Health Policy and Management Handout 3143

Health Policy and Management (SPHM-3143) hand out for Emergency & critical care nursing
students
By FELEKE TAFESSE(MPH/HSM)
2009E.C
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CHAPTER 1 ............................................................................................................................................. 1
Development and organization of the health system ...................................................... 1
1.1 Global typologies for health systems ........................................................................... 1
1.2 Development and organization of the health system in Ethiopia
(Public/private) ................................................................................................................................. 4
1.3 Approaches in organization and delivery during various periods ................. 6
1.4 Policies, strategies and programs during various periods ............................. 13
Chapter 2 ............................................................................................................................................... 17
Health planning .................................................................................................................................. 17
2.1 WHAT IS PLANNING ............................................................................................................. 17
2.2 TYPES OF PLANNING .......................................................................................................... 19
2.3 STEPS IN PLANNING................................................................................................................... 20
2.4.A Organizing ............................................................................................................................. 23

2.4.1 Organizing concepts ........................................................................................................ 23
2.4.2 Organizational Structure ............................................................................................... 23
2.4.3 Coordination......................................................................................................................... 24
2.4.4 Organizational culture .................................................................................................... 25

2.4.5 DELEGATION ....................................................................................................................... 25
2.4.B Monitoring and evaluation ........................................................................................... 26
2.5 HRH, time and material resources............................................................................... 28

2.6 Concepts and applications of leadership in the health sector ..................... 33
Chapter 3 ............................................................................................................................................... 36
3.1 The concept of coverage and patterns of health care utilization
(including organization and use of the referral system) .......................................... 36
3.2 Quality of health care ......................................................................................................... 43
Chapter 4 ............................................................................................................................................... 46
4.1 Application of economics to the health sector..................................................... 46
4.2 Demand and supply in the health sector .................................................................. 46
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4.3 Issues of equity in the health sector .......................................................................... 48

4.4 Methods of economic evaluation and costing of health care programs . 49
4.5 Principles and types of healthcare financing ........................................................ 51
4.6 Healthcare financing in Ethiopia .................................................................................. 52
Chapter 5 ............................................................................................................................................... 54
5.1 Principles and components of HIS/HMIS .................................................................. 54
5.2 Ethical and legal issues in HMIS .................................................................................. 55
5.3 Application of IT in the analysis and management of health systems .... 56
5.4 Ethiopian HMIS ....................................................................................................................... 57
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CHAPTER 1
Development and organization of the health system

1.1 Global typologies for health systems
1.1.1 EXISTING AND EMERGING HEALTH ISSUES AND TRENDS
Introduction to existing and emerging health issues and trends

Existing vs. Emerging Issues
Emerging issues we will say are trending since after or around the last ten years
Existing issues have been around since before
Emerging Issues in Existing Issues
Some existing issues have new emerging components like water contamination and new toxic
dumping practices
Nations in the world collaborate and work with others towards a common health concern in a
number of ways: as international, continental, regional or national level.
In general, the issues of concern for the globe are:
 Primary health care
 Health for all
 Reproductive health
 Neglected-tropical diseases
 Poverty (fight against diseases related to poverty)
 Good governance
 Health sector reform, etc.
Currently important global health issues
Major existing pandemics include: Emerging macro health issues
 HIV/AIDS  Climate change, environmental degradation and
 Malaria deforestation
 Tuberculosis  Changing industrial and agricultural practices
 Malnutrition  Water development projects (i.e.; dams)
 Influenza  Inappropriate or excessive use of antibiotics
 Non-communicable (degenerative & chronic  Substance abuse
diseases)  Increasing World population
 Avian influenza (or other influenza)  Changing life style
 Acute respiratory syndrome  Human Trafficking
Extrinsic factors complicating health issues Intrinsic factors
 Politics  Different societal needs of different health care
 Inadequate/inappropriate policies/policy services
making  Culture, societal morals and philosophies
 Competition (Market)  Medical technology
 Government  Universal (or socialized) health care
 Science  Private Health Care
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 Economy
 Abrupt changes of policies of international
cooperation
 Globalization
 Urbanization
1.1.2 Current health issues
As Africa’s second most populous country, Ethiopia has a large, predominantly rural, and
impoverished population with poor access to safe water, housing, sanitation, food and health
services. These factors result in a high incidence of communicable diseases including TB,
malaria, respiratory infections, diarrheal diseases and nutritional deficiencies.
Despite major strides to improve the health of the population in the last one and half decades,
Ethiopia’s population still face high rate of morbidity and mortality resulting to a relatively poor
health status. To just mention few:
 Malnutrition
 High population growth rate
 One of the highest rates of maternal and neonatal mortality
 Communicable diseases such as HIV, malaria and TB burden
 Health workforce shortage
 Increasing number of people affected by Non Communicable Diseases/NCD/
 Neglected Tropical Diseases
 Inadequate immunization coverage
 Low institutional delivery
1.1.3 Implication of global and local health issues/trends on the health care system
Implications of emerging health problems on health systems
Contrary to prevailing beliefs, 80 per cent of non-communicable disease deaths today are in low-
and middle-income countries. Systems for managing the continuum of care – be it for HIV/AIDS
or hypertension–pose different demands from those needed for acute intermittent care. New
delivery strategies may create new demands on the health system. For example, the shift from
traditional birth attendants to skilled birth attendants has implications for staffing, for referral
systems, and in terms of upgrading facilities to deliver emergency obstetric care.
Opportunities
 New delivery strategies create new demands on the health system
-communicable diseases
 Internationally coordinated disease control system

 Demands the need for proactive and strategic leadership at all levels
 Linkage of Community and health care organizations strengthen
 Decentralization and Devolution
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Challenging situations
Doing more with less financial inputs
Shifting burden of disease
Decentralization and Devolution
In adequacies on the key Leadership, Management, & Governance skills
1.1.3 Health System Strengthening

Health system strengthening can be defined as any array of initiatives and strategies that
improves one or more of the functions of the health system and that leads to better health through
improvements in access, coverage, quality, or efficiency. Health system strengthening sits in the
broader process of health sector reform and involving the six key components described below.
In well-developed management system, routine transactions are systematic, replicable,
consistent, and complete. Effective management systems are continuously maintained, updated,
and improved to serve changing organizational needs and resources.
Health care managers and providers in facilities, ministries, and non-governmental and civil
society organizations have to operate and sustain management systems and service delivery
whenever the technical experts leave.
The health system relies on overlapping and interconnected management systems and
subsystems. Changes in one system can trigger changes in the other.
Health system building blocks and the role of the management system strengthening
Health system components:
Health System Building blocks as defined by the WHO include (WHO 2007);
1. Service delivery: packages; delivery models; infrastructure; management; safety & quality;
demand for care
2. Health workforce: national workforce policies and investment plans; advocacy; norms,
standards and data
3. Information: facility and population based information & surveillance systems global
standards, tools
4. Medical products, vaccines & technologies: norms, standards, policies; reliable
procurement; equitable access; quality
5. Financing: national health financing policies; tools and data on health expenditures; costing
6. Leadership and governance: health sector policies; harmonization and alignment; oversight
and regulation
The Ethiopian Health System Strengthening Initiatives
Several initiatives have been implemented in Ethiopia as part of strengthening the health system.
Although most of the points depicted below are part of the reform process, it can be taken as
components of the Health System Strengthening Initiatives.
Business Process Reengineering - leading to a set of new approaches like benchmarking
best practices, designing new processes, revising organizational structures and a selection
of key processes.
Decentralization of Health Service
Health Care Financing
Health Insurance
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Hospital Reform Initiatives

Harmonization and Alignment
Different Health Work Force Development initiatives
Health Management Information System
1.1.4 Health care delivery system
It is a network of integrated components designed to work together coherently, to provide
healthcare to a population in various settings. Concepts from general systems theory are useful in
understanding the structure and operation of a nation’s health system. For this purpose the
following must be identified:
* The major actors, which can further be classified as :
 healthcare users/consumers
 healthcare providers
 policy makers/regulators
* Their resources, which can be further classified as:
 funding
 personnel
 facility
 technology
 information
* The mechanism through which they interact
* The external forces which affect the process
The healthcare delivery system like all systems is dynamic with many feedbacks loops among
providers, consumers and regulators, allowing for change in the system’s performance
History of the Ethiopian Healthcare Delivery System
Ethiopia has one of the worst health statuses, with poor environmental condition and inadequate
health services. Long periods of civil strife, rapid population growth and environmental
degradation have further aggravated these health problems.
The country has a new health policy and strategy; the health service is to be re-organized into a
more cost effective and efficient system that can contribute better to the overall socio-economic
development effort of the country. To understand the current healthcare system we must look
back to the historical background of modern medicine in Ethiopia, and the role traditional
medicine plays.
1.2 Development and organization of the health system in Ethiopia

(Public/private)
Contributors of Health Care Provision in Ethiopia
The main healthcare providers in Ethiopia are:
 The Government
 Private providers
 Non-government
 International Health Agencies:
o Multilateral Agencies
o Bilateral Agencies
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1.2.1 The Government

For many countries, especially in the developing countries, it is very likely that the government
remain the largest single provider of health care giving an impression of dominating health care
provision.
1.2.2 Private Providers
Private providers work for profit and increasingly the private providers are getting involved in
the delivery of health services. Nearly all pharmacies (drug stores) are privately owned. The role
of private hospital and clinics and medical services is growing especially in urban areas and
those who afford can be managed there and help in reducing load at government facilities.
1.2.3 Nongovernmental Agencies (NGO’s)
NGO’s are sometimes known “people to people” aid; their activities are sometimes very specific,
for example targeting Trachoma and cataracts. Whereas some have more general agendas, for
example aid for orphans. They are usually funded by voluntary donations although some act
under contract to governments and other agencies. The largest and NGO is the international Red
Cross which has national offices within most countries. Other well-known NGO’s are USAID,
CDC, Oxford Famine Relief (OXFAM), Care international, save the children.
1.2.4 International Health Agencies
International Health agencies play an auxiliary role. They are funded by member governments.
A) Multilateral Agencies
The leader among such agencies is the World Health Organization (WHO), which began its work
in 1948 in Geneva under the United Nation (UN) .Its headquarters, is in Geneva. It has six
regional offices and representatives in most of its 200 member countries. Its tasks are:
 To review and approve policies and program initiatives
 To coordinate and promote technical cooperation among countries
 Facilitate training and technical assistance
 Assimilate, analyze and disseminate health related data
A good example of its achievement is the way it leads in the eradication of smallpox in 1979.
Other such multilateral agencies are:
* UNICEF – a program concerned with the healthcare of infants and children
* United Nation Development Program (UNDP)
* World Bank (WB)
* UNAIDS – is a program for HIV/AIDS
* Food and Agriculture Organization (FAO)
* United Fund for Population Activities (UNFPA)
B) Bilateral Agencies
The most industrialized nations provide aid on a country to country basis, attempting to match
the recipients need with the donor’s objectives and capacity to assist, usually subjects to political
considerations. The United
States links aid to democratic reforms and human rights.
In 2004 only five countries met the United Nations target of contributing 0.7% of gross national
product in official development assistance. These countries are Norway, Denmark, the
Netherlands, Luxembourg, and
Sweden. In contrast to the United States provided only 0.16% and the UK 0.36%.
Donor countries often rely on their own expertise through competitive bidding to design,
implement, and monitor projects funded under bilateral agreements, sometimes requiring that the
donors own products and services be used. It is critical that such development assistance is
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effectively placed, and fairly counted, so as to help build sustainable capacities for all the people
of the world.
1.3 Approaches in organization and delivery during various periods
1.3.1 Indigenous health services

