood the information; and s/he has made an informed
decision.
Relevant information includes:

• The nature of the illness
• Any alternative forms of treatment that may be available
• The consequences of those forms of treatment
• The consequences of remaining untreated
Medical records that clearly reflect the decision-making process can be pivotal in the success
or failure of legal claims. In addition to the discussion with the patient, the medical record
should describe any involvement of family or other third parties. If imminently or potentially
serious consequences are likely to happen because of patient refusal, health care providers
should make the refusal signed, witnessed and documented.
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Activity: 1
Write down the common security measures
Activity: 2
Elaborate the following concepts.
a. Information Access
b. Unauthorized Access
_________________________________________________________________
____________________________________________________________
c. Information Disclosure
d. Information security
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Activity: 3
As part of the security measures, a health organization should develop and use policies
and procedures related to health information handling of patients. What are the key
points that the developed policies and procedures should address? Write the points
using your own words.
Activity: 4
W/o Askale Taye is 50 years old patient, from Shashemane town, Admitted to Hawassa
Referral hospital for severe injury she sustained on her left leg. The surgeon decided to
perform amputation of the leg below the knee as the lower part of the left leg become
gangrenous (dead tissue). However, she refused the surgery and requested for discharge
from the hospital. As HIT of the hospital, what information elements (that has to be
recorded by the health care provider on here treatment refusal) should be checked for
completeness before her discharge is completed?
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Topic 8: Hospital Admission and Discharge
8.1 Introduction
A health facility that provides inpatient service receive patient from the nearby lower level
health facility such as health center or other private health facility with a referral note. A
patient should be seen at emergency department or other service units of the health facility
before she or he get admitted. Topics related to patient reception and preparation for
admission; identification and application of patient medical record location in a ward;
monitoring and updating patient information; performing basic inpatient statistics including
calculating length of patient stay and bed occupancy rate; patient discharging procedure and
completeness of information will be discussed with adequate detail. In Addition, medical
recording tools pertaining to admission/discharge procedures are also described.
Upon completion of this topic, you should be able to:
• Identify the content of admission\discharge recording tools

