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Human Resources for Health Implications of
Scaling Up For Universal Access to HIV/AIDS
Prevention, Treatment, and Care: Ethiopia
Rapid Situational Analysis
March 2010
Gijs Elzinga
Degu Jerene
Gebrekidane Mesfin
Samrawit Nigussie
GLOBAL HEALTH WORKFORCE ALLIANCE TECHNICAL WORK GROUP
SECRETARIAT: INTRAHEALTH INTERNATIONAL
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia ii
TABLE OF CONTENTS
EXECUTIVE SUMMARY ............................................................................................................. 1
BACKGROUND AND INTRODUCTION .................................................................................... 2
METHODOLOGY FOR RAPID SITUATIONAL ANALYSIS ........................................................ 3
FINDINGS .................................................................................................................................. 3
Promising Mechanisms and Practices ......................................................................................................... 3
Gaps and Challenges .......................................................................................................................................... 5
Critical Interventions to Address Challenges ............................................................................................ 8
Leadership Action and Partner Support ..................................................................................................... 9
Key Messages .......................................................................................................................... 10
Overview .............................................................................................................................................................. 10
Universal Access and the Existing Workforce ........................................................................................ 10
Universal Access and the Future Health Workforce ............................................................................ 12
Appendix A: List of Key Informants Interviewed ................................................................ 14
Appendix B: List of Steering Committee Members ............................................................ 15
Appendix C: Background Data Collected ............................................................................. 16
Appendix D: Key Documents Reviewed ............................................................................... 28
HRH implications of scaling up for universal access to
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EXECUTIVE SUMMARY
Ethiopia is one of the poorest countries in sub-Saharan Africa, with a gross domestic product
(GDP) per capita of $223 per year. For the past five years, the HIV/AIDS prevalence was 2.2%
and is expected to rise to 2.4% in 2010. There are substantial prevalence differences between
urban (7.7%) and rural (0.9%) settings. With a population of approximately 74 million,
Ethiopia is home to one of the largest populations of people living with HIV and AIDS.
Key Messages
Scale up efforts to decrease HIV incidence. HIV prevention is difficult and requires the
kind of multisectoral approach that is already embraced in Ethiopia. However, since
incidence is not decreasing, acceleration of the comprehensive national strategy is
recommended.
Address human resources for health (HRH) retention as a matter of utmost urgency. In
Ethiopia, the loss of every health worker counts. The draft Human Resources for Health
Strategic Plan (HSP 2009-2020) lists a number of suggestions to address retention and
promising practices that are being used in Oromye. Those approaches should be further
developed and implemented presently.
Strengthen the health workforce by regulating, coordinating, and managing in-service
training. Regulation and coordination of in-service training (IST) is weak or nonexistent.
With the improved health outcomes in mind, health workers should be permitted to leave
service for training. An IST conceptual framework, policy, and guidelines are needed, as well
as a coordination mechanism.
Boost mechanisms to focus preservice education on all aspects of service delivery, and
to maximize efficiency in the balance between preservice education and in-service
training. Upon leaving preservice education (PSE), health workers should be fully capable to
professionally handle the health services delivery challenges they may meet in their jobs.
Competence gaps in PSE are costly and inefficient to fill later by IST.
Support and regulate private sector HRH education and health service delivery. The
private sector is an integral part of the health sector for which the government is equally
responsible. Norms, standards, and support should be the same for the health sector as a
whole. This holds true for the production of health workers and service delivery.
Accelerate in full partnership completion of the HRH Strategic Plan 2009-2020.
Completion of the HSP 2009-2020 with buy-in and ownership of all partners should be
pursued much more aggressively. Severe resource limitations will impact plan
implementation, so partners must set priorities and explore the limits of task shifting and
condensation of PSE.
Reconsider the conceptual flooding sequence: volume–speed–quality. The volume-
speed-quality sequence carries the risk that interventions and policies may be implemented
at full-scale before they are ready, while they may perhaps be counterproductive. Quality
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must be ensured before scaling up. Pilot experiments, operational research, and monitoring
and evaluation (M&E) are key.
To facilitate priority-setting, structure the HSP 2009-2020 as an assembly of coherent
building blocks that develop over time. Coherent building blocks are separately costed
parts of the HSP 2009-2020 that can be implemented independently from one another
within the integrated health system. It would be useful for the HSP 2009-2020 to include
information for priority setting between building blocks.
Begin implementing consensus priorities within the resource envelope. It will still be
some time before the HSP 2009-2020 will be completed. However, some actions in line with
the HSP 2009-2020 can begin. Strengthening retention and rapidly reducing maternal
mortality appear to be consensus priorities.
Explore the full possibilities of the 2009 PEPFAR Partnership Framework for scaling up
universal access, while at the same time strengthening the general health workforce.