The Traditional Medicine Practice in Ethiopia
Long before the advent of modern medicine, Ethiopia had its own method for combating disease.
These methods are usually referred to as Ethiopian traditional medicine. Not only was a
traditional medicine structure operation prior to the advent of modern medicine, but it can be said
that even today the rural populations depend on it.
Ethiopian traditional practitioners practiced not only curative but also preventive medicine, and
the first “Cordon Sanitaire” was established in Gondar as early as 1830 G.C. Similar actions
were taken in the whole country in 1918 G.C. during the notorious influenza pandemic
variolization was very widespread as a means of preventing small pox, and in certain times in the
18th century the variolization was even compulsory.
The traditional Ethiopian pharmacopoeia comprised items from the animal and vegetable
kingdoms. And even some minerals (e.g. floss from iron melting). Counter-irritants (burning of
the skin over the diseased part of the body), bleeding and cupping were other routinely used
procedures. Several surgical procedures, including trepanation and Cesarean section, have been
repeatedly reported, but probably the greatest skills were observed in bone-setting (‘Wegesha’),
including even operations and insertions of sheep’s bone.
In connection with traditional medical practices, one has to mention some harmful procedures
that have been widely practiced in the country, such as female circumcision, removal of tonsils
by means of a nail, uvula cutting, and pulling healthy children’s teeth.
In recent times the Ministry of Health has been making an effort to integrate traditional medicine
into the general network of health services, particularly since the skills of certain healers are
known to be effective.
Among the most prominent practitioners, bone-setters (wogeshas), herbalist’s (kitel betash),
traditional birth attendants and particularly different types of “spiritual healers” can be useful in
general, and the people appreciate their services.
Formal recognition to traditional medicine in Ethiopia was given in 1942 (Proclamation 27),
where legitimacy of the practice was acknowledged as long as it does not have negative
consequence on health.
Despite the relatively rapid expansion of modern medicine, traditional medicine (TM) is still the
predominant health care resource in Ethiopia. Because traditional medicine is culturally
entrenched, accessible, and relatively affordable, up to 80% of the Ethiopian population relies on
traditional remedies as a primary source of health care (Kassaye et al., 2006).World Health
Organization estimated that 80% of the population in developing countries and as many as 90%
of the Ethiopians use TM for their illnesses.
1.3.2 Modern health services
Historical Background of Modern Medicine in Ethiopia
There have been occasional contacts between modern medical practitioners and Ethiopians prior
to the end of the 19th-century.A Portuguese “barber surgeon” was known to be at the courts of
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King Lebne-Dengel in the 15th century: then the German missionary, by the name of Peter
Heiling, was at the court to Emperor Fasiledes in the 16th century, and several others have been
recorded.
If we reflect back in history, the years just before and after the turn of the millennium can be
considered as a centenary for health services in Ethiopia. It was just at the end of the 19th and the
beginning of the 20th centuries that modern health care was introduced in the country. The first
modern health care facility in the country (a Russian Red Cross Hospital) was established in
Addis Ababa in 1987 with a capacity of 50 beds. It is interesting to note that the mission
produced a small booklet in Amharic of 22 pages, which was to serve as a textbook for Ethiopian
staff. The Russian mission stayed in the country for ten years, and in 1906 the hospital was
closed.
Following that a leprosarium and hospital were opened in Harar in 1901 and 1903 respectively.
In the year 1909 the first public hospital Menilik II established on the site of the Russian
hospital. At the beginning it had 30 beds .The hospital has been in operation ever since on the
same site and even today it’s called by its original name, “Menilik II hospital”.
After Minilk II Emperor Hilesilase I continued and the reform drive of Emperor Halile Selassie I
during 1917- 1935 focused on economic and social conditions that included health expansion
and management reforms. This drive was interrupted during the brief occupation of Ethiopia by
the Italians. Until Soon after the liberation of Ethiopia in 1941 the period of reconstruction time
that a Department called “Public Health Directorate” was established under the then powerful
Ministry of Interior (MOI). The first director of the unit was a British Doctor known by the name
Colonel Maclean. It was made responsible for the establishment of the first hospital, and for the
general problems in the health field.
During that time, there were several Christian missions operating in the country, they provide
health care to the people in addition to their religious and sometimes educational activities. In
1922 another hospital was established in Addis Abeba. An American missionary named Dr.
Thomas Lambie collected money, erected a building in the Gulele area, and established a
hospital with 70 beds. This hospital had 4 medical doctors and
5 nurses on its staff. The hospital was converted into a research Institute in 1942, then into the
Institutes of Pasteur in 1950. In 1964 it was converted into the central laboratory and research
institute, and finally it was merged with Ethiopian Nutrition Institute (ENI), today it’s called
Ethiopian Health and Nutrition Research
Institutes (ENHRI).
Because of expansion of health service government has taken Major step in the autonomous
development of health care which did not happen until the formal establishment of the Ministry
of Public Health (MOPH) in 1948. By 1948 there were already several hospitals in the country.
At that time, the majority of hospitals, and health facilities were run by different mission
organizations.
In speaking of the historical development of health services in Ethiopia, one must mention the
contribution of first Ethiopian medical doctors. Dr. Martin Workineh
The second Ethiopian medical doctor was Dr. Melaku Beyan, who early in this century obtained
his medical degree at Howard University in the United States.
The Basic Health Service Period (BHS) from 1953-1974
For Ethiopia (following the WHO recommendation), BHS was seen as a long term strategy for
providing adequate and essential health care by making available a HC for a population of
50,000 and a Clinic for a population of 5,000. A new chapter in the development of health
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services was opened when, with the assistance of international organizations, Gondar Public
Health College and training center was established in
1952. The Institute trained three categories of health personnel; public health officers,
community nurses and sanitarians, who were intended to serve in the health centers, a new type
of the institution. One health center was supposed to serve 50,000 people, with the help of
satellite health stations.
The first organized training of health personnel can be traced back to 1945, when a six-month
course was offered to all hospital orderlies, who were then upgraded to the status of “dressers”.
The first nursing school was established in Addis Abeba by the Red Cross society in 1950. The
training center for medical and health technicians was established in 1963 within Menilik II
hospital. The first medical school was established in 1962.
Due to the slow development of general health services and subject to some international
pressure, special projects to combat individual disease were embarked upon. The most important
project is the Malaria eradication project, established in 1959; the TB control project, a Leprosy
control project, the Ethiopian nutrition institutes, and the small pox eradication service are
examples of the bigger projects. Some of these projects are still in existence.
The Primary Health Care (PHC) Period (from 1978-1991)
Concepts of primary healthcare
Definition
The international conference on PHC held At ALMA-ATA in 1978 defines as follows:
PHC is defined as Essential Health Care based on practical, scientifically sound, and socially
acceptable methods and technology made universally accessible to individual and families in the
community through their full participation and at a cost that the community and country can
afford to maintain at every stage of their development in the spirit of self-reliance and self-
determination. It forms an integral part of both the country's health system, of which, it is the
central function and main focus and the overall social and economic development of the
community. It forms the first level of contact of individual, the family and the community with
the national health system, brining health care as close as possible to where people live.
PHC Principles and Approaches
The following principles underline the concept of PHC
Intersect oral collaboration
Community participation
Appropriate technology
Equity
Focus on prevention and health promotion
Decentralization
A. Intersect oral Collaboration
Inter-sect oral collaboration is one of the key principles of PHC. It means a joint concern and
responsibility of sectors responsible for development in identifying problems, programmers and
undertaking tasks that have an important bearing on human well-being. Health has several
dimensions that can be affected by other sectors. The causes of ill health are not limited to
factors related to the health sector. Education for literacy, income supplementation, clean water,
sanitation, improved housing, ecological sustainability, more effective marketing of products,
construction of roads and water ways, enhanced roles of women, are changes that may have
substantial impact on health. The reverse is also true that economic, social and cultural
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development cannot proceed smoothly without concomitant and consequent health development.
Health therefore is fundamental to socio-economic development and plays a critical role.
Why is intersectoral collaboration important?
To save resources (effective use of resources)
To identify community needs together
Which are the sectors that should collaborate?
All those sectors involved in the development process such as Health, Agriculture, Education,
Information, transport and communication, housing and non-governmental organization (NGOs).
B. Community Involvement
Community: Is a collection of people living together in some form of social organization and
cohesion.
Its members share in varying degree of political, economic, social and cultural characteristics as
well as interests and aspirations including health.
Community involvement
The community should be actively involved:
In the assessment of the situation
Problem identification
Priority setting and making decisions
Sharing responsibility in the planning, implementing, monitoring and evaluation.
C. Appropriate Technology
Take account of both the health care needs and the socioeconomic context of a country. This
must include consideration
Of: - Costs (both capital and recurrent) appropriate technology does not necessarily mean low
cost.
Efficiency and effectiveness in dealing with health problems
Acceptability of the health approach to both target community and health service providers.
Broader social and economic effects
The sustainability including the capacity to maintain equipment of the approach.
Based on these points, all levels of health system have to review their methods, equipment and
techniques.
Criteria for Appropriateness
To be appropriate, a technology must be:-
Effective - Culturally acceptable and valuable
Affordable. i.e cost effective.
Locally Sustainable
Possessive of an evolutionary capacity
Environmentally accountable
Measurable
Politically responsible
D. Equity
In view of the magnitude of health problems, the inadequate, inequitable distribution of health
resources between and within countries, and believing that health is a fundamental human right
and world-wide social goal, the conference called for a new approach to health and health care.
This is to close the gap between the have's and "have not's" which will help to achieve more
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equitable distribution of health resources, and attain a level of health for all the citizens of the
world that will permit them to lead a socially and economically productive life.
Planning for equity in PHC requires the identification of groups which are currently
disadvantaged in terms of health status access to or utilization of services.
E. Focus on Prevention and Promotive Health Services
Health promotion relates to the importance of adopting, where possible a promotive or
preventive approach to health problems.
Such an approach sees health as a positive attribute, rather than simply" the absence of disease".
One of the important tasks of the planner is to redress the imbalance in allocation of resources to
preventive and curative care, enhancing the role of resources available to prevention and
promotion.
F. Decentralization
Decentralization away from the national or central level brings decision making closer to the
communities served and to field level providers of services, making it more appropriate. There is
also a greater potential for multisectoral collaboration at the lower service-delivery level.
Decentralization may enhance the ability to tap new sources for financing health care. However
decentralization may lead to geographical inequalities in resource availability and technical
quality. If handled inappropriately decentralization may actually result in a shift away from the
principles of PHC. Planners should, therefore, consider whether specific strategies and decisions
will enhance or hinder the achievement of PHC.
PHC – The level of Care

The term PHC- historically means most peripheral level of organized health care- the point of
contact between community & the health services.
The ALMA-ATA declaration states that this level is an:- " Integral part of the national health
care system of which it is the central function and main focus."
The Components/Elements of PHC
Essential Health Care consisting of at list 15 Elements
1. Health Education
2. Provision of Essential Drugs
3. Immunization
4. MCH/FP
5. Treatment of Common Diseases & Injuries
6. Adequate Supply of Safe Water & Basic Sanitation
7. Communicable Disease Control
8. Food Supply And Proper Nutrition
9. Oral Health
10. Mental Health
11. The use of traditional Medicine
12. Occupational Health
13. HIV/AIDS
14. ARI
15. Adolescent and youth reproductive health
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Health Extension Package Program

1. Hygiene and environmental sanitation
I. Proper and safe excreta disposal system
II. Proper solid and liquid waste disposal system
III. Water supply safety measures
IV. Food hygiene and safety measures
2. Disease prevention and control
I. HIV/AIDS prevention and control
II. TB prevention and control
III. Malaria prevention and control
IV. First Aid
3. Family health service

I. Maternal and Child Health
II. Family planning
III. Immunization
IV. Adolescent Reproductive Health
V. Nutrition
4. Health education and communication
1.3.3. Sector wide Approach Period (1991-till now)
The government of Derge is overthrown by EPRDF in 1991 and transitional government was
established for 1991-1995. During this period health policy and strategy were developed.
Currently the Ethiopian government is following a twenty-year health development
implementation strategy, known as the Health Sector Development Program (HSDP), with a
series of five-year investment programs.
HSDP proposes a sector-wide approach to achieve the government’s objectives.
The Health Sector Development Program, launched by the government in 1998, was devised
after studying the kind of health problems that affect Ethiopia and researching their root causes.
It also took into consideration emerging serious health issues such as HIV/AIDS and put a strong
emphasis on the needs of the rural Ethiopia, where overwhelming majority of the country’s
citizens live.
Sector wide approach-based health care delivery system is owned by the state, but its
implementation is firmly based on strong partnership between the Central Government, the
Regional Government, the Health Development Partners, the Private and NGO sectors. The
focus of health delivery system is expansion and improvement in the quality of care and is
guided by the eight components of the Health Sector Strategic Plan
(HSDP) at all levels.
The eight components of HSDP are:
1) Health service Delivery and Quality of care.
2) Health facility Rehabilitation and Expansion.
3) Human Resource Development.
4) Strengthening Pharmaceutical Services.
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5) Information, Education and Communication.