• Demonstrate patient admission and discharging procedure
• Describe patient information’s that should be recorded while admitting a
patient
• Monitor and update admitted patient medical record
• Identify basic hospital statistics for inpatient services
• Identify the content of discharge summaries
• Explain patient discharge and clearance procedures
• Verify patient’s medical records for completeness before filing
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8.3 Hospital Admission
Before we discuss the admission and discharge procedures, let us try to define terms related to
admission and discharge process in a hospital.
Outpatient (or out-patient): is a patient who is not hospitalized for 24 hours or more but
who visits a hospital, clinic, or associated facility for diagnosis or treatment. Treatment
provided in this fashion is called ambulatory care.
Inpatient (or in-patient): is a patient "admitted" to the hospital and stays overnight or for an
indeterminate time, usually several days or weeks. Treatment provided in this fashion is
called inpatient care. Inpatients usually occupy a bed in a health care facility for at least four
hours or overnight. The time needed before a person is declared an inpatient varies from
country to country. In this regard, there is no written document in Ethiopia that specifies the
time that should be spent in hospital before it is declared as inpatient. . The admission to a
hospital involves the writing an admission note and it documents the patient's status, reasons
why the patient is admitted for inpatient care, and the initial instructions for that patient's
care. Patient’s leaving of the hospital is commonly termed as patient discharge, and involves
a corresponding discharge note or summary.
Where a patient is admitted on the expectation that he or she will remain overnight, but the
patient dies or is discharged before the midnight census, the patient should still be regarded as
inpatient, whether or not a hospital bed is occupied or treatment is provided. Such admission
is commonly known as ‘admission for 24 hours observation’ in Ethiopia.
Admission: Is a formal process whereby a person is accepted by a hospital for the purpose of
hospital treatment as an inpatient.
Bed management: is the allocation and provision of beds, especially in a hospital where beds
in specialist department (wards) are a scarce resource. The "bed" in this context represents
not simply a place for the patient to sleep, but the services that go with being cared for by the
medical facility: Admission processing, physician time/visit, nursing care, necessary
diagnostic work, appropriate treatment, and so forth.
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Admission procedure
The admission of a patient to hospital is ordered by a doctor and carried out by an admission
clerk. At the time of admission, a patient already has a medical record number and medical
record. Thus, a new number is not issued. The hospital, however, needs to keep a daily list of
all admissions. All patients admitted, whether admitted for the first time or not and other
admission related information on the appropriate recording tool.
8.4 Admission /Discharge recording tools
With the reformed HMIS, there are three basic recording tools for inpatient services: The
Admission/discharge card, Register and Tally. However, there are many clinical forms by
which healthcare providers document the entire patient’s information captured during the
inpatient stay of the individual. Our focus in this module will be introducing those card,
register and tally sheets mentioned earlier. Other inpatient forms, on which most of the
clinical events related to a patient are documented, will be summarized in the subsequent
subtopic.
Admission/discharge Card
Admission / Discharge card is very useful recording tool of the patient’s information related
to personal identification, ward admitted, admission diagnosis, discharge diagnosis, condition
at discharge, admission and discharge dates and other financial information related to the
inpatient services offered.
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Figure 8.1 part of hospital Admission/discharge card
Admission/Discharge Register
The purpose of completing this register for each inpatient service is to gather information that
enables the facility to identify top causes of morbidity and mortality of inpatient department.
In addition, the data contained by the register helps to identify specific diseases or clinical
conditions of priority that are targeted for eradication or control. The register is case register
(not longitudinal register) where each row is used to record information of one patient
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admission and the same row will be completed at the time of discharge of that patient. It is
located at all the wards (rooms where admitted patients receive inpatient services).
The data to be filled in the admission/discharge registered is available in the medical records
of each inpatient cases and it will be collected and entered at the time of admission and
discharge each case.
Content of Admission/ Discharge Register
The admission/discharge register has five basic groups of columns. These groups of related
columns are for identification, admission, provider initiated HIV testing and counseling
(PIHTC), discharge and finance information.
Identification includes: Medical Record Number (MRN), Age, and Sex, woreda / sub-city.
Admission includes: Date of Admission, Admission diseases classification (HMIS diagnosis)
PIHTC includes: HIV test offered, HIV test performed and HIV test result
Discharge includes: date of discharge, length of stay, condition at discharge and discharge
diagnosis (Based on HMIS disease classification)
Finance includes: Cost of service, Amount paid, and Voucher Number.
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Figure 8.2 Admission/discharge register
IPD Tally sheet:
This tally sheet is important to summarize the inpatient services and diseases disaggregated
by age group, sex and New/repeat status. It is filled by the care provider at the end of each
day. Counts should be summed and state at the bottom the tally sheet at the end of each
month.
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8.5 Information Recorded while Admitting a patient
Most of the documents in the health record are clinical services and some of these clinical
forms are discussed in the previous learner module 2 (Managing Medical Records). However,
here we will try to describe and summarize the most important one as follows.
I. History and physical examination recording form/patient form
Function: To record patient history and physical examination findings.
Location: Inside the Medical record folder
Work process: When a patient is admitted as an in-patient a full history and physical
examination should be conducted by the attending physician.
II. Progress note
Function: To record clinical findings and progress of the patient during the hospital stay.
Location: Medical record folder
Work process: When patient is seen by a clinician, the information obtained will be recorded
with date, clinical details, and signature of the attending clinician.
III. Nursing Process Forms

• Nursing admission assessment form
• Nursing problem statement list
• Nursing care plan
• Nursing patient progress report
Function: To describe the nursing assessment, care plan and outcome of nursing care of an
admitted patient.
Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as part of the permanent record.
IV. Medication Administration Record
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Function: To record all medications ordered and administered to a patient.
patient’s MR as part of the permanent record.
V. Fluid Balance Chart
Function: To record all fluid inputs and outputs for patients at risk of fluid overload or
dehydration.
patient’s Medical record folder as part of the permanent record.
VI. Consent forms
Function: The consent form outlines the risks associated with a particular procedure. A
signed consent form indicates that the patient (or designated proxy) has been informed of the
risks and has authorized the procedure.
Location: Medical record folder
VII. Referral and Feedback Form (if relevant)
Function: To document patient history at the hospital and to provide reason for referral
Location: One copy in the Medical record folder and one copy to patient.
8.6 Monitoring and Updating Patient Information during patients