The 2009 PEPFAR Partnership Framework opens promising opportunities to contribute to
strengthened HIV/AIDS services within the context of the broader health system, integrating
services to maximize impact and efficiency.
BACKGROUND AND INTRODUCTION
The Global Health Workforce Alliance (GHWA), in recognition that HRH are a major obstacle
to the scale-up of HIV services for universal access as well as achieving the health-related
Millennium Development Goals (MDGs), established the Task Force on Human Resources for
Health Implications of Universal Access to HIV Prevention, Treatment, Care, and Support. The
main purpose of the Task Force is to:
Develop evidence-based recommendations for a global strategic direction to guide
the process and approaches needed to meet country-level HRH requirements in
order to achieve national targets for scaling up toward universal access that enhance
other national health delivery systems
Make strategic recommendations that will inform, contribute to, and influence
political and policy discussion and action at global, regional, and country levels to
address the HRH crisis and assist countries in implementing recommendations.
Six countries accepted the invitation to participate in this initiative: Cote d‘Ivoire, Ethiopia,
Haiti, Mozambique, Thailand, and Zambia. Rapid situational analyses conducted at the
country level obtained up-to-date information on:
Country-specific promising practices that promote scale-up toward universal access
to HIV/AIDS services
Gaps and challenges that relate to country goals/targets for HIV/AIDS
Critical interventions that will address challenges and lead to effective scale-up
Leadership action and partner support required to enable critical interventions.
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Ministries of health and the World Health Organization (WHO) country offices were asked to
join with GHWA international HRH specialists to carry out the work in the six countries.
Results of this fieldwork at the country level form the content of a final report published by
GHWA that will provide global strategic direction to guide decision-makers for how to
address the HRH challenges to scale up HIV/AIDS services.
This report will outline the findings and key messages resulting from the rapid situational
analysis in Ethiopia.
METHODOLOGY FOR RAPID SITUATIONAL ANALYSIS
The technical working group (TWG) developed a common protocol to be followed in each
country. Basic elements of this protocol are the following:
1. Specific, focused information at the country level was collected on HIV epidemiology,
HIV program indicators, actual strength of the health workforce, national HRH system
including HRH plans and strategies, and progress on implementation of task- shifting
policies.
2. Select key informant interviews focusing on these four questions:
a. What promising practices exist that have a positive impact on scale-up?
b. What are the HRH gaps/challenges that relate to country goals/targets for
HIV services?
c. What are the most critical interventions that if implemented would address
these challenges and lead to effective scale-up?
d. What leadership action and partner support are required to enable
implementation of HRH scale-up?
3. A small four to five member steering group was formed from national HRH and HIV
experts, representatives from the MOH and other appropriate ministries or
stakeholder groups, selected key informants, and international partners. This group
will meet with the field team to provide guidance and input into the rapid analysis
and will continue to engage with the government and partners to use the key
messages and recommendations coming from this fieldwork to strengthen national
responses to the HRH crisis.
4. A final concise report of the rapid situational analysis for each country will be made
available in the country and will be provided to the TWG. Two members of each
country team will be invited to attend the final TWG meeting in Geneva on March 23
and 24, 2010 to present their findings.
FINDINGS
Promising Mechanisms and Practices Ethiopia is one of the poorest countries in sub-Saharan Africa, with a GDP per capita of $223
per year. For the past five years, the HIV/AIDS prevalence was 2.2%; it is expected to rise to
2.4% in 2010. There are substantial prevalence differences between urban (7.7%) and rural
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(0.9%) settings. With a population of approximately 74 million, Ethiopia is home to one of
the largest populations of people living with HIV and AIDS.
According to the World Health Report 2006, Ethiopia has a total health workforce of 0.25
doctors, nurses, and midwives per 1000 inhabitants. This is one of the lowest HRH per
population ratios of the 57 crisis countries. As of 2009, the total number of health workers is
66,314. The density of all health worker cadres varies between regions from 0.24 to 2.7 per
1000 population. In spite of this, the country has shown good progress in rolling out
universal access for HIV/AIDS prevention, treatment, care, and support.
A number of reasons underlie Ethiopia‘s relative success in rolling out universal access:
Political will and commitment. Ethiopia provides widespread access to free
HIV/AIDS services; there are awareness raising efforts as well as public campaigns to
promote voluntary counseling and testing (VCT) and antiretroviral therapy (ART).
Multisector approach. HIV/AIDS is mainstreamed in the curricula of all three
education sub-sectors (vocational, general, and higher education), and students are
invited to visit HIV/AIDS resource centers, clubs, peers, etc.
Institutional arrangements. Federal and regional level structures and mechanisms
for policy setting and implementation are in place in Ethiopia.