6) Health Management Information Systems.
7) Healthcare Financing.
8) Monitoring and Evaluation.
A. Millennium Development Goals (MDGS)

How MDGS are developed?
Many of the targets of the MDGs were first set out by international conferences and summits
held in the 1990s. They were later compiled and became known as the International
Development Goals.
These are some of the world conferences which attribute to MDG
 World conference education for all
 World summit for children
 UN conference on environment and development (UNCED)
 International conference on nutrition
 World conference on human rights
MDGs
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development
CHALLENGES FACED ON meeting MGDs
Progress towards the goals is now threatened by:
 Economic crisis
 Climate change
 Diminished resource
 Fewer trade opportunities for the developing countries
 Possible reductions in aid flows from donor nations
B. Sustainable Development and Poverty Reduction Program
(SDPRP)
1. The overall objective of the Ethiopian Government-led Sustainable Development and
Poverty Reduction Program (SDPRP) is to reduce poverty by enhancing economic
growth while maintaining macroeconomic stability. It is built on four pillars:
a) Agricultural development-led industrialization and food security,
b) Governance, decentralization and empowerment,
c) Reform of the justice system, and civil service and
d) Capacity building).
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2. In addition, the SDRP identified key sectoral measures and cross-cutting issues including
education, roads, water and sanitation, HIV/AIDs, health, and gender and development.
In health, in particular, it seeks to improve the balance between preventive and curative
health care through a community based health care delivery system aimed at creating a
health environment and lifestyle.
3. Aiming to reach the MDGs, the SDPRP envisages progress in three interrelated areas:
i. Expanded coverage of current public sector programs and improvements in the quality
of service delivery;
ii. Faster and more equitable economic growth and;
iii. A reduction in Ethiopia’s vulnerability to weather, sickness, and trade related shocks
1.4 Policies, strategies and programs during various periods

A health policy is a set of clear statements and decisions defining priorities and main directions
of improving health and health care in a country.
Health policy includes actions or intended actions by public, private and voluntary
organizations that have an impact on health.
National Health Policy
The 1993’s health policy issued by the government of Ethiopia is one among the prominent
developments of the country. The policy envisioned the health care sector development (HSDP)
for the next twenty years. It reorganized the health services delivery system so as to contribute its
own to the overall socio-economic development. The policy principally focuses on fiscal and
political decentralization, expanding the PHC services to all segments of the population and
encouraging partnerships and the participation of nongovernmental actors.
General theme of the policy
1. Democratization and decentralization of the health service system.
2. Development of the preventive and promotive components of health care.
3. Development of an equitable and acceptable standard of health service system that will reach
all segments of the population within the limits of resources.
4. Promoting and strengthening of inter-sectoral activities.
5. 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.
6. Assurance of accessibility of health care for all segments of the population.
7. 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.
8. Development of appropriate capacity building based on assessed needs.
9. 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.
10. Promotion of the participation of the private sector and nongovernmental organizations in
health care.
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Summary of strategic areas
Empower the community to play a significant role in the health sector

1.1. Engage community members and build community ownership of health systems
1.2. Ensure healthcare organizational governing boards have community representation
1.3. Ensure health is properly addressed by activities and policies involving multiple sectors
1.4. Increase household production of health and support improved health behaviors through
community engagement strategies which are well informed with evidences generated locally and
beyond.
1.5. Ensure community engagement with new financing approaches, especially community-based
health insurance (CBHI)
2. Strengthen Health Service Delivery with emphasis to primary health units (PHCU) within
the wider health sector context
2.1. Establish standardized care packages delivered at PHCU, secondary, and tertiary levels, and
update over time as needed with a clear referral and consultation network
2.2. Expand and sustain numbers of functioning health care facilities (PHCUs, secondary
hospitals, and tertiary hospitals) in the country including provision and maintenance of medical
equipments
2.3. Establish effective management structures in PHCUs and its governance systems at all levels
of the health system
2.4. Establish a team-based approach to Primary Health Care with appropriate skill mix for health
promotion, diseases prevention and curative services
2.5. Set a clear career path to health work force working in the PHCUs including the HEWs
2.6. Ensure the health delivery system is supported by a well-functioning supply chain, health
management information system (HMIS), quality assurance system and innovative health and
information technologies
2.7. Ensure the PHCU is capacitated to handle public health emergencies
3. Ensure a robust Human Resources Development system that commensurate with socio
economic development of the country as LMIC by 2025 and middle-middle IC by 2035
3.1. Strengthen mechanisms to develop and retain high quality health care professionals including
health care leaders (licensure, accreditation, and board certification), as flooding strategy
continues
3.2. Support growth along defined career paths in clinical care and public health including clear
path of the HEWs
3.3. Strengthen the Human Resources Information System (HRIS) for accurate planning,
implementation and monitoring.
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4. Enhance the role of non-state actors in improving health status

4.1. Build capacity to develop and manage public-private contracts and partnerships
with private providers to strengthen Health Care access and quality of services that complement
government programs and to help fill gaps in services provided by the government (e.g., clinical
and diagnostic services, tertiary care, medical tourism),
4.2. Strengthen FMOH and other departments’ capacity to regulate private sector actors
Health Sector strategies and reforms in Ethiopia
Definition of Health Sector Reform:
National health sector reform has been defined as a sustained process of fundamental change in
national policy and institutional arrangements led by government and designed to improve the
functioning and performance of the health sector and ultimately the health status of the population
(WHO/SHS/96.1).
Rationale for Health Sector Reforms:
The 1990s brought a rethinking of how government and donor agencies approach health. A
combination of factors-rising costs, scarcity of resources, lack of impact of health spending on
health status, growing health problems (including a resurgence of old infections and an emergence
of new ones), and anticipated shifts in burden of diseases as population age and adopt new life
styles-revealed major fault lines in traditional modes of financing and organizing public sector
involvement in health.
Reforms are undertaken for a variety of reasons:
efficiently and used effectively
g the quality and client focus of public and private health services
Reform initiatives to address these goals/rationales include:
ening the way for government to

contract with private providers for service delivery and to hold them accountable for performance
systems
d management of tertiary care facilities to private nonprofit or
commercial organization and allowing community oversight through local boards and other
mechanisms
-based sectoral program
support
management of service delivery to standard setting, advocacy, and evaluation.

Declining and even negative economic growth rates of various types of economic reforms, some
of which had unfavorable consequences in the health sector. The health care delivery systems of
some countries were so weakened; urgent and thorough reform of the health sector is required.
Governments across the developed world are constantly active in reforming healthcare, chiefly
because of the extent to which governments pay healthcare costs.
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political or economic events unrelated to healthcare. Incremental reform is highly influenced by

the balance of power of key professional and corporate institutions present in each country and the
system of government.
who gets
paid, and how much.
The Health Sector Development Program
The Health Sector Development Program (HSDP) was launched in 1998 in response to the
prevailing and newly emerging health problems in Ethiopia and in recognition of weaknesses
observed in the existing health delivery system. The initial HSDP which was drafted in 1993/94
was designed for a period of 20 years, with a rolling five-year program period. Its main goals were
threefold:
and supplies and develop and
the grassroots level.

Health Sector Development Plans
HSDP I (1997/98–2001/02)
–2001/02)
-tier system for health service delivery
satellite health posts; the district hospital, zonal hospital and specialized hospital.
HSDP-II (2002/03–2004/05)
Introduced the Health Service Extension Program (HSEP).
with focus on sustained preventive health actions and increased health awareness.
HSDPIII (2005/6-2009/10)
-related MDGs
-impact health system strengthening interventions needed to accelerate scale-
up and increase coverage of key health services for HIV,TB, malaria, as well as maternal and
child health.
HSDP IV (2010 –2015)
Policy influencing national development policies and strategies.
major communicable diseases, such as HIV/AIDS.

an resource
development and health infrastructure.
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Chapter 2
Health management with focus to the Ethiopian health system
(planning, organizing implementation, monitoring and evaluation)
Health planning
2.1 WHAT IS PLANNING

Definitions:-
Planning is the combination of compiling and analyzing information, dreaming up ideas, using
logic and imagination and judgement in order to arrive at a decision about what should be done.
Planning can also be defined as:- Systematic method of trying to attain explicit objectives for the
future through the efficient and appropriate use of resources, available now and in the future.
Health Planning- is the process of defining community health problems, identifying needs and
resources, establishing priority goals, and setting out the administrative action needed to reach
those goals
Planning/Health planning
Planning is a systematic process of identifying and specifying desirable future goals and outlining
appropriate courses of action and determining the resources required to achieve them.
Health planning is simply a planning pertaining to health and health care system.
As a health planning, it should aim at improving the health status of a given population; maintaining
equity and fair access of health/health care; and responsiveness of the health system to the
community’s perceived needs. The health plan should also seek to achieve its goal towards the
provision of an efficient and effective health services using the means and resources at its disposal.
Strategic planning is medium-to long-term planning that involves all the organization’s management
areas and includes goals, strategic objectives, strategies, and measurable results. It focuses on broad
and long-lasting issues related to the organization’s long-term effectiveness and survival. It asks and
answers four questions:
1. Where are we now? (situational analysis: strengths, weaknesses, opportunities, threats)
2. Where do we want to go? (mission, vision, strategic objectives)
3. How will we get there? (strategies)
4. How will we know we are getting there? (measuring implementation, monitoring progress)
An organization’s board and management staff are usually responsible for strategic planning.
However, the planning process should in clued input from all levels of the organization as well as
stakeholders, for example, major donors, relevant ministries and other government agencies, and
beneficiaries of the organization’s services.
Planning is deciding in advance what is to be done, it is projected course of action for the future.
Planning thus becomes a device for change
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It is clear that individual activity and organizational activity without a plan will be ineffective- "
If you don't know where you are going no road will get your there”.
All these definitions have one common point, that planning is a process that lays the base for
future action.
The important components of this and other similar definitions are concepts of:-
 Where are we going (objectives)
 With what (Resources)
 How (efficient and appropriate implementation)
 When (future)?
Degree for formalization (explicitness, systematic and method) about the process
2.1.1 THE RATIONALE FOR PLANNING
The importance of planning:- it helps:-
 Coping with future uncertainty and change
 Focus attention on objectives
 It obtains economical operation
 Provides performance standards and facilitates control
Principles underlying the planning process
1. Government ownership and leadership of all health planning processes
2. Consultation with all stakeholders
3. Linkage to resource mapping from all stakeholders at that particular levels of the health
system
4. Approval of the plan and budget by the relevant local government authority through the formal
political process
5. Maintenance of vertical and horizontal linkage
6. Alignment of annual plans to strategic plans(in terms of priority and time) at all levels of the
health system Helps foreseeing and identifying potential risks.
2.1.2 FEATURES OF PLANING
A. A Good Plan Should Give
 Clear vision/mission, goal and objectives
 A clear picture of the tasks to be accomplished
 The resources needed to accomplish the task. In terms of human, material, financial and
time resources
B. Planning Takes Place at All Levels
 Planning takes place at any level in health system
 Planning takes place continually, it is cyclic/spiral process
Planning methods can be applied to :-
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A large programme at national level

Example –Malaria control programme
Small one - at village level
Example –construction of community health post
C. Planning must be Collective Undertaking
 It requires the participation of:-
 Professionals (from health and other sectors)
 Community/Non-Governmental Organizations (NGO)
 Government/Party
2.2 TYPES OF PLANNING
In this unit different forms of planning will be looked at in more detail.
There are two types of planning:-
I. Strategic planning-often referred as allocative planning –Normally five years or more.
II. Tactical/operational planning -may be referred to as activity planning.
It covers a short period of time medium term-usually one-year.
2.2.1 STRATEGIC PLANNING