hospital stay
This part of managing medical record is entirely done during the inpatient stay of the patient.
Main responsibility lay on the care providers involved in the treatment process of the patient.
As described earlier, most of the clinical documents that constitute the medical records of
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inpatient cases are the clinical forms. The HIT has to check for the accuracy, completeness
and on-time recording of these clinical forms on regular bases. The methods and the tools
used to monitor and update these forms are similar to those medical records produced during
the outpatient services as it is covered in the learner module of ‘Managing medical records’.
8.7 Basic hospital statistics for inpatient services
Even though healthcare statistics is well covered in other learner module, it is important to
highlight the most important hospitals statistics required to monitor its performance. Each
relevant statistics are described by its name, definition and formula.
1. Inpatient Death/mortality rate
Definition: A patient who expires/died while he/she is inpatient of a hospital. The term
‘mortality’ is referred as death. It is a ratio of all inpatient deaths for a given period to the
total number of discharges and deaths in the same period.
Formula:
Inpatient death rate: Total number of deaths of inpatient in a given period x 100
Total number of discharges and deaths in the same period
N.B Inpatient death rate should be calculated based on discharge data not admission data.
This is because a patient who is hospitalized has a chance of being discharged as died.
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2. Average length of stay
Definition: a length of stay for one patient is the number of calendar days from admission to
discharge. The average length of stay is the average of the sum of length of stay of any group
of inpatients discharged during a specified period of time.
Formula:
Ave. Length of stay= Total inpatient service days of discharged (including deaths)
Patients for a given period
Total number of discharges and deaths in the same period
Example: In June, a hospital has discharged 2,086 patients (including deaths, but excluding
newborns).
Their combined inpatient service days were 13 654 days. Using the above formula, the
average length of stay of these patients was:
= 13654
2086
= 6.54 or 6.5 days
That is, the average stay as inpatient during June was 6.5 days.
3. Bed occupancy rate
Definition: the percentage of inpatient beds occupied over a given period. To calculate the
bed occupancy rate for certain period, you need to know the number of patient days (also
known as inpatient service day) which is a unit of measure of denoting the services received
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by one inpatient during one 24 hour period. A total patient day is the sum of all inpatient
service days for each of the days during a given period.
Formula:
Bed occupancy rate= Total number of patient days for a given period X 100
Available beds X the number of days in the period
Example: Black lion hospital has 500 available beds and provided 13,250 patient days in
Hidar (November). Hidar has 30 days. The bed occupancy rate of the black lion hospital was:
13,250 x 100 Æ 88.3%

500x30
4. Case fatality rate
Definition: The case fatality rate is defined as the number of deaths assigned to a given cause
(disease) in a certain period, divided by the number of cases of the disease reported during
the same period.
Formula:
Case fatality rate of disease x = Number of deaths for a given disease y x100
Number of cases of the same disease reported y
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The number of days of care rendered to an inpatient is from admission to discharge.
The duration of an inpatient's hospitalization is considered to be one day if he is admitted and

discharged on the same day and also if he is admitted on one day and discharged the next
day. The day of admission should be counted but not the day of discharge.
8.8 Discharge and clearance procedures
The hospital discharge process is initiated on the recommendation of a physician. The process
may vary from hospital to hospital as hospitals have their own policies regarding discharge.
Patients should make sure they understand any follow-up instructions before leaving the
hospital and, if not, they should ask for clarification. Possible questions they might need
clarification on include:
• Does the patient need a follow-up visit? Who should he/she see? Should the
patient call to make the appointment or is it already arranged?
• What medications have been prescribed? Are there any side effects? If there
are, should the patient stop taking the medication?
Medical record staff responsible for this procedure should be trained to ensure that the
medical records are completed promptly and correctly.
Completing Discharge Summaries
A discharge summary is a summary of the patient’s stay in hospital written by the attending
doctor. The minimum detail provided in a discharge summary is:
• Patient identification
• Reason for admission
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• Examinations and findings

• Treatments while in hospital and
• Proposed follow up/ Death summary
Upon the discharge a patient, the following information should be recorded on

admission/discharge register entry that corresponds to the particular patient admission related
information.
• Date of discharge of the patient