Substantial external support. In Ethiopia there are 30-40 development partners, the
three largest donors are the Global Fund, GAVI, and PEPFAR. The (planned) total
health resources for 2008/2009 was 600 million USD1, of which $253 million was
domestic; 346 million came from donors, PEPFAR not included. PEPFAR contributed
approximately 350 million USD (FY 09).
Task shifting. ART has been successfully shifted from doctors to nurses; lay
counselors have also been engaged.
The health extension program. In four years‘ time (2004-2008), two governmentally
employed health extension workers (HEWs) were placed in each health post, totaling
30,000 HEWs. This program also addressed gender equity by selecting almost
exclusively young women. HEWs received one year of training and were then
responsible for rolling out four packages of promotive and preventive services at the
community level, including HIV/AIDS related prevention, care, and support. Plans are
underway to further involve them in service delivery, household counseling and
testing, and prevention of mother-to-child transmission (PMTCT).
Accelerated health officers training program. The number of health officers
increased from 683 in 2004 to approximately 1,600 in 2009; additional health officers
are currently enrolled in the training.
Decentralization. Policy development and standard-setting takes place at the federal
level. Implementation (including more specific budgetary choices; HRH management;
and the hiring and firing of health workers) has been decentralized to the regional,
zonal, and district levels. Hospitals can use the revenues they receive from patients
1 Scaling up for better health in Ethiopia, IHP+, 2007
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for facility upgrading. Most of the HIV/AIDS care and support activities have moved
from hospitals to regional health centers.
Expansion of facilities. Of the 15.000 health posts planned for completion in 2010,
14,445 have already been constructed. New health centers are under construction,
aiming for a total of 3,200 in 2010, which would achieve full coverage.
Expansion of higher education. The number of universities has increased from five
at the start of this century, to 22 in 2008. An additional ten are under construction.
Private sector education and training. The number of private sector health science
teaching institutions has expanded from just a few ten years ago, to nine colleges
that provide degree level and 38 that provide certificate or diploma level training in
2008.
In-service training. In-service training is important in scaling up health workers‘
knowledge and skills for dealing with a rapidly developing new epidemic. The
majority of IST has been provided by donors. While donors have contributed
substantially toward achieving universal access, their contributions have often been
tailored to their own objectives rather than to the needs of public institutions.
Quite a number of the promising mechanisms and practices listed above are achieved by the
flooding strategy, which recommends training thousands of health professionals to resolve
the extreme weaknesses of the Ethiopian health workforce, and to respond to the ongoing
internal and external migration of skilled health workers. The flooding strategy adheres to
the volume-speed-quality sequence, and the pressures exerted on the system by this
approach unfortunately leave little room for pilot studies, oversight, M&E, or operations
research. Furthermore, this approach maybe too ambitious in view of the relative amount,
nature, and origin of the resources supporting the overall health budget.
Gaps and Challenges In view of the very limited GDP and modest contribution of the government to the total
health expenditures, there can be little surprise that implementation of these ambitions is
confronted with considerable gaps and challenges. The Health Sector Development Plan
stretches over a period of twenty years with separate five-year investment programs.
The Health Sector Development Plan III (2005-2010) reveals substantial financing gaps2 for
the period 2007/2008 to 2009/2010 for three scenarios under consideration. Scenario 1 (gap:
$1.561 million) involves roll-out of the Health Extensions Program as well as upgrading health
centers and limited upgrades of hospital and curative services. Scenario 2 (gap: $2.344
million) involves full implementation of accelerated expansion of primary health care
coverage, gradually increasing access to health centers to 94% of the population in five years,
and significant expansion of hospital coverage. Scenario 3 (gap: $2840) is based on the MDG
needs assessment and involves full attainment of all targets, without resource constraint.
In the Dire Health Center, located in a rural area just 70 km from Addis Ababa, only 15 of the
25 approved positions were funded. The head of staff was a nurse, the two approved
positions for health officers could not be filled by the woreda (district health office) because
2 Scaling up for better health in Ethiopia, IHP+, 2007
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they lacked the budget. In a woreda 40 km north of Addis Ababa with a population of 87,000,
there was only one health center, and the staffing level adhered to a standard based on a
catchment area of 25,000 people.
Looking at Ethiopia‘s universal access targets in relationship to what has been achieved to
date, the following numbers are of interest: VCT (target 2010: 9.27 million people counseled
and tested; actual 2009: 42%), PMCTC (target 2010: 80% of HIV positive pregnant women will
receive PMTCT services by 2010; actual 2009: 10%), ART (target 2010: people receiving ART
will increase from 32% in 2007 to 100% by 2010; actual 2009: 62%)3.