1.1 What is Strategic Planning?
Strategic Planning is the process of determining what an organization intends to be in the future
and how it will get there. It is finding the best future for your organization and the best path to
reach that destination.
Due to the rapid rate of change of today's world it has become necessary for every dynamic
organization to keep their plan as current as possible through strategic planning. Strategic
planning is often used in place of long range planning.
1.2 SWOT Analysis
SWOT (strengths and weakness, opportunities and threats) is a strategic planning tool that
matches internal organizational strengths and weakness with external opportunities and threats.
By reviewing strengths, weaknesses, opportunities and threats a useful strategy for achieving
objectives will become evident.
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2.2.1.TACTICAL/OPERATIONAL PLANNING
Major differences between Strategic and Tactical Planning
Area of differences Strategic Planning Tactical Planning
Individuals involved Developed mainly by upper- Developed mainly by lower level
level management management
Facts on which to base Facts are generally difficult to Facts are generally easy to gather
planning gather
Amount of details in plans Plans contain relatively little Plans contain substantial amount of
detail detail
Length of time plans Plans cover long periods of time Plans cover short periods of time
cover
In spite of their differences, tactical and strategic planning are integrally related.
" In general, strategic planning is concerned with the longest period worth considering. Tactical
planning is concerned with the shortest period worth considering. Both type of plans are
necessary. They complement each other. We can look at them separately, even discuss them
separately, but we cannot separate them in fact".
2.3 STEPS IN PLANNING
The aim of presenting the planning process in "steps" is to provide a general framework of action
to be performed to ensure a systematic approach. However, many activities may be carried out at
the same time providing a mutually supportive flow back and forth among stages of the process.
In the process of planning, one has to consider several steps at the same time.
In health management, health services utilize resources in response to certain health problems for
producing an outcome in the form of improved health status.
In the planning process, there are six steps:
I. Situational analysis
II. Selecting priority problems
III. Setting objectives and targets
IV. Identifying potential obstacles and limitations
V. Designing the strategies
VI. Writing the plan
2.3.2.SELECTING CRITICAL PRIORITY PROBLEMS
The second stage sets priorities for the organization, in the light of competing needs and limited
resources. Setting priority is, perhaps the most critical and hardest planning stage and yet cannot
be avoided. For the state providing an overall strategic plan these needs to be sufficiently broad
allowing for local variations as a result of differing needs. There is a series of issues around how
priorities can be set. Under planning all of these is a tension between attempts to make decisions
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on priorities as rigorous as possible and recognition of the essentially "Political' or value laden
nature of such decisions. Within any priority-setting decision there are two broad processes
which need to be conceptually disentangled.
The first concerns the provision of information. This is an important function of the planning
system, and in situational analysis which form such a base for priority setting.
Secondly there is decision as to how health and health need is viewed. Proceeding section
examined a number of possible different perspectives on health and health needs. As we have
seen, assessment of health needs and priorities is not a simple technical issue. Different
individuals, professions, or groups will have different attitudes and a critical decision relates to
how such views are to be weighted.
Define a problem: A problem is a difficulty or obstacle seen to exist between a present
situation and desired future objectives
The selection criteria for priority setting are:-
 Magnitude of the problem
 Degree of severity (consequent suffering and disability)
 Feasibility-interns of cost effectiveness and social acceptability of intervention.
 Sustainability in terms of resources and organizational capacity
 Community concern
 Political and social acceptability with consideration of equity
 Consistence with multi - sectoral approach
 Consistence with governmental planning and budgetary system
 Clear defined system with donors (if linkage exists)
Ranking which health problems they think were most important. This can be done by using
criteria on five point scale
5 points-very high
4 points-high
3 points-moderate
2 points-low 1 point-very l
2.3.3. SETTING OBJECTIVES AND TARGETS
Let us first define some related terms, a clear understanding of which is important for a rational
planning.
Goals, aims, objectives, and targets
Goals, aims, objectives and targets are all ways of describing the desired direction of a service.
They differ in terms of breadth and detail.
Goals:- Are broad statements. There is generally one goal for a service. This might be:'
Health for all by 2000 and beyond.'
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Aims:- There are a number of aims relating to the goal. They are specific to particular
health problems. One might be: 'To raise the nutritional status of women and children.'
Objective:- For each programme aim, there may be a number of objectives
which are specified in measurable terms. An objective for the above aim might be:
‘To ensure that 95 per cent of children are adequately nourished.'
Targets:- For each objective, there may be various targets which specify various points on
the way to the attainment of the objective. They are defined in relation to a point in time. For
example, a target for the above objective might be:
' To ensure that 75 per cent of children are adequately nourished by 2002.'
If the programme is made to have an objective and target, it must be SMART:-
S -Specific M -Measurable
A -Achievable R -Realistic
T -Time specific/Time framed
Example
By the end of 2002, 90% of eligible children will be vaccinated against six target diseases in
Omo Nada Woreda.
2.3.4. IDENTIFYING OBSTACLES AND LIMITATIONS
After setting objectives and targets the planner should ask himself/herself about the presence of
any situation (obstacle/limitation) that may prevent the achievement of each objective and target.
2.3.5 DESIGNING THE STRATEGIES
Once objectives and targets are set, the planner assesses the different ways (strategies) for
achieving them. Choosing the best strategy again entails analyzing resources available and
needed for each strategy. The potential strategies often include technology to be applied,
procedures to be used and defining the role of communities and other sectors.
For each chosen strategy, the corresponding activities to be undertaken and the resources needed
should be detailed, including who will do the activities (job description of all involved
personnel) which things would be needed (equipment, materials and money), where the work
will be done and the methods of controlling.
Who will help the contribution of communities and other sectors? The health planner should
identify what information should be collected for controlling and decide how it would be used.
Determine resources required in terms of proposed strategy -the time, staff, acilities/materials
and money. Estimate strategy costs and assess adequacy.
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2.3.6 WRITING THE PLAN

The purposes of writing the plan are:-
To request funds or resources from the government or funding agencies
For monitoring and evaluating the implementation process by all concerned
2.4.A Organizing
2.4.1 Organizing concepts

It is the next step after planning.
A key issue in accomplishing the goals identified in the planning process: structuring the work
of the organization.
The purpose is
 To make the best use of the organization's resources to achieve organizational goals.
to make the organization a stable place for employees
Organizing
Deciding what work needs to be done, Deals with formal assignment of tasks and authority
and coordination. And arranging them into a decision-making framework. What is the decision-
making framework? The organizing function deals with all those activities that result in the
formal assignment of tasks and authority and a coordination of effort. The supervisor staffs the
work unit, trains employees, secures resources, and empowers the work group into a productive
team.
The steps in the organizing process include
(1) Review plans,
(2) List all tasks to be accomplished,
(3) Divide tasks into group’s one person can accomplish - a job,
(4) Group related jobs together in a logical and efficient manner,
(5) assign work to individuals,
(6) Delegate authority to establish relationships between jobs and groups of jobs
2.4.2 Organizational Structure

The way, in which an organization’s activities are divided, organized and coordinated.
Is the formal decision-making framework by which job tasks are divided, grouped, and
coordinated?
Why formal?
It is the official organizational structure conceived and built by top management.
Formalization is an important aspect of structure. And
 It is the extent to which the units of the organization are explicitly defined and
 Its policies, procedures, and goals are clearly stated.
Organization charts?
 The formal organization can be seen and represented in chart form.
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 An organization chart
 Displays the organizational structure and shows job titles, lines of authority, and relationships
between departments.
 Is helpful for managers as it is an organizational blue print for deploying human resource.
Dimensions of Organization charts
Representing the organization's structural skeleton, organization charts have dimensions
representing
 vertical hierarchy and
 Horizontal specialization.
Vertical hierarchy is the chain of command.
Horizontal specialization involves the division of labor.
Why do we need an organizational structure?
Problems of unclear or lack of an organizational structure?
A clear organizational structure
clarifies the work environment,
creates a coordinated environment,
achieves a unity of direction, and
establishes a chain of command unclear or lack of an organizational structure or
Without an organizational framework and lines of reporting, there would be
frustration,
loss of productivity, and
limited ability to pursue a strategy
 Can different organizations have similar organizational structure?
 Why the need for different organizational structure?
 Environment and Strategy
Approaches and theories of organization
 Traditional and modern views of organizations.
Steps of organizing
 Reviewing plans and goals
 Determining work activities
 Classifying and grouping activities
 Assigning work and delegating authority
 Designing a hierarchy of relationships
2.4.3 Coordination
It is the integration of activities of separate parts of an organization for accomplishing the
organizational goals.
 Integration: the degree to which various departments work in a unified manner
What is the effect of lack of coordination?
The degree of coordination depends on
Nature of task
Degree of interdependence of people in the various units
When do organizations need a high degree of coordination?
Coordination
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High degree of coordination is needed:

When communication between units is important
For non-routine and unpredictable works
When organizations are challenged with unstable environment
When there is high interdependence between units
When the organization has set high performance objectives
For highly specialized task such as coordination among different organizations
Differentiation and division of work related to coordination
Differentiation: differences in attitude and working styles, arising naturally among members of
different departments that can complicate the coordination
Division work : role how individuals perceive the organization, their role and how they relate
Differentiation
may complicate coordination and
Can lead to conflict among units and individuals.
2.4.4 Organizational culture

Organizational Culture is a dynamic system of shared values, beliefs, philosophies, experiences,
habits, expectations, norms, and behaviours that give an organization its distinctive character.
The culture helps
guide the activities of the organization,
provide an unwritten code of behaviour,
provide a shared sense of identity
The corporate culture may be manifested in various ways such as
 statements of principle,
stories,
slogans,
heroes,
ceremonies,
 Symbols, climate, and the physical environment.
Managers may influence the culture
by defining company mission and goals,
identifying core values,
 determining levels of autonomy,
 structuring the workplace,
 developing reward systems, and
 Creating socialization opportunities that reinforce the culture.
Culture contributes to the effectiveness of the organization.
2.4.5 DELEGATION
 Delegation of authority, although generally resisted for a variety of reasons, is crucial to
Decentralization. Effective delegation permits managers to tackle higher-priority duties while
helping train and develop lower-level managers.
Although delegation varies in degree, it never means abdicating primary responsibility.
Successful delegation requires plenty of initiative from lower-level managers.
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 Many factors, with global competition leading the way, are forcing management to reshape the
traditional pyramid bureaucracy.
These new organizations are characterized by fewer layers, extensive use of teams, and
manageably small subunits.
To organize effectively, managers need to master a number of concepts including
authority,
power,
Delegation,
Span of control, and centralization /decentralization
Implement: Health leaders who manage execute and delegate execution of planned activities,
coordinating multiple efforts to achieve desired results. This includes the capacity to work under
pressure, the ability to improvise with resources that are available (and do without the ones that no
longer are) and - in spite of conflict and insecurity - get the work done.
2.4.B Monitoring and evaluation
The purpose of a good M&E practice is to properly monitor measure and demonstrate results
evaluate your program perhaps. All you really need to know is the “M”— how to monitor
progress toward your measurable result.
Indicator
Indicator—a marker of change over time that can be measured
 In your team, agree on one or more indicators that are measurable markers of progress
toward your desired result and give their data sources.
 You need indicators only for your measurable result—not for each of the activities in your
Action Plan. Write down where you will get the data that you will use to measure your
indicator(s). Will it be from service statistics, a questionnaire, or client interviews? Use
the handout to help you.
 Indicators should be expressed in neutral terms without words like “improved” or
“decreased” (e.g., the indicator is “temperature” not “higher or lower temperature.”).
 The words “increase” or “improve” can be put in the measurable result statement.
 Select baseline data which describes the current situation for developing an M&E plan.
Without it, a team cannot track its progress, determine whether activities are going
according to plan, or measure the extent to which they have achieved their results. It is
difficult to correctly implement an M&E plan either.
Prepare Monitoring & Evaluation Plan
What is monitoring?
Monitoring is a systematic and continuous assessment of the progress of an activity over time.
Monitoring can be done through the process of collecting, coordinating, processing, measuring
and communicating information to assist management in decision-making.
Monitoring encompasses follow up of Inputs (vaccines, funds, personnel, etc.), the Process
(activities/ tasks being done according to accepted norms and standards), Outputs (products meet
specifications, services are delivered as planned, training results in new skills, etc.) and finally
the Outcome (the short-term effect of the programme or campaign).
Monitoring ensures that:
 work progresses according to schedule;
 standards such as storage and administration of vaccines are maintained;
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 resources are used rationally and as planned;

 the required information is available and used, etc.;
 problems are detected during implementation period so as to undertake corrective
measures; and
 plans are verified to ascertain that they are being implemented in the way and manner
planned.
Tools for monitoring
These are:
 Health Management Information System and periodical reports.
 Supervision reports.
 Programme progress reports.
 Project plan of action.
Monitoring is carried out internally in the course of implementation of the district health plan.
Implementation of the district health plan should be the main focus of deliberations during the
meetings.
Evaluation
Definition
Evaluation is the systematic assessment of actions in order to improve planning or
implementation of current and future activities. Evaluation includes areas of context, input,
process and impact to assess whether the set objectives have been achieved. It can be internal,
that is carried out by the implementers, or external.
Why evaluation?
The essence of evaluation is to determine programme performance, effectiveness and efficiency.
In other words, an evaluation can be carried out to:
 Decide whether an activity was worth doing.
 Determine whether the objectives set were achieved.
 Determine (formative evaluation) whether activities should be continued or not.
 Determine whether the project should be extended elsewhere, etc.
When to evaluate
Before implementation:
 To assess development needs and potentials;
 To determine feasibility of the plan.
During implementation (formative evaluation):
 To identify areas for changes or modifications;
 To detect deficiencies and ensure immediate redesign of intervention strategies.
At the end of programme (summative evaluation): to assess programme or project effect and
outcomes with a view to obtaining information on:
 effectiveness of the programme in achieving its stated objectives;
 its contribution to developmental goals;
 efficiency of the programme or project in utilization of resources;
 sustainability of the project results; and
 Whether to continue, modify or terminate the project.
Comprehensive evaluation addresses context, inputs, process, and outcome. However,
comprehensive evaluation may be too demanding in terms of resources and, hence, is extremely
expensive.
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Before carrying out an evaluation, proper plans must be made to include correct logistics and
methodologies to be followed in advance.
2.5 HRH, time and material resources