• Length of stay (the difference of data of discharge and date of admission)
• Condition at discharge: the possible value can be improved or referred or dead left
against medical advice or absconded (runaway from the hospital suddenly).
• HMIS Diagnosis: Based on the HMIS disease classification.
• Cost of the service: exact cost in terms of Birr.
• Amount Paid: the amount of money paid for the service during stays and discharge
(see figure 8.4).
• Voucher number: from the payment receipt.
Organizing Documentation of Discharged Patients
While in hospital, the patient’s medical record develops with the recording of clinical
information by doctors and other health professionals. Results of pathology tests etc. are
added as they are received. Nurses record daily progress notes and special observations. If a
patient has any special tests and/or surgical procedures, relevant information is included. On
discharge/death of the patient the medical record, including all forms relating to the
admission plus any previous records, should be sent to the Medical record unit as soon as
possible or within 24 hours.
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Figure 8.4 Admission/discharge service payment form.
Medical record staff responsible for the discharge procedure should be trained to ensure that
the medical records are completed promptly and correctly.
The discharge procedure begins with the receipt of the medical records of discharged
patients/deceased.
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• The medical records of discharged client/deceases should be sent to the Medical

Record Department by the ward staff on the same day of discharge/death or the
next morning. In some countries, a staff member from the Medical record unit
collects the medical records of discharged/deceased from the wards at a specific
time every day.
• The Medical record unit staffs are responsible for the daily bed census, which they
receive from each ward at the beginning of the day.
• From the bed census forms staff are able to record details of discharges and deaths
and prepare a daily discharge list. This list is extremely important and should be
duplicated and sent to a number of sections in the health care facility.
8.9 Verifying Medical Records for Completeness for discharged

patient
The Medical record unit staffs are responsible for managing the medical records of
discharged patients and should check to see if they have all the medical records of discharged
patients from the previous day. If any are missing they should contact the ward to find them.
Once a patient has been discharged, the medical record should be returned promptly to the
Medical Record Unit. Failure to do so may result in a missing medical record. Once the
patient is no longer in the ward, their medical record can easily be misplaced.
Medical record completion procedure begins with the receipt of the medical records of
completed services, discharges and deaths. Those medical records should be sent to the
medical record department by the health care staff by the end of the day and before that all
the processes should be completed from each unit. In some cases, a staff member from the
medical record unit collects the medical records from the health care facility wards every day.
It is a good practice to list and send the summary of discharged and dead patient to the
medical record unit.
149
• The clerk in the medical record unit checks each medical record to ensure that all
the forms are in the record. For example, if the patient has had an operation an
operation report should be in the record. In addition all progress notes, pathology
and x-ray forms, nursing notes etc. should be included. There should also be a
final discharge note made by the attending doctor including to where the patient
has been discharged and arrangements for follow-up.
• The clerk then sorts the forms into the correct order (if they are not already sorted).
In the case of new patient the forms are attached to a medical record folder with a
clip or fastener. If the patient has been in health care facility before the old records
are retrieved and the latest admission forms are added by placing them behind the
appropriate divider or in a chronological order.
• The clerk also needs to check if the doctor has completed the lower part of the front
sheet. That is, the HMIS diagnosis has been recorded along with any other
condition treatment while in the facility.
• The signature of the health care provider is important as it shows that the doctor has
completed the medical record and takes responsibility for the content.
Returning Patient Document to MRU
The Medical Record of discharged patients or the deceased should be returned to the Medical
Record unit within 24 hours of discharge. The Medical Record unit should review the
Medical Record to see if all forms have been properly signed, particularly the discharge
summary. If they are not signed, the Medical Record Department should alert the physician
on record or case team leader to complete and sign the discharge summary.
150
Self Check Assessment

Activity: 1
Describe the following concepts and hospital statistics
a. Admission
b. Inpatient
c. Wards
d. Discharge Summary
e. Average length of stay
f. Bed occupancy rate
151
Activity: 2
In May, 2012, the total number of discharged client at Zewditu referral Hospital have added
up to 2,086 patients (including deaths, but excluding newborns).Their combined inpatient
service days were 13, 654 days. What is the average length of stay of these patients?
_________________________________________________________________
___________________________________________________________________
Activity: 3
Write down relevant information included in patient discharge summary.
_____________________________________________________________________
Activity: 4
Who decide to discharge patient from a hospital?
_____________________________________________________________
_____________________________________________________________
152
Activity: 5
W/o Selamawit is a 45 years old female who sustained injury to her left shoulder and
admitted at Dessie referral Hospital. Her physician performed physical examination and
requested for x-ray of the shoulder joint area. Her physical assessment and radiological
examination reveals a fracture and dislocation of the shoulder joint. After six weeks of
inpatient treatment, her condition was improved and was discharged from the hospital, then
after; a discharge summary was prepared and signed. Finally, the health information
technician checked her medical record while returning to the medical record unit for filing.
Unfortunately her radiology report sheet and physical examination sheet were missed from
the chart.
a. How do you handle the missing document? Explain the steps involved with your own
words.
_____________________________________________________________
b. Who will be responsible for the missed document? How do you correct this
documentation problem?
153
154