The number of patients started on ART increased from 900 in 2003 to 179,810 by December
of 2008. However, a quarter of the patients have been lost, or no longer follow up with the
Ethiopian ART cohort. Of those lost, 34% have been reported as dead, with two-thirds of the
deaths occurring within the first six months after beginning ART. These numbers further
indicate that:
Universal access for prevention, treatment, and care is rolling out more slowly than
planned, especially PMTCT
Mortality is still substantial and probably related to HIV infected patients accessing
treatment at stage when their disease is too advanced
Approximately 15% of all patients drop out of chronic care.
Apart from HIV/AIDS, there are other MDG-related health problems in Ethiopia as well. In
2006, infant mortality was 77 per 1000 live births (down from 122 in 1990), under five
mortality stands at 123 per 100 live births (down from 204 in 1990), and maternal mortality
still stands at a high 673 per 100,000 live births. Though these numbers have obviously
improved since 1990, they still remain high, perhaps as a result of the limited and declining
numbers of physicians in public health services.
The draft HRH Strategic Plan 2009-2020 (HSP 2009-2020) shows an HRH scale-up for all
cadres from 67,000 in 2010 to 193,264 in 2020. By then, the population is expected to be
over 100 million. If this plan can be realized at all, it will put in place 1.8 health workers per
1000 population. Counting all doctors, nurses, and midwives, in 2020 this will be about 0.85
health workers per 1000 population, only 37% of the WHO critical HRH shortage level.
The HSP 2009-2020 is ambitious, but it‘s far from finalized and is not yet costed. The
development process—which took place with limited engagement from partners and
stakeholders—seems to have slowed down. Recently, a joint working group formed to move
this important work forward. At this stage, it can already be noted that implementation of
the plan will meet substantial resource limitations, which will thus put further pressure on
task shifting and condensing of curricula. Moving such a plan toward implementation will call
for priority setting and quality control of the outcome of strategies, policies, and
interventions.
3 HAFCO Mid Term Review 18-02-2010 (Hawassa)
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Almost all key informants mentioned the very serious problem of the high attrition rate
among health professionals in public service, especially among higher cadres. In 2002, 17%
of Ethiopian nurses and 30% of doctors left the country. The number of physicians in the
public services decreased from 1,613 in 2003 to 1,037 in 2007, while the number in the
private for profit and nongovernmental organization (NGO) sectors increased from 419 in
2003 to 769 in 2007. The NGO sector physicians were mainly active in AIDS programs,
training, and mentoring health workers in the public sector. The total number of 2,152
physicians in 2009 shows a modest increase. This internal brain drain is depleting HRH in the
public sector, and although there is still some support, it is almost exclusively technical
assistance and is not geared toward direct patient service for HIV/AIDS programs.
Seventy-two percent of medical students and 62% of nursing students consider migrating
abroad (Serra et al., 2008). Staff turnover of HIV/AIDS focal points in the regional education
bureaus was noted as a problem by the Federal Ministry of Education and was also flagged
by trainers and mentors with I-TECH, the largest NGO training institution, specializing in
HIV/AIDS related education and training.
Health worker productivity suffers from lack of motivation and rampant absenteeism. One of
the underlying causes of the latter is the abundance of training opportunities in which health
workers take part, wanting both to enhance their career opportunities and boost their
income through the per diem. Interviews revealed that sometimes between 40% and 50% of
a health worker‘s time on the job was spent taking courses. Unfortunately such accounts
could not be confirmed by hard statistics, as the appropriate management system is lacking.
Motivation also suffers from tasks being shifted without any increase in compensation.
Salaries are extremely low. A general physician in the public serves earns about $150 per
month, which is far less than salaries abroad (e.g., less than 10% of salaries in Botswana), or
salaries paid by one of the many NGOs, development partners, or donors. The fulltime health
officer for HIV/AIDS in the Bishoftu hospital stated that in order to cope with the patient
load, she worked as a part-timer on weekends and holidays for 75 Birr ($ 5.22) per day. A
nurse doing this would earn 50 Birr.
Eighty-four percent of Ethiopia‘s population lives in rural areas, and as in many other African
countries, working in these areas is less attractive for health workers. Thirty-seven percent of
the public sector physicians are found in Addis Ababa (2006/7), which is home to only 5% of
the population. Working and living conditions are difficult outside the cities, and the
incentive packages considered in the HSP 2009-2020 take this into account.
It is not easy to get an objective view of the quality of service delivery in this system, which is
stressed by the ambitious goal of rapid expansion. Additionally, the local capacity for
supportive supervision and M&E falls critically short in the absence of development partners,
and verbal accounts of quality issues in service delivery surfaced during the interviews. While
this has been acknowledged and measures have been taken, reliable data is still limited.