2.5.1 Human Resources for Health Management
HRH management is an integrated use of systems, policies, and management and leadership
practices to recruit, maintain and develop employees to create access to quality health care to all
people. Effective human resources management requires governance structures with adequate
number of well qualified human resources management and leadership professionals who have
capacity and motivation to assess HRH needs, develop and implement relevant policies,
strategies and operational guidelines to ensure health workforce planning, development,
recruitment and equitable distribution, career development, motivation, retention and
performance.
Ethiopia has major HRH management challenges including shortage, urban/rural and regional
disparities, and poor motivation, retention and performance. Human resource management is sub
optimal as modern HRM concept and practices are lacking and HR functions are generally
limited to traditional personnel administration attitudes and tasks. Due to limited efforts to
modernize HR functions as strategic resource in health sector there is limited investment into
HRM capacity development as evidenced by limited technical skills and experience of existing
HR staff in HRM and leadership, inadequate HR structure and staffing at all levels, limited
capacity and practices in strategic and operational HR planning and budgeting. HR policies and
procedures are not accessible to all staff, and as a result, not consistently implemented. Human
resources information system (HRIS) is not fully functional to support HR planning and
development, supportive supervision, performance monitoring and improvement. There are also
major gaps in performance management and accountability where strong system and practices
are required to link performance planning/goal setting with monitoring and improvement and
regular performance appraisal, rewards/sanctions and professional development needs. In-service
training needs are not systematically reviewed to link with individuals/teams and organizational
performance and there is little or no in-service training opportunities to develop HRH leadership
and management skills.
The Ethiopian plan of Human Resource Development for health

Health Sector is one of the labor-intensive sectors heavily relying upon the availability of adequate
skilled human power. The Ministry of Health has prepared the Health Sector Human Resource
Development Plan to address human resource problems of absolute shortage, mal distribution and
low productivity.
This plan is part of the HSDP III underway by the joint effort of Ministry of Health and Ministry of
Education. The health policy of Ethiopia also emphasizes training of community based task-oriented
frontline and midlevel health workers.
As a mechanism to retain health workers the policy supports developing an attractive career
structure, remuneration and incentives for all categories of workers within their respective systems of
employment. Besides, there will be a focus on developing appropriate continuing education for all
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categories of workers in the health sector. Strengthening administration and management of health
systems is another area the policy gave priority.
The major objective of the human resource development component of HSDP III is to train and
supply relevant and qualified health workers of different categories governed by professional ethics.
Estimating requirement of Human Resource for Health
Human Resource Planning includes the estimation of numbers and categories of personnel required
both in the immediate and long-term and the allocation of resources to train and pay these staff.
There are four methods used in calculating health personnel requirements:
1. Health needs approach
The approach is based on assessments by experts of the future health needs of a population that is
based on demographic and epidemiological forecasts. This approach is difficult to operationalize and
would require extensive research.
2. Health care demands or utilization method

This is the common method employed by ministry of health. The health staff requirement is
estimated by taking into account the effective demand i.e. utilization of services.
3. Human resource to population ratios

This done based on desired empirical or normative population to health worker ratios.
The problem with this approach is that it does not take into account socio-economic realities. The
ratios have little meaning if health personnel are mal distributed.
4. Service targets
-service targets
and then assesses the human power requirement by taking into account priorities, health wants,
technical and financial feasibility of providing the services
2.5.2 Managing Time

Time is a precious commodity that cannot be replaced, once gone it is unrecoverable. Our ability to
manage our time is the ONE thing that will make a difference to what we achieve in life.
What Is Time Management
It is the ability to decide what is important in life, both at work and in our home and personal life. To
prioritize certain jobs so that we complete the tasks we need to and also those that we think are really
important.
Making the best use of time
Sometimes it is useful to know what proportion of time is really spent on the work. If for instance a
worker’s travel to a distant health unit takes four hours, he/she would have an hour only to spend on
the work followed by four hours to return back home. In this case, the ratio of time spent on health
work to that spent in travelling is 1 to 8.
Why Is Time Management Important
It gives us the ability to keep a balance in our lives or to recognize where the imbalance is
It is a skill that can be learnt, practiced and improved upon all the time
It enables us to fix our undivided attention on what needs to be done and take away the stress of
having things going round and round in our minds
It is a skill that everyone needs unfortunately not everyone will acquire it and as a result they will
achieve less in their lives that they are capable of.
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Identifying Your Priorities

To balance your time, you need to know what your priorities are. With your salary, you know that a
priority is your mortgage or rent, therefore you will ensure that you have enough money to pay for
that. Similarly with time, you need to ensure that you are spending it on your priorities.
To identify your priorities you need to know:
What is the purpose of your job?
What are you expected to achieve and
In what time scale?
What do you need to do [which tasks do you need to carry out] in order to achieve that purpose?
The answers to the above questions are your priorities. When deciding which task to tackle first,
remind yourself of your purpose. For example, if you are short of time, you should perhaps deal with
the customer’s query rather than write the internal report.
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Preparing a program chart

A program
A plan that outlines a series of events/ activities that take place in the future. Usually includes
what to do, where it takes place, who does it and when it occurs. The time plan is therefore only part
of the total program.
A simple program of health education may be a series of monthly discussions in the community,
indicating when different health workers will help with discussions on various health problems.
In more complex programs later activities depend on earlier ones; for example, to organize a
special or extra immunization program, it may be necessary first to order the equipment (e.g.
syringes) or, if a new activity is to commence, a staff member may have to be sent on a training
course, and the public must be informed.
There are several ways to make a program chart. A convenient way is to list the activities; in the
order, in which they must occur, down the left side of the page, then fill in the weeks or months
across the top of the page and then show with a line opposite each planned which activity it is to take
place.
Preparing a year calendar
In the course of a year many things happen that are outside the normal routine. These may be
matters of administration such as annual stocktaking, estimates, annual reports, and statistical returns,
or they may be external events such as festivals, elections, courses and seminars, or visits by
dignitaries.
To see the whole year at once, it is very convenient to have a page on annual calendar or year
planner pinned on the wall, with important events marked. This has two functions.
It acts as a reminder of definite events, usually outside one's control.
It shows where to fit in new events such as special meetings or periods of travel.
Time plans
Time table: for daily, weekly or monthly regularly recurring events.
Schedule: for intermittent, irregular or variable events, including where the events take place.
Roster: for duties planned for different staff members, for different times, in turn.
Program: for long term arrangements of survey on different events or activities of which the
time-plan is only a part.
2.5.3 Material resources
Health Facility Construction and Expansion
Since HSDP I, major activities under the health facility construction, expansion, rehabilitation,
furnishing and equipping focused mainly on the PHC facilities: HPs and HCs and to a certain extent
hospitals. By the end of HSDP II, the number of public HCs has increased by 70% from 412 in
1996/97 to 519 in 2003/04.
For the same periods, the number of HPs increased from 76 in 1996/97 to 2,899. The number of
hospitals (both public and private) also increased from 87 in 1996/97 to 126 in 2003/04. There has
been also considerable health facility rehabilitation program and furnishing during the HSDP I and
HSDP II including improvements in support facilities.
As a result, the potential health service coverage increased from 45% in 1996/97 to 64.02% by
2003/04. The HSDP III plan was to further expand these and other services with the aim of achieving
universal health service coverage by the end of 2008 and also improving the delivery of primary
health care services to the most neglected rural population.
Common problems faced in Physical Infrastructure Management
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Health centres are under-utilized mostly due to patients’ tendency to choose secondary and
tertiary-level facilities over the primary level;
New or rehabilitated health facilities often require recurrent expenditure, which is not available in
the government’s budgets.
Constructions are in many cases completed timely but with other arrangements on human
resources, medical equipment, electricity, water etc. lagging behind.
Omission of some important components in design level make it difficult to achieve required
standards and functionality of the health facilities,
One type of constructional design for setting with different climatic conditions
In many cases, constructional designs do not accommodate sewerage, disposal and other hygiene
related systems.
Lack of expertise and resources at remote location to maintain compromised the quality and
efficiency of health facilities
Setting of Health Infrastructure Priorities

The health facilities priority should consider selection of site for construction, status of medical
equipment, utilities (water, electricity) and availability of qualified health professionals.
When decisions are being made concerning specific health facility, the above mentioned checklist
data need to be supplemented by on-site-collected observations.
-Standard health centre plans are usually available at the Ministry of Health.
Factors that Influence the Size and Distribution of Health Services at a health facility
Frequency with which the population visit health facilities;
Services the population require when they arrive at the facility;
Capacity of individual staff members or items of equipment to satisfy the requirements of the
population;
Rate of admission of in-patients;
Average length of stay of in-patients in the different wards;
Acceptable bed occupancy rate
Maintenance and rehabilitation of Health Facilities and Equipment

As one of the major components of HSDP III the objective of this component is to increase
accessibility and improve quality of health services through the health facility construction,
expansion, rehabilitation, furnishing and equipping them giving special emphasis to primary health
care facilities (HPs and HCs) and to some extent to hospitals.
Most importantly, issues of maintenance are inevitable throughout. Therefore, Problems of
maintenance should be anticipated and mechanisms should be put in place to solve them as follows:
A. General consideration
Establish a guideline that indicate the responsibilities of each level of the administrator (Health
facilities, Regions, Contractors)
Establish a maintenance information system (possibly as part of the HMIS).
Proper handling of medical equipment and entire building maintenance should be considered.
B. Medical equipment
Identifying and recruiting the necessary experts/technicians/health workers with special training
to conduct prevent and basic maintenance
Establishing primary workshops in the health centers and secondary workshops at regional level
The procurement of equipment should be inclusive of an adequate number of the respective basic
spare parts lasting for 3 years maintenance and service period.
Further service contracts with suppliers should be proposed and funded where possible
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Small workshops and maintenance stores meant for health facility needs should be in place where
ever possible (this is possible in central ,regional or Woreda HMS)
Much of the maintenance required for health facilities (particularly in rural areas) can be done
using basic level skills, requiring few spare parts and very little organisation.
C. Constructions
A basic assessment and maintenance should be conducted based on damage observed,
The maintenance should consider at facility level or outsources based on the level of work.
2.6 Concepts and applications of leadership in the

health sector
1. Understanding the concept and practices of leadership
Definition: There is no single definition for leadership. There are almost as many different
definitions of leadership as there are many people who defined it. Some of these definitions are
presented here. Leadership is defined as a process by which an individual influences a group of
individuals to achieve common goals. Leadership as a process produces change and includes
establishing direction through visioning, aligning people with the vision and strategies, and
motivating and inspiring staff. In another definition, leading an organization means marshalling
the people, capital and intellectual resources of the organization to move it in the right direction.
Marshaling resources involves focusing attention, organizing/collecting and empowering their
use. Even when your team or organization has direction, the internal and external complexities
can prevent it from advancing in the agreed-upon direction. When you are aligned or
coordinated, with the rest of the organization, your staff resist going their own way and they will
be more likely to work together to support the whole organization.
Leading practices: Leaders can adapt to changing conditions in the environment and lead others
to adapt as well. By using their adaptive skills, they enable the staff to achieve results despite
complex conditions and scarce resources. They are well informed about opportunities and
threats. Their direction is clear to staff. People and resources are aligned around a common
shared vision. And because of their commitment, work groups deliver the results that leaders
promised. Therefore, when you apply the following specific leadership practices, you and your
team will be able to face your main challenges and work together with your organization to
address them.
1) Scanning for up-to-date knowledge about yourself (to be aware how your behavior and values
affect others), your work group, your organization, and your environment. To apply this practice,
accomplish the following activities.
t practices
— values, strengths, and weaknesses
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The expected organizational outcome as a result of this practice is that leaders have up-to-date,
valid knowledge of their clients, the organization, and its context; they know how their behavior
affects others.
2) Focusing staff ‘s work on achieving the organizational mission, strategy, and priorities;
The expected organizational outcome of focusing is that your organization‘s work is directed by
well-defined mission, strategy, and priorities.
3) Aligning and mobilizing stakeholders‘ and staff‘s time and energies as well as the material
and financial resources to support organizational goals and priorities;
s, mission, strategy, structure, systems, and daily actions
The organizational outcome of this practice is that internal and external stakeholders understand
and support the organization‘goals and have mobilized resources to reach these goals.
4) Inspiring your staff to be committed and to continuously learn how to adapt and do things
better. Moving an organization to the right direction involves energizing through removing
obstacles to progress, and making the changes necessary to improve performance and enabling it
to learn and grow.
outcome that your organization displays a climate of continuous learning and staff show
commitment, even when setbacks occur.
Therefore, leadership is based on an action that is combined with on-going learning