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Applying Health Information System

Principles for Service Delivery and

Outcome-Based Learning Module for HIT level IV

Topic 1: Healthcare Delivery System ........................................................................................... 13

1.1 Introduction ........................................................................................................................... 13

1.2 Learning Objectives .............................................................................................................. 13

1.3 Basics of health care delivery system ................................................................................... 14

1.5 Major Components of Ethiopian Health System .................................................................. 21

1.6 Organization of the Ethiopian Healthcare Delivery System ................................................. 22

1.7 Health Services and facilities ................................................................................................ 31

1.8 Health Information Flow ....................................................................................................... 33

Self- check Assessment..................................................................................................................... 35

Topic 2: Ethiopian Health Service Program and Regulations ................................................... 37

2.1 Introduction ........................................................................................................................... 37

2.2 Learning objectives ............................................................................................................... 37

2.3 Ethiopian health policy ......................................................................................................... 38

2.4 Health Service Development Program .................................................................................. 45

2.5 Major Health Related Legislations in Ethiopia ..................................................................... 56

2.6 Healthcare Regulation System .............................................................................................. 58

2.7 Regulating Ethiopian Healthcare Facilities operational procedures ..................................... 61

Self-check Assessment...................................................................................................................... 69

Topic 3: Health Service Planning ................................................................................................. 71

3.1 Introduction ........................................................................................................................... 71

3.2 Learning objectives ............................................................................................................... 71

3.3 Basics of Health Service Planning ........................................................................................ 72

3.4 Planning steps ....................................................................................................................... 74

3.5 Planning Approaches ............................................................................................................ 79

3.6 Features of planning .............................................................................................................. 80

Self-check Assessment...................................................................................................................... 82

Topic 4: Fundamentals of Monitoring and Evaluation System ................................................. 83

4.1 Introduction ........................................................................................................................... 83

4.2 Learning Objectives .............................................................................................................. 83

4.3 Monitoring and Evaluation Concepts.................................................................................... 84

4.4 Commonly used terms in Monitoring &Evaluation .............................................................. 86

4.5 Monitoring and Evaluation plan ........................................................................................... 88

4.6 Monitoring and Evaluation Framework ................................................................................ 90

4.7 Monitoring and evaluation tools ........................................................................................... 90

4.8 Monitoring and Evaluation Activities ................................................................................... 92

Self -check Assessment..................................................................................................................... 97

Topic 5: Ethics and Laws in Medical Record Handling ............................................................. 99

5.1 Introduction ........................................................................................................................... 99

5.2 Learning objectives ............................................................................................................... 99

5.3 Ethics and Health Related Laws ......................................................................................... 100

5.5 Professional Obligations ..................................................................................................... 103

5.6 Law and Health Related Laws ............................................................................................ 107

5.7 Medical Record as a Legal Document ................................................................................ 111

5.8 Application of Ethics and The law in HIT .......................................................................... 114

Self-check Assessment.................................................................................................................... 116

Topic 6: Patient Privacy and confidentiality of Health Information....................................... 118

6.1. Introduction ......................................................................................................................... 118

6.2. Learning Objectives ............................................................................................................ 118

6.3. Privacy and Confidentiality ................................................................................................ 119

6.4. Release of Individual Health Information ........................................................................... 119

6.5. Ethical standards related to Patient Privacy Right .............................................................. 121

6.6. General Medico legal principles ......................................................................................... 122

Self-check Assessment.................................................................................................................... 124

Topic 7: Security and Access to Health Information ................................................................ 126

7.1. Introduction ......................................................................................................................... 126

7.2. Learning Objectives ............................................................................................................ 126

7.3. Security Measures to Patient/Client Medical Record ......................................................... 127

7.4. Patient access to their health information ........................................................................... 131

7.5. Record Keeping during Refusal of treatment by Patients ................................................... 132

Self-check Assessment.................................................................................................................... 133