Ethiopia‘s private health sector is growing, but is currently unregulated. Approximately 35%
of surgeons, 53.5% of gynecologists, 12% of general practitioners, and 4.6% of nurses work
in the private sector. Regulation of private sector providers and the setting of quality
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standards for private sector service delivery would not be costly and is highly necessary.
Expertise to get this off the ground could easily be obtained from abroad.
The rapid creation of so many teaching and training opportunities, in comparison with what
existed in the country less than a decade ago, has caused a large shortage of qualified staff
and tutors. Education and training quality, as measured in terms of knowledge, skills, and
competencies of graduates, is a potential issue. The MOH should take a leadership role to
assure that the PSE curricula are optimally designed from the service delivery point of view.
This is one of the areas where the volume-speed-quality sequence may deserve some
reconsideration.
During the interviews, respondents noted that the relationship between IST and PSE (which
are overseen) Ministry of Education and the MOH, respectively) needs to be improved. This
warrants deeper analysis as it could result in substantial efficiency gains at low costs.
Since 2003, the impact of PEPFAR and GFATM funding on HIV/AIDS control in Ethiopia has
been substantial. However, these funds can hardly, if at all, be used to directly pay for new
HRH posts or regular salaries, so the greater impact has mainly been achieved through both
the existing health workforce and intermediary organizations. These intermediary
organizations fund large numbers of technical advisors, trainers, site mentors, M&E staff,
pharmacy personnel, and project managers, but not clinical personnel. The relative size of
PEPFAR support implies that the health budget is heavily skewed towards costs other than
personnel. At the macro level, this brings into question the overall efficiency of such an out-
of-balance system.
Critical Interventions to Address Challenges It is well beyond the scope of this report to undertake a discussion of interventions aimed at
closing the large finance gaps mentioned above. It is quite unlikely that Ethiopia‘s economic
growth will suddenly rise exponentially, and there are indications that the resources coming
in from abroad will grow much less rapidly in the years to come—if at all— than during the
last decade. Accordingly, plans to substantially strengthen the health workforce and to scale
up universal access for HIV/AIDS should be kept within realistic budget development
expectations. Thus, the following may be worthwhile to consider for universal access scale-
up:
HIV prevention appears to be a top priority. VCT, PMTCT, and ANC all are in need of
much faster progress. Given the resource limitations it is worthwhile to explore
further contributions by HEWs (HIV testing, PMCTC drugs, etc.) and how primary
health care can do more. It is also necessary to see how multisector social drivers of
HIV infection can be tackled with even more vigor.
Scale-up of ART is moving more slowly than targeted. This is likely a result of the
severe limitations of the Ethiopian health workforce. Interventions addressing those
limitations are part of the HSP 2009-2020 and will be briefly addressed under that
heading below.
Twenty-five percent of AIDS patients who started ART discontinued treatment, which
could be a serious symptom of low quality. Of these 45,000 patients, one-third
apparently died, while the others did not continue treatment for other reasons.
Operational research indicated that the mortality might be related to late onset of
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therapy, and it would be of interest to learn how effective HEWs are in their
contributions to HIV/AIDS control. This question relates directly to the issue of quality
control and M&E as discussed above in relation to the volume-speed-quality
sequence.
HIV/AIDS is not the sole MDG health problem affecting the Ethiopian people. Fortunately,
Ethiopian leadership is explicit that it is necessary to have a fully integrated health system. It
would be useful to examine how other health problems can be addressed in synergy with
HIV/AIDS control. Due to their inherent cause-effect relationship, HIV infection has been
linked to tuberculosis for quite a number of years. Addressing HIV/AIDS together with other
health problems may offer similar added value. The recently published PEPFAR Partnership
Frameworks may suggest interesting opportunities along these lines.
Many of the above gaps and challenges are being, or should be, addressed by the HSP 2009-
2020. Unfortunately, the development of this document is lingering. It is pivotal to ensure
that the plan is soon brought to completion; that it is fully supported by all partners, donors,
and stakeholders; and that it presents proposals that can be readily implemented in the
Ethiopian context. The Joint Working Group responsible for completing the HSP II should
take into account several consequences of the resource limitations:
Resource limitations will impact the ability to follow the volume-speed-quality
sequence of the flooding concept. When resources are short, task shifting and
curriculum abbreviation may be too heavily depended upon, and quality could be at
risk.
Scaling up when quality is not ensured may be very costly or even counterproductive.
More priority should be given to thorough M&E and piloting new steps in
implementing the HSP 2009-2020.
To allow priority setting, the HSP 2009-2020 should be developed and presented as
an assembly of separately-costed, coherent building blocks.
Not all hope and efforts should be focused on the new workforce. There are also
efficiency gains that can be realized within the existing health workforce.