(perseverance) and practice as opposed to a one-time effort. It is speaking and listening in a way
that individuals are enabled to act to create a future that was not predictable at the time of the
conversation. Leadership is concerned with the future and is critical for the development of
individuals, organizations and societies. Effective leaders are expected to answer the following
five key questions satisfactorily:
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1. What do we want to happen or create? Refers to understanding where we want to go,

involving the aspirational dimension of leadership, including creating a shared organizational
vision, mission, and core values.
2. What is happening now? And why is there a difference? These questions refer to assessing
where we are and analysing the gap. It is the process of collecting relevant information and
making sense of the organization‘s competitive environment.
3. What do we need to change? Involves learning how to get there involves understanding and
formulating the critical elements of strategy.
4. How do we take care of change and accountability? Refers to making the journey by
translating the strategy into action through identifying and implementing tactics.
It is also about checking our progress is the continuing assessment of effectiveness. This part
then leads to a reassessment at the organization‘s new level of performance, starting the learning
cycle over again. You can make a self-assessment to see if you are an effective leader by
responding to the questions: Do you believe in working in concert with others, you can make a
difference as leadership is always exercised with others? Are you a critical thinker and
innovative to create something of a value that did not exist before? Do you exhibit positive
energy to your followers through inspiring and being a role model? Do you actualize and
welcome change by matching your words with deeds?
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Chapter 3
3.1 The concept of coverage and patterns of health care utilization
(including organization and use of the referral system)
Introduction
3.1.1 Achieving universal health care coverage
Countries have used different means of making health care available to all: universal coverage is
achieved either through the extension of social insurance or government provision to the whole
population.
The concept of coverage was ﬁrst emerged in the 1960s as a key indicator for measuring the
proportion of populations that were covered by health care, particularly with respect to
communicable diseases and immunization programmes. WHO has defined the term in a manner
that intrinsically links effectiveness with coverage—‘the proportion of the population in need of
an intervention which has received an effective intervention’ (Hogarth, 1975; WHO, 2001).
Coverage received particular attention in the early 'Health for All ’era related to the Alma Ata
Declaration of 1978. Later, in 1980s the focus apparently shifted towards access and utilization.
Due to interest of policy makers and political acceptability (justification of investment &
resource allocation). In the mid- and late 1990s, rising concern with equity resulted in the shift of
attention towards measuring inequalities in health and health care.
In the 1990s and early this century, there have been increasing calls for ‘high-coverage’
interventions. As a concept, ‘coverage’ has become the term frequently used in both academic
and program related literatures. In this sense, ‘coverage’ has become inspirational—a call to
action and a spur to move beyond small scale demonstration projects.
3.1.2 Concept and views of health service coverage
Health service coverage depends on the ability of a health service to interact with people who
should benefit from it (target population)i.e. is the ability to transform the intention to serve
people into successful intervention for their health. These transformation process involves a
variety factors such as availability of resource and man power ,distribution of facilities supplies,
and peoples attitude to health and health care. It is impossible to observe the whole of such many
sided process and evaluate in every detail, but it is possible to observe the number of peoples for
whom the service has fulfilled certain criteria relating to its intended health intervention and to
compare that number with the target population. This has given rise to the concept of coverage
and its evaluation. Coverage is normally expressed by the proportion of target population who
can receive or have received, the service. The number of people for whom the service can be
provided expresses the service capacity and indicate the potential of service.
On the other hand the number of people who have received the service expresses the service
output and indicates the actual performance of the service. Therefore coverage related to service
capacity is potential coverage and that related to output is actual coverage. The relationship b/n
service capacity and service output is another important aspect of health service which is called
utilization or service utilization. It is normally expressed as the ratio b/n output and capacity
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assuming the capacity of the service to be known. Utilization refers only to service and its
measurement is only indirectly related to the size of target population
Health service coverage is considered as concept expressing the extent of interaction b/n the
services and the people for whom the service is intended. This interaction is not being limited to
particular aspect of service provision but ranging over the whole process of resource allocation to
achievement of the desired objectives. For the measurement of coverage several key stages are
first identified each of them involving realization of several conditions for providing the service.
A coverage measure is then defined for each stage, namely the ratio b/n the number of people for
whom the condition is met and the target population. So that a set of these measures represent
the interaction b/n the service and target population
3.1.3 Domains of coverage measure
* There are number of ways of describing the capacity and output of service; hence there
are number of ways of measuring coverage. it is unlikely that single measurement of coverage
could satisfactorily reflect the complex interaction b/n the health service and target population.
In order to identify the measurements of coverage that reflect essential requirement for the
service provision; - let us imagine the process where by a person in need of certain kind of health
care obtain the appropriate service, First he looks for service in his area that is relevant to his
problem When he has found there is one he can use it only if he has the means of reaching for it.
Whether he can affords it and decide to use it is another matter ; if he does then he receive the
service but the service may or may not solve his problem depending on the quality of service as
well as the nature of his condition.
Looking at this process from a point of view of service provision it is possible to identify five
important stages that successfully lead to desired health intervention and to define measurement
of coverage appropriate to these stages
1. Availability coverage;-
First of all, some resources human power, facility, drugs etc-always required in order to provide
a service, the availability of such resources limits the maximum capacity of a service, which in
turn decides the amount of the service that can be available to the target population. The ratio b/n
this capacity and size of target population gives us the measurement of coverage is availability
coverage.
2. Accessibility coverage
Even if all the necessary resources are available, the service must be located within the
reasonable reach of people who benefit from it. Meeting this condition can be considered as the
next stage in the process of service provision. Here the capacity of service is limited by the
number of people who can reach and use it.The measurement of coverage based on this capacity
is accessibility coverage.
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3. Acceptability coverage
Once the service is accessible it still needs to be acceptable to the population, otherwise people
may not come for it and may even seek alternative care. This acceptability may be influenced by
cost of service, the religion the users follow etc.
If service is accepted by potential user this is another step forward in the process of service
provision. Here service capacity is limited by the number of people who are willing to use the
accessible service. The measurement of coverage based on this capacity is defined as
acceptability coverage.
4. Contact coverage;-
The next stage in the process of service provision is the actual contact b/n the service provider
and the user. The number of people who have contacted the service is measurement of service
output. - The ratio b/n this and the size of target population gives a measurement of coverage that
is called contact coverage
5. Effectiveness coverage;-
The contact b/n the service provider and the user does not always guarantee the successful
intervention related to user’s health problem or an effective service.we can therefore consider
another stage in the process of service provision where a service performance that is appraised as
satisfactory by specific criteria is achieved. The number of people who have received satisfactory
service is thus another measure of service output and measurement of coverage based on this
output is called effectiveness coverage.
Note ; It measures the health system's efforts (performance of health service delivery function) in
terms of providing the population with a set of services that are believed to be effective if
individuals use them
3.1.4 Description of coverage measurements
Fundamental to measurement of coverage is the description of services;-
* In observable or measurable terms of the service whose coverage is to be measured.
The description must at least answer the following questions;-
• What is the aim of providing the service?
• What does the service do?
• For whom or what is the service intended?
• What are the essential resource required for the service?
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• How much of the essential resources would a unit of service require?

• How can the performance of the service be measured?
• What are the criteria for satisfactory performance of the service?
3.1.5 Importance of measurement of coverage

Suppose that the five measurement of coverage are obtained. The stage in service provision have
been defined in such a way that certain in equalities exists b/n them. In other words, large
difference implies the existence of problem or bottle neck in the service provision. Bottle neck in
the availability and accessibility implies poor allocation and deployment of resource and
facilities. Low acceptability implies poor appreciation of service by the public. A large
difference b/n adjacent pair of the coverage measurement implies that ,for a significant
proportion of target population the service is failing to meet the requirement for progress in
service provision
Inadequate coverage by contact can be a lack of public demand for the service or failure to
provide service to some people because of faulty operation. Bottle neck in effectiveness implies
poor quality service.
3.1.6 Coverage evaluation
A bottle neck shows where the difficulty in service provision lies but it does not pinpoint the
factor responsible for the poor coverage. For example poor quality of service may be due to the
use of ineffective drug. A good knowledge of a health service and of the situation of the target
population is thus required in order to analyze the constraining factor.
Gathering relevant information for the analysis is an integral part of coverage evaluation.
Health personnel as well as clients and potential users are important source of information ,and
consultation with them may very well be sufficient to permit the cause of bottle neck to be
identified.
The development of coverage evaluation scheme
It requires three things
A. information
Demographic, epidemiological and socio economic on the population with which the service is
concerned.
B. knowledge of the health problem that the service is intended to deal with and the activity of
the service.
C. ability to gather information on the operation of the service.
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Health Service Coverage is considered as a concept expressing the extent of interaction between
the service and the people for whom it is intended. This interaction not being limited to particular
aspect of service provision but ranging over the whole process from resource allocation to
achievement of the desired objective.
3.1.7 Health service delivery and referral system of Ethiopia
The Ethiopian health service is now restructured into a three tier system. These levels are:
a) The primary care level has three kinds of service points – health posts, health center and
primary hospitals.
• The Health Posts and Health Centers are organized into PHCUs, which is composed of a HC
and five satellites HPs. Taken together; the PHCU provides services to a population of about
25,000 persons.
• Each Health Post (HP) is staffed with two HEWs, and is responsible for a population of 3-5,000
persons. The HEWs are expected to spend less than 20% of their time in health posts, and more
than 80% of their time is meant to be spent on community outreach programme visits to
households, especially mothers and children. The HEWs provide 96 hours of training to
households on the selected packages of HEP and follow the household’s practices before
certification and graduation of the household. HEWs also provide selected health care services,
including family planning, EPI, OTP, clean delivery and essential newborn care services,
diagnosis and treatment of malaria, diagnose and treatment of pneumonia, and management of
diarrhea and dehydration using ORS.
• A HC has an average of 20 staff. It provides both preventive and curative services. It also
serves as a referral center and practical training institution for HEWs. The HC has an inpatient
capacity of five beds. Rural HCs serve populations up to 25,000 persons; urban HCs serve up to
40,000 persons.
• 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 emergency surgical
services, including Caesarean Section and gives access to blood transfusion service. It also
serves as a referral center for HCs under its catchment areas, and is a practical training center for
nurses and other paramedical health professionals. A primary hospital has an inpatient capacity
of 25-50 beds. On average, a Primary Hospital has a staff of 53 persons.
b) The secondary care level is comprised of General Hospitals.
• A General Hospital provides inpatient and ambulatory services to an average of 1,000,000
people. It is staffed by an average of 234 professionals. It serves as a referral center for primary
hospitals
c) The tertiary care level is comprised of Specialized Hospitals.
• A specialized hospital serves an average of five million people. It is staffed by an average of
440 professionals
.
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The Ethiopian health service evolution, six, four, and three tier system .
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3.2 Quality of health care

Quality Management in the Health Care Setup
Definition of Quality in Health Care

Quality in the health sector is becoming a major concern for patients, public health officials,
funding agencies and governments during the last two decades.
What constitutes quality in health care?

Quality in Health Care
What constitutes quality in health care?
Different for different groups of stakeholders/actors
o Health care providers
o Health care financers/donors
o Patients
o Others
Definition depends on what people value more focus of stakeholders
Patients focus on physician-patient interaction, physical environment, time
Health workers
o appropriateness of provided care
o provision of appropriate care
o fulfillment of required equipments and medical supplies
Funding agents
Emphasize the importance of efficiency and accessibility of care
Almost everyone who has stake in health care delivery considers appropriateness of provided
care and provision of appropriate technical care as a major component of quality
Definition
 Quality is the degree to which a set of inherent characteristics of something comply with
a set of expectations. It is a relative concept which cannot be defined in a vacuum.
The totality of features and characteristics of a product or service that bear on its ability to satisfy
(customer) stated or implied needs. Medical quality is the degree to which health care systems,
services and supplies for individuals and populations increase the likelihood for positive health
outcomes.
 The application of medical science and technology in a way that maximizes its benefits to
health without correspondingly increasing its risks. The degree of quality is, therefore,
the extent to which the care provided is expected to achieve the most favorable balance of
risks and benefits.
Proper performance (according to standards) of interventions that are known to be safe, that are
affordable to the society in question, and that have the ability to produce an impact on mortality,
morbidity, disability, and malnutrition.
IOM of the National Academies (American)
 Health care quality is the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current
professional knowledge.
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Important concepts in the definitions