Leadership Action and Partner Support Leadership action There is little doubt that political will and clear leadership supporting health in general—and
universal access to HIV/AIDS prevention, treatment, and care as part of a fully integrated
general health system, in particular—exists in Ethiopia. However, the following specific
actions could lead to better, more explicit leadership:
Place even more multisectoral effort into HIV prevention.
Accelerate completion of the HSP 2009-2020 with full engagement of all partners and
stakeholders.
Acknowledge that resources will be too limited to move toward implementation of
the HSP II, and instead prioritize the separate building blocks.
Take action where possible, within the scope of resources, so as to not lose valuable
time while the HSP 2009-2020 continues to be developed.
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Further emphasize M&E to enhance the impact of new policies and those already
underway.
Stress the need to optimize the effectiveness and efficiency of the existing health
workforce.
A more explicit leadership at all levels of the system promotes the alignment and
harmonization of partners and donors.
Partner support Partner support is extremely important for the Ethiopian health sector. Partners and donors
strongly agree that full alignment under the leadership of the MOH is the only way forward.
However, the leadership should manifest itself by engaging in full transparency with all
partners, and all should move forward together.
The alignment and harmonization of external partners and donors can be limited by the
mandates and systems with which they have to comply. However, this does not prevent
creative solutions and productive collaboration to support the development of the Ethiopian
health workforce in universal access scale-up, or in seeing this as an important responsibility
of the general health system.
KEY MESSAGES
Overview This rapid situational analysis looks at the HRH implications of universal access to HIV
prevention, treatment, care, and support. It is only possible to weigh those implications by
looking at the health workforce as an integral part of the health system as a whole. The
integration of HIV/AIDS services is a leading theme of the Ethiopian MOH and all partners.
The below recommendations are intended to focus on a limited set of actions that would
have a significant impact on the scaling up universal access, and can be implemented at
modest cost. Some of these suggestions have also been made by others and are strongly
supported and easier to move along.
No recommendations have been made about funding the substantial scaling up of
preservice education and training, which is needed; about increasing the health sector
budget to move the Ethiopian health workforce up to 2.28 health workers per 1000 people;
or about increasing the compensation of health workers to a level comparable with
neighboring countries, in order to stop migration abroad. These major limitations are too
well known by all partners and stakeholders in the country and actions have been taken or
are underway as far as the limited resources permit. Yet another recommendation addressing
these problems, based only on a rapid situational analysis, will add no weight.
Universal Access and the Existing Workforce Scale up efforts to reduce HIV incidence The HIV epidemic is expected to rise in 2010, contributing to the rising number of PLHIV.
VCT is well below target and so is PMTCT. Prevention of HIV is complex and difficult as it
requires people to change their behavior; the drivers of which are rooted deeply in society.
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To address those requires the kind of multisector approach which is already embraced in
Ethiopia. However, since incidence is not declining, acceleration of the comprehensive
national prevention strategy is recommended. More specific suggestions include:
Explore the Clinton Foundation‘s pilot study to see if there is sufficient evidence to
allow HEWs in rural areas to perform HIV testing.
Develop and implement specific prevention programs for most at risk populations.
Consider HEWs playing a role in the availability of PMTCT drugs.
Address HRH retention as a matter of utmost urgency The HRH crisis hit Ethiopia extremely hard, and the loss of every health worker counts. All
partners agree that moving ahead with a full comprehensive package to resolve this
challenge is needed now. In this context it is of interest to note that attrition of HIV/AIDS
experts, physicians in particular, is partly due to positions offered to them by partners—
NGOs, training institutions, etc. The draft HSP 2009-2020 lists a number of suggestions to
address retention as well as promising practices which are being pilot-tested in Oromye.
These approaches should, with the support of all partners, be developed into a general
policy and implementation plan.
Do not wait till the HSP 2009-2020 is finalized to implement (see below), as valuable time will
be lost.
Strengthen the health workforce by regulating, coordinating, and managing
in-service training In-service training is pursued by various organizations, programs, projects, and initiatives for
HIV/AIDS as well as for other purposes. Coordination between these is weak or non-existent.
Additionally, enrollment in IST is largely health worker driven to enhance his/her career
opportunities and benefit from per diems. The goal of improved patient care, should be the
reason for leaving service for training. A clear IST conceptual framework, policy, and
guidelines4 for managers is needed, as well as a coordination mechanism that is supported
by all partners. The policy would need to address how to optimize efficiency through
coordination, and where additional training is really needed for better service delivery.
Perhaps a limit should be set for individual health workers of no more than a small number
of training days per year. Perhaps training should be done on weekends.
Boost mechanisms to focus preservice education on all aspects of service
delivery, and to maximize efficiency in the balance between preservice
education and in-service training Upon leaving PSE health workers should be fully capable to professionally handle the health
services delivery challenges they may meet in their jobs. The linkage between PSE and IST
should be strengthened to prevent expertise gaps, particularly for programs focusing on
priority diseases such as HIV/AIDS. Competence gaps in PSE are costly and inefficient to fill
later by IST.
4 In January 2009 the FMOH published ―Guidelines for Coordination and Implementation of HIV training in
Ethiopia‖ but implementation is not pursued.
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 12
Support and regulate private sector human resources for health education
and health service delivery The private sector is an integral part of the health sector for which the government is equally
responsible. Norms, standards, and support should be the same for the health sector as a
whole. This holds true for the production of health workers as well as for service delivery.
Universal Access and the Future Health Workforce Accelerate completion of the HRH Strategic Plan 2009-2020 with full
partnership support Since buy-in and ownership of all partners is the only way forward, completion of the HSP II
can only be pursued with full engagement of all partners under the leadership of the MOH.
The ambition of the plan is such that its implementation will meet severe resource
limitations. Therefore, priorities must be set, and the limits of task shifting—as well as
shortening of PSE (e.g., training physicians in four years, which is in progress now) —should
be more fully explored. The quality of service delivery limits shifting tasks and shortening
curricula. Exploring the limits of task shifting may be done most productively by developing
a regulatory framework for it.
Reconsider the conceptual flooding sequence: volume-speed-quality The order volume-speed-quality carries the risk that interventions/policies implemented
could potentially be inefficient, ineffective, or even counterproductive. Two illustrative
examples include:
1. The Clinton Foundation‘s approach in carefully piloting the shifting of HIV testing to
HEWs rightly puts quality before going to scale.
2. The policy to allow hospitals to set up a private wing may be effective to boost
income and motivation of health workers, but at the same time it may cause serious
access inequities and therefore may not be effective in promoting the health of the
people. The volume-speed-quality sequence holds value only when quality is ensured
from the start (a risk assessment should be considered). Pilot experiments, operations
research, and M&E are key.
Structure the HSP 2009-2020 as an assembly of coherent building blocks,
which develop over time, to facilitate prioritization Coherent building blocks are separately costed parts of the HSP 2009-2020 that can be
selectively implemented and fit fully in an integrated general health system. Two
conceptually different entry points may be considered in creating separate coherent building
blocks:
The health workforce entry point—i.e., retention
The disease burden entry point—e.g., maternal mortality or HIV prevention.
Note that these separate building blocks may overlap, which needs to be taken into account
in the costing of the plan as a whole.
There needs to be a discussion and subsequent agreement reached on how to set priorities,
as there may be not be consensus. Apart from cost-effectiveness, other criteria that may be
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 13
relevant are impact on (healthy) life expectancy, national goals, service area, etc. To facilitate
prioritization on the basis of these criteria it makes sense to use information already in the
HSP 2009-2020.
Start implementing consensus priorities within the resource envelope It will still be some time before the HSP 2009-2020 is completed. Therefore it is worthwhile
to assess what actions should be prioritized once the plan is finalized, and to define a
starting point (or points). All key informants regarded retention of health workers as a high
priority. The draft HSP 2009-2020 lists a number of incentives that may be further explored
and developed. From the point of view of cost containment, it is recommended that
incentives should be used where they are really needed—i.e., where attrition is unacceptably
high. Another consensus priority supported by all key informants is maternal mortality.
Reducing maternal mortality can only be done when it is embedded in the general health
system. Emergency obstetric care and surgery is just one end of the line. It will not bring
maternal mortality down without standard quality and properly focused primary health care
as an accessible entry point. Maternal mortality is inherently linked to universal access for
HIV/AIDS.
Explore the full possibilities of the 2009 PEPFAR Partnership Framework for
scaling up universal access while at the same time strengthening the general
health workforce
―Partnership Frameworks should contribute to strengthened HIV/AIDS services within the
context of the broader health system in an environment with diverse development needs,
and should be aligned with the Global Health Initiative (GHI) approach of integrating services
to maximize impact and efficiency‖ 5. The Ethiopian Health Workforce may also benefit from
the specific attention of the document for M&E and setting measurable goals, objectives,
and concrete commitments.
5 Guidance for PEPFAR Partnership Frameworks and Partnership Framework Implementation Plans. Version 2.0
September 14, 2009
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 14
APPENDIX A: LIST OF KEY INFORMANTS INTERVIEWED
INTERVIEWS
Name Position Organization
Dr. F. Nafo-Traoré
Dr. Seblewongel Abate
WHO Representative
NPO-HIV/AIDS
WHO
Mrs. Marina Madeo Senior Advisor, Health & HIV/AIDS Italian Coop.
Dr. Y.A. Assemere Country Director Clinton Found.