Quality of health care is about: components of care that can impact outcomes of care positively
execution of components of care in compliance with recommendations with scientific grounds
Execution of care in a way that maximizes advantages while keeping costs and other undesirable
effects minimal
Meeting these involves
 Research
 Education
 Policy making
 Resource allocation/Donation
 Health facilities practices
 Patient/client behavior
Components of Health Care Quality
According to Donabedian, quality of health care has seven pillars/components
I. Acceptability
II. Legitimacy
III. Equity
Efficacy:
Is the ability of the science and technology of health care to achieve desired outcomes under best
circumstances.
What constitutes “best circumstances” is always difficult to define and Controlling other factors
is always challenging
Therefore, a more realistic definition could substitute “specified circumstances” for “best
circumstances”
Effectiveness:
Is the degree to which attainable outcomes are attained in reality.
It is the comparison between what is achieved in reality with what is potentially achievable with
the ‘best’ care provided
Efficiency the ability to achieve attainable outcomes of care at a lower cost. Improving
efficiency means decreasing the cost of care without compromising achievement of maximum
attainable results This can be done by: improving the technology of health care (producing more
efficient drugs, diagnostic algorisms, etc) improving the process of health care to avoid medical
errors (harmful, useless or less effective decisions) appropriate use of resources for health care
Optimality the balancing of improvements in health against the cost of such improvements
Equity covered in chapter 4
Maximizing Vs Optimizing benefits
Acceptability
Is the level of conformity to the wishes, desires and expectations of patients
Usually related to what beneficiaries of health care value more including
Accessibility
Provider – patient interaction
Accommodations of care
Patient preferences regarding the effects, risks and costs of care
Legitimacy
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It is the conformity of health care to social preferences as expressed in ethical principles, values,
norms, laws and regulations. It is the equivalent of acceptability as applied to the society
Quality Improvement
Infrastructure for QM
Quality Improvement
Is the step during which series of actions will be taken to: identify factors underlying observed
levels of quality
Why? Why? approach (the problem tree) Fish bone
Involves:
Planning and implementation of potential solutions to change underlying root problems
Study if changes bring improvement expand those changes that are found effective and modify
those found ineffective
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Chapter 4
4.1 Application of economics to the health sector
Can economics be applied to health?
Anyone who has worked in health care will be well aware of the scarcity of resources. Therefore
choices are inevitably made about what treatments are provided and about who receives
treatment; that is, there is some form of rationing.
Economists advocate making such rationing decisions explicit. Most importantly in the context
of limited resources, the provision of one service, X, necessarily means that a second service, Y,
is displaced. The health gain that we would have got from service Y is the opportunity cost of
our decision to provide service X. Economists try to ensure that the opportunity cost of providing
X does not exceed the health gain from X.
Economics is the study of scarcity and choice; it follows that if economics is relevant anywhere
then it should be relevant in health. However, health care has some interesting characteristics that
mean the more basic economic models should be used cautiously (Arrow 1963). None of these
characteristics is unique to health but the combination of characteristics together with their sheer
number have contributed to health economics becoming a distinct sub discipline of economics.
Another characteristic of health economists that has moved them away somewhat from
mainstream economics is their interest in measuring and optimizing an objectively defined
‘population health’, rather than ‘social welfare’, which is explicitly based on individuals’
preferences. This approach is often referred to as ‘extra-welfarism’.
The aim of health economists is often to inform decision makers so that the choices they make
maximize health benefits to the population. Health economics is not concerned with ‘saving
money’ but with improving the level and distribution of population health with the resources
available.
4.2 Demand and supply in the health sector

The demand for health care
As you have seen, demand requires that a person desires the service, that they can afford to pay
for that service and that they are willing to pay for it. The (normative) need for health care is the
care that practitioners believe is necessary for a person to remain or become healthy. On some
occasions the patient decides they require health care (felt need) but their doctor decides that
they could not benefit from such care. On other occasions, the doctor would have considered
there to be a medical need but the patient does not consult their doctor because they prefer not to
have treatment or do not recognize the need. Even if patients are as well informed as their doctor,
it is quite possible that their demand is different from their need.
The use of services depends on the availability of services (the supply side) as well as the
demand. The following factors influence the demand for health care:
 need (as perceived by the patient);
 patient preferences;
 income;
 price/user charge;
 travel cost and waiting time;
 Quality of care (as perceived by the patient).
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Use depends on demand and accessibility. If planners allocate resources on the basis of need
instead of demand then they may find that some services are underused while other services are
over-subscribed. There are various reasons why the demand for health care continues to exceed
supply: an ageing population in which the elderly require more health care than younger adults;
new health technologies which means more conditions have become treatable; and increased
expectations from people
The major purpose of demand analysis for medical care is to determine those factors which on
the average, most affect a persons utilization of medical services.
Demand analysis seeks to identify which factors are most influential in determining how much
care people are willing to purchase.
Demand for health care
Demand is based on the individual and community expectations. The individual may feel that he
needs a service, but expert opinion may say that this is not a reasonable demand
E.g. patient may ask the physician for an antibiotic to treat viral infection, which would not help
in cure and may cause harm.
Need, demand and utilization of health services
Need in medical care defines as the amount of medical care that medical experts believe a person
should have to remain or become as healthy as possible
Need in medical care exists when an individual has symptoms, illness or disability for which
there may be an effective or acceptable treatment or cure from which the patient can benefit
Demand for medical care exists when an individual considers that he has a need and willing to
spend resources of money, time, energy, loss of work, travel and inconvenience to receive care.
Utilization occurs when the individual actually acts on this demand or need and receives health
services.
Supply means, the quantity of goods or services a seller is willing to produce and sell.
The supply schedule of a commodity refers to the relationship between the market price and the
amount of that commodity that producers are willing to produce and sell.
Supply in health care
Demand may also be induced by the supply or provision of care
Making more hospital beds may increase their use beyond justifiable need or it may lead to an
un necessary long stay in hospital. Providing some services at no cost to patients may induce
people to utilize those services more really that require for health reasons.
An inappropriate or excessively frequent use of a service is promoted and used by upper middle
class, while the important services may be lacking to serve the poor due to inequitable allocation
of resources.
A model of demand for medical care
Consumer purchase goods and services for the utility. If the commodity demanded by consumers
is good health, then health can produced by goods and services purchased in the market as well
as by the time devoted to preventive measures
Demand for medical care is derived from the more basic demand for health
According to Michel Grossman” consumers have a demand for health for two reasons
Health is a consumption commodity—it makes the consumer feel better
Health is an investment commodity—a state of health will determine the amount of time
available to the consumer
Factors affecting the demand for medical care
Grover C Wirick has identified 5 fundamental factors those have an impact on medical care.
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First is need, when a person suffers from an illness that requires attention or has some other
reasons for seeking medical care or examination.
Secondly there must be a realization of the need. Either the individual or someone acting on
behalf of him must know the that the need exists
Third financial resources must be available to implement a medical care.
Fourth, there must be a motivation to obtain the medical care.
Fifth, is availability of service.
The first 3 forces are the characteristics of the patient, fifth is a phenomenon of his environment.
The forth may be of either.
4.3 Issues of equity in the health sector

Ideas about fairness
Mortality and morbidity are not distributed equally across socioeconomic groups, not even
in high income countries. The following are potential explanations of the observed
socioeconomic inequalities in health: inequalities are an artefact: there are no real differences
between the health of social classes; any apparent difference is due to statistical errors such as
missing data;
• Health status affects social status: people with poorer health have low paid jobs or are
unemployed and as a result are in lower social classes;
• Behavioral differences between social classes lead to health differences: people in lower social
classes take more risks with their health such as smoking, a poor diet and drug abuse;
• Material inequalities lead to health inequalities: people in lower socioeconomic groups are
exposed to health risks such as poor housing, dangerous jobs and worse environmental pollution.
The last two are probably the most convincing explanations. The behavioral differences were
expressed in terms of preferences and education levels.
Many health systems are concerned not only with the maximization of welfare (efficiency) but
also with the fair distribution of welfare (equity). But what exactly is a ‘fair distribution’? What
makes a health system fair? Is there any single definition of justice that should be applied to
health systems? Furthermore, does this objective conflict with the need to make health systems
efficient? The following extract by Michael Parkin and colleagues (2003) considers the different
philosophical approaches to equity that have been proposed.
Equity and health care
Now that you have considered some different perspectives on fairness, you can see what work
has been done in applying these theories to health care. First, you need to consider whether end-
stage equity (equality of health) is a practical health care objective.
Given these difficulties, perhaps process equity should be the goal of health systems. There are
several ways in which process equity can be defined:
 Equal access to health care for equal need
 Equal use of health care for equal need
 Equal health care expenditure for equal need
All of these refer to equity between people with the same health care needs. This is known as
horizontal equity. It is also important to recognize the corollary, that people with different or
unequal needs should receive different or unequal health care. This is known as vertical equity.
Note that the difficulties involved with measuring equality of access mean that equality of use is
usually used as a proxy when equity is being assessed
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Equality of access requires that, for different communities:

 Travel distance to facilities is equal
 Transport and communication services are equal
 Waiting times are equal
 Patients are equally informed about the availability and effectiveness of treatments
 Charges are equal (with equal ability to pay)
Even though it is more feasible than equality of health, equality of access clearly poses quite a
challenge to health planners.
The ability to achieve an equitable health care system will be tempered by the need to be
efficient. That is, it is not possible to both maximize health and equalize access to health care.
4.4 Methods of economic evaluation and costing of health care

programs
Economic evaluation
Economic evaluation with the outcome measured in health units is called cost-effectiveness
analysis (CEA). You can calculate the ‘cost per unit of outcome’, such as the cost per reduction
in cases of illness.
There is a subset of cost-effectiveness analysis (CEA) called cost–utility analysis
(CUA) where the outcomes are measured in health units, which capture not just extension to the
length of life but also changes in the quality of life. The most commonly used measure is the
Quality Adjusted Life Year, or QALY.
When outcomes are expressed in monetary terms, the technique is called cost–benefit analysis
(CBA).
Framing an economic evaluation
There are three steps in undertaking an economic evaluation:
 framing the evaluation;
 Identifying, quantifying and valuing the resources needed;
 Identifying, quantifying and valuing the health consequences.
Purpose
It’s important to be very clear about why you are carrying out the economic evaluation. The
statement of purpose should include the following information:
the intervention;
the health problem addressed by the intervention;
the reason for conducting the evaluation and its importance;
the units of analysis.
Reviewing economic evaluations
Economic evaluation can be applied to a variety of different areas. Not all relate to health care
interventions. Some evaluate the economic consequences of management activities in the health
sector. The following extracts illustrate the broad range of economic evaluations that are carried
out. They will give you practice in identifying the salient points when reading reports of
economic evaluations.
Approaches to Health Status Measurement
 Morbidity and mortality
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 Measure of function and dysfunction

 Health profiles
 Generic/Global measures
 Utility measures (QALY & DALY)
Main Methods of Economic Evaluation
I. Cost minimization analysis (CMA)
II. Cost effectiveness analysis (CEA)
III. Cost utility analysis (CUA)
IV. Cost benefit analysis (CBA)
Measuring Costs of a Health Intervention
Program Costs patent
Costs to Participants (Users)
Costs Associated with side effects of the Intervention
Program Costs
 Capital
 Buildings
 Equipment
 Vehicles
 Consultancies (non-recurrent)
 Recurrent
 Personnel
 Supplies
 Vehicle operation and maintenance
 Building operation and maintenance
 Consultancies (recurrent)
 Other
Costs to Participants (Users)
Out-of-pocket costs
Travel costs and child, elderly care or any other cost paid by user
Contribution to the service (e.g. drugs, food, etc)
Productivity Losses in the form of:
o Travel time
o Waiting time
o Actual service time
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Costs Associated with side Effects

 Cost of treating the side effects (prob. of side-effect X cost of treat.)
 Classification of Costs
 Total and Average costs
 Variable and fixed costs
 Capital and recurrent costs
 Financial and economic costs
 Marginal and incremental costs
Identifying costs
 Direct medical costs
 Organizing and operating costs borne by the health sector
 Direct nonmedical costs incurred by patient/families in the course of treatment
Indirect costs
Losses in production due to absence from work
Intangible costs
Psychic costs associated with treatment
Approaches to Cost Studies
4.5 Principles and types of healthcare financing

Principles of health care financing
There are various well-known models for implementing these basic functions— national health
service systems, social health insurance funds, private voluntary health insurance, community-
based health insurance, and direct purchases by consumers. More important than the models,
however, are three basic principles of public finance:
• Principle 1. Raise enough revenues to provide individuals with a basic package of essential
services and financial protection against catastrophic medical expenses caused by illness and
injury in an equitable, efficient, and sustainable manner.
• Principle 2.Manage these revenues to pool health risks equitably and efficiently.
• Principle 3. Ensure the purchase of health services in ways that are allocative and technically
efficient.
All health financing systems try to follow these principles, but the evidence reviewed here shows
that there is no single road. Countries operate within highly different economic, cultural,
demographic and epidemiological contexts, and the development of their health provision and
financing systems—and the optimal solutions to the challenges they face—will continue to be
heavily influenced by these and other historical factors as well as political economy
considerations. Even so, countries can learn from both the successes and the failures of each
other’s health financing efforts.
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Four types of health care financing

Four types of health insurance are widely used to pool risks, foster prepayment, raise revenues,
and purchase services:
I. state-based systems funded by the government and operated through ministries of health
or national health services,
II. social health insurance,
III. community-based health insurance,
IV. And voluntary health insurance.
The four approaches differ in important aspects that can affect their performance in countries
with different income levels, employment structures, health needs, and administrative capacities.
4.6 Healthcare financing in Ethiopia

Financial Management
Simply put, financial management could be defined as the planning, directing, monitoring,
organizing and controlling of the financial resources of health facilities to ensure regular and
adequate supply of funds to provide health services and optimum utilization of resources.
The purpose of financial management is to assure adequate funding for all health care services in
the nation, provided they are shown to be necessary, effective, and economical.
Basic accounting procedures and cycle in the health system
Managers within the sector have to ensure that deferent units of the health sector are following
and implementing proper financial management system. Revenue collection, utilization and
reporting systems should align with government financial management following modified
government cash base accounting system
Health Care Financing
the health sector activities.
needs of the people and for specific types of health care services.
o Is concerned with the whole process of health care financing: where the money comes from;
how it is collected; how it is pooled; and how it is used to pay health service providers
Health care financing reform, similarly, is an alternative arrangement for mobilizing, collecting,
paying and managing health resources in order to increase efficiency, promote equity and
improve access and quality of health services.
The main elements of Health care financing include:
• Raising sufficient revenue in a sustainable manner
• Pooling risk equitably and efficiently
• Purchasing health services to cover the health needs of the community
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Health Care Financing in Ethiopia

Lack of sufficient funds has been one of the most critically limiting factors to improve access
and quality of the health care system in Ethiopia. To alleviate the persistent under-financing of
the health sector and mobilize sufficient amount of resources, the Federal Ministry of Health of
Ethiopia has been implementing the Health Care and Financing Strategy since its development in
1998.
Financial resource is a crucial input for provision of adequate and optimum quality health
services. However, the ever increasing cost of health care and multiple competing priorities in
resource poor countries makes financial resources insufficient to make substantial improvements
in access and quality of health care.
The strategic objective sets out in HSDP were following proactive approaches to the
mobilization of resources from domestic and international sources. It includes enhancing pool
funding; addressing collection and use of revenues by health institutions; and establishing a risk
pooling mechanism. It also includes attention to effective and efficient use of resources; sound
financial and program management leading to performance-based financing; as well as equitable
and evidence-based allocation of resources to priority interventions and programmes in the
health sector.
The financing sources of the Ethiopia’s health sector include the government treasury at different
levels, Official Development Assistances (ODA), out-of-pocket expenditures, nongovernmental
organizations (NGOs). The finance generated through these sources are too small to ensure and
equitable quality service to all segment of the population as evidenced by per capita health
spending.
Develop a robust financial projection and monitoring tool covering both external and
internal funds to track health care expenditure including those for Primary Health Care
services
Given Ethiopia’s current inability to monitor all external funds and given the need to have more
sustainable domestic resource flows the FMOH should develop a robust financial projection and
monitoring tool of external and internal funds to track and project future health care
expenditures. Expenditures tracked would include those for Primary Health Care services in
order to ensure adequate support strategies with Primary Health Care approach. This is especially
important with more fiscally intensive plans, including building new health facilities and
equipping them with the resources and staffing needed to operate.
Expand pooling and purchasing mechanisms to accelerate progress towards universal
coverage using health insurance schemes
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Chapter 5
5.1 Principles and components of HIS/HMIS
Information system
It’s a set of interrelated components that collect or retrieve process, store and distribute
information to support decision making and control
Health management information system (HMIS) is an information system specially designed
to assist in the management and planning of health programs. (WHO, 2000)
Components of Health Information System (HIS)
1. Health information system resources (inputs)
These include legislative, regulatory, planning frameworks required to ensure a fully functioning
health information system. Such resources involve personnel, financing and information
communication technology.
2. Indicators
Process indicators
o Determinants of health: socioeconomic, environmental, behavioral, demographic and genetic
determinants or risk factors.
o Health system: input indicators (policy, organization, human resources, financial resources,
health infrastructure, equipment and supplies).
Output indicators: health service availability and quality, as well as information availability
and quality.
Immediate health system outcome indicators: service coverage and utilization.
Health status: levels of mortality, morbidity, disability and wellbeing
3. Data sources
Population-based approaches: Censuses, civil registration and population surveys.
Institution-based data: Individual records service records and resource records.
Others: Occasional health surveys, research etc…
4. Data management
-assurance to
processing, compilation and analysis.
5. Information products (Outputs)
knowledge to shape health action.

6. Dissemination and use
-
makers.
The HMIS reform in the Ethiopian health system was introduced due to address the following
“bottlenecks”.
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These are:
1. Limited definition and implementation of HMIS/M&E staffing standards, both for sanctioning
and filling positions; few trained staff
2. Limited standardization of recording and reporting definitions, forms, and procedures
3. Unnecessarily high data burden, with duplicative and poor quality data.
4. Limited implementation of evidence-based planning and monitoring procedures
5. Limited consistency amongst health related information sources and limited collaboration
amongst generators of health related information
6. Limited use of technology
Hence, the strategic plan for HMIS (2008) specified the following major objectives of the
reform:
1. Capacity building within the organizational structure and its staff
2. Standardization, integration, and simplification of data collection and reporting tools
3. Linkage between sources of health and health-related information
4. Enhanced action-oriented performance monitoring
5. Appropriate technology
Basic principles
1. Standardize: standardization of the following elements was indicated:
2. Simplify: it is related to reduction of data burden and streamlining data management

procedures.
3. Integrate: the integration is related to integration of data channel client/patient information at
facility.
4. Institutionalize: is related to facilities owning and leading the implementation.
Steps in Developing a Health Management Information System
1. Review the existing system
2. Define the data needs of relevant units within the health system
3. Determine the most appropriate and effective data flow
4. Design the data collection and reporting tools
5. Develop the procedures and mechanisms for data processing
6. Develop and implement a training program for data providers and data users
7. Pre-test, and if necessary, redesign the system for data collection, data flow, data processing
and data utilization
8. Monitor and evaluate the system
9. Develop effective data dissemination and feedback mechanisms
10. Enhance the HMIS
5.2 Ethical and legal issues in HMIS

5.2.1. Introduction
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Delivering healthcare services to the population is dependent on information for proper planning.
To have a properly functioning Health Management Information System (HMIS), there must be
policies and procedures which are adequately enforced.
5.2.2. 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 access, to protect
confidentiality, etc.
In Ethiopia, there is legislation providing the framework for health information covering specific
components, such as notifiable diseases, private sector data, confidentiality, fundamental
principles of official statistics, etc. With regard to vital statistics, starting from the 1960 Civil
Code of Ethiopia, the country has declared different legislations at different times to implement
the legal and official registration of births and deaths.
However, no significant progress has ever been made to put this in to action. Currently, Ethiopia
is in the stage of publicizing the registration law, creating organizational and administrative
structure and establishing local registration offices and training of registrars. Ethiopia does not
have a regular system for monitoring of the performance of HIS. The National Advisory
Committee (NAC) of the HMIS is in charge of coordinating the health information system
although it has a limited mandate and resource to run the activity on a regular basis.
NAC was initially founded in 2005 with an objective of assisting in the review of the existing
HMIS and M&E system, development of a comprehensive HMIS and M&E strategy as an
implementation tool for monitoring and evaluation of HSDP III and beyond.
Ethiopia has limited capacity in core health information sciences to meet health information
needs. There is a functional central HIS unit in the Ministry of Health which plays a significant
role in coordinating, strengthening and maintaining the national HIS, including the ongoing
HMIS reform. However, it lacks adequate resources to effectively maintain and upgrade the
status of HIS to a level that meets the health information requirements of the country. The
problem progressively increases as we move down to the Woreda health offices. To make things
worse, at all levels of the health system, the professional mix is poor and the attrition rate is very
high, which calls for major intervention in the area of HIS capacity building activities.
5.3 Application of IT in the analysis and management of health

systems
Information and Communications Technology (ICT). At woreda level and upwards. Data
analysis and transmission will be automated through data entry of facility data at the woreda
level. At woreda level and upwards production of reports (tables, charts, and maps) will be
automated. Data will be transmitted electronically, by CD, internet, or direct input into a data
warehouse, depending on the infrastructure available.
The health information system requires managing the health information through health
management information system (HMIS), research and development (R&D) and knowledge
management (KM).
HSDP put this strategic objective to support improved evidence-based decision making through
enhanced partnership, harmonization and alignment, including integration of projects and
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programs at the point of health service delivery. It will comprehensively address identification of
health system bottlenecks; research; HMIS; performance monitoring; quality improvement;
surveillance; use of information for policy formulation, planning, and resource allocation
Woreda Based Planning (WBP) is now the formal planning process in most regions. Planning is
taking place at different levels, involving more stakeholders, such as the head of health centres,
community representatives, NGOs, community leaders, administrative leaders and development
partners. There is an increasing emphasis on gender issues in the WBP, including in trainings,
reports and MNCH. There are various positive impacts of the WBP process, such as increased
ownership, growing participation and collaboration at different levels. WBP has contributed to
the alignment and harmonization of the planning, budgeting, resource allocation, prioritization,
tracking and reporting systems. WBP has improved access and awareness of various issues such
as related to capacity building, CEmOC, BEmOC and others.
WBP has helped to provide evidence for resource allocation, in detailed activity based planning,
and more flexibility in reprogramming.
Knowledge management is lacking in the health sector. Knowledge management is the
systematic management of an organization's knowledge assets for the purpose of creating value
and meeting tactical & strategic requirements; it consists of the initiatives, processes, strategies,
and systems that sustain and enhance the storage, assessment, sharing, refinement, and creation
of knowledge. Knowledge management (KM) therefore implies a strong tie to organizational
goals and strategy, and it involves the management of knowledge that is useful for some purpose
and which creates value for the organization. Little emphasis has been given to KM so far
evidenced by loss of institutional memory or tracing documentation in major undertakings.
5.4 Ethiopian HMIS

5.4.1 Health Information Related Initiatives
The HMIS related initiatives are best understood in light of the overall objectives of the Health
Management
Information System, which are:
o Develop and implement a comprehensive and standardized national HMIS and ensure the use
of information for evidence based planning and management of health services.
o 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.
o To achieve 80% completeness and timely submission of routine health and administrative
reports.
o Achieve 75 % of evidence based planning.
The strategy for implementation of HMIS objectives is:
• 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 ICT Authority.
• Define the minimum standard of inputs required for HMIS at different levels of the health
system.
• Initiate and sustain regular programme review and feedback system.
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The breakdown of the plan is detailed according to what activities are carried out by the various
levels in the healthcare system. These being:
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 form the health
extension workers to the HMIS personnel
* Provide the necessary health and administrative reports to the RHBs as per the guideline.
* Allocate funds for HMIS and provide the necessary facilities for the HMIS units/personnel
* Implement and monitor the pilot 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, and 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, programme managers and health
workers.
* Equip HMIS units at all levels.
* Implement HMIS on pilot basis 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 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 ICT to HMIS, pretest and implement the
application and expand geographic information system.
* Mobilize funds for implementation of National HMIS.
* Monitor the implementation of programme review and research recommendations through
HMIS.
* Publish Health and Health Related Indictors bulletin annually.
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Health Policy and Management (SPHM-3143) hand out for Emergency & critical care nursing

2.1 WHAT IS PLANNING ............................................................................................................. 17

2.2 TYPES OF PLANNING .......................................................................................................... 19

2.3 STEPS IN PLANNING................................................................................................................... 20

2.4.A Organizing ............................................................................................................................. 23

2.4.2 Organizational Structure ............................................................................................... 23

2.4.4 Organizational culture .................................................................................................... 25

2.4.B Monitoring and evaluation ........................................................................................... 26

2.5 HRH, time and material resources............................................................................... 28

4.3 Issues of equity in the health sector .......................................................................... 48

Development and organization of the health system

Introduction to existing and emerging health issues and trends

1.1.2 Current health issues

Implications of emerging health problems on health systems

 Internationally coordinated disease control system

1.1.3 Health System Strengthening

Hospital Reform Initiatives

1.2 Development and organization of the health system in Ethiopia

1.2.1 The Government

1.3 Approaches in organization and delivery during various periods

1.3.1 Indigenous health services

PHC – The level of Care

Health Extension Package Program

3. Family health service

5) Information, Education and Communication.

A. Millennium Development Goals (MDGS)

a) Agricultural development-led industrialization and food security,

b) Governance, decentralization and empowerment,

c) Reform of the justice system, and civil service and

ii. Faster and more equitable economic growth and;

1.4 Policies, strategies and programs during various periods

Summary of strategic areas

Empower the community to play a significant role in the health sector

4. Enhance the role of non-state actors in improving health status

efficiently and used effectively

ening the way for government to

management of service delivery to standard setting, advocacy, and evaluation.

political or economic events unrelated to healthcare. Incremental reform is highly influenced by

and supplies and develop and

the grassroots level.

-tier system for health service delivery

Policy influencing national development policies and strategies.

major communicable diseases, such as HIV/AIDS.

2.1 WHAT IS PLANNING

A large programme at national level

2.2.1 STRATEGIC PLANNING

2.3.6 WRITING THE PLAN

2.4.1 Organizing concepts

2.4.2 Organizational Structure

High degree of coordination is needed:

2.4.4 Organizational culture

 resources are used rationally and as planned;

2.5 HRH, time and material resources

The Ethiopian plan of Human Resource Development for health

2. Health care demands or utilization method

3. Human resource to population ratios

2.5.2 Managing Time

Identifying Your Priorities

Preparing a program chart

Setting of Health Infrastructure Priorities

Maintenance and rehabilitation of Health Facilities and Equipment

2.6 Concepts and applications of leadership in the

— values, strengths, and weaknesses

Therefore, leadership is based on an action that is combined with on-going learning