Dr. C. Green-Abate Country Coordinator PEPFAR
Dr. H. Adus Training Director I-TECH Ethiopia
Mr. Meskele Lera
Mrs T. Teferi
Deputy Director
Chief Advisor
HAPCO
Dr. M. Workalemahu Former HIV Care and Treatment Team
Leader
Medical Services
Directorate/MOH
Dr. D. Broussard Deputy Director CDC Ethiopia
Prof. A. Ali Professor of Public Health Addis Ababa University,
Department of Public Health
Jeanne Rideout Health specialist USAID
Mesrak Nadew Health AIDS, population and Nutrition USAID
Petros Faltamu Health AIDS, population and Nutrition USAID
Dr. Alti Zwandor UNAIDS
Mr. H. Gyes and HIV/AIDS expert MOE
Dr. G. Desta HIV/AIDS project coordinator EPHA
Dr Dorsisa Legesse Medical Director Hayat Health College
Mr Solomon Adugna Deputy Director Hayat Health College
D. Yohannes Chanyalew NPO-HIV/AIDS and World of Work ILO
Mr. Refissa Bekele ART Coordinator Oromia Regional Health Bureau
Dr. Girma Azene
Dr. Birna Abdosh
Planning, M&E Head
HRH Department Head
Tulane University
Dr. Yirgalem Mekonnen Project Coordinator Ethiopian Medical Association
Abera Dereno HRH Dept FMOH HRH Dept. MOH
Gebresellasie Equbagzi Health specialist World Bank
SITE VISITS
Name Center Catchment Area
Staff in Charge Bishoftu Health Centre >1 million
Staff in Charge Dire Health Centre 32,000
Staff in Charge Holeta Health Centre 28,919
Staff in Charge Markos Health Post 3,000
Staff in Charge Guntuta Health Post 4,380
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 15
APPENDIX B: LIST OF STEERING COMMITTEE MEMBERS
Name Organization
Dr. Seblewongel Abate WHO
Dr. Carmela Green-Abate PEPFAR
Dr. Neghist Tesfaye Belayneh DPHP/MOH
Dr. Alti Zwandir UNAIDS
Dr Tom Kenyon CDC
Dr. Marina Madeo Italian Cooperation
Mr Berhanu Fiyessa Directorate for HRH/MOH
Mr. Meskele Lera HAPCO
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 16
APPENDIX C: BACKGROUND DATA COLLECTED
1. HIV epidemiology
a. HIV prevalence and
trends
Epidemiological Fact Sheet 2008
on HIV and AIDS (UNAIDS/WHO)
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 17
b. Number of PLHA
Epidemiological Fact Sheet 2008
on HIV and AIDS (UNAIDS/WHO)
c. Estimated number in
need of ART (pediatric
and adult)
Epidemiological Fact Sheet 2008
on HIV and AIDS (UNAIDS/WHO)
d. Number of HIV+
pregnant women per
year
Epidemiological Fact Sheet 2008
on HIV and AIDS (UNAIDS/WHO)
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 18
e. HIV prevalence in TB
patients
Country TB Profile 2008 Ethiopia
f. Estimated number of
HIV and TB/HIV
deaths, trends
Epidemiological Fact Sheet 2008
on HIV and AIDS (UNAIDS/WHO)
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 19
g. HIV prevalence in
most-at-risk
populations – CSW,
IDU, MSM, other
UNGASS Country Report 2008 Ethiopia
h. HIV prevalence in
health workers,
mortality
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 20
2. HIV program indicators
a. Universal/National
targets for care/ART
(adult and
pediatricss),
counseling and
testing, PMTCT,
TB/HIV, male
circumcision, OVC,
MARPS (CSW, IDU,
MSM, other)
b. Number (%) provided
counselling and
testing last year
c. Number of PLWHA on
ART, trends (pediatric
and adult)
Epidemiological Fact Sheet 2008
on HIV and AIDS (UNAIDS/WHO)
d. Provider-initiated
counselling and
testing policy,
guidelines, status of
implementation
Since 2007, Ethiopia has a national HIV/AIDS policy and guidelines on provider
initiative testing and counselling (see ttachment)
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 21
e. Percent who
understand modes of
HIV transmission
Epidemiological Fact Sheet 2008
on HIV and AIDS (UNAIDS/WHO)
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 22
UNGASS Country Report Ethiopia 2008
f. Percent who used
condoms with casual
partner
Epidemiological Fact Sheet 2008
on HIV and AIDS (UNAIDS/WHO)
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 23
g. Number (%) of
pregnant women
tested, HIV+
women/infant pairs
who receive ARV
drugs
Epidemiological Fact Sheet 2008
on HIV and AIDS (UNAIDS/WHO)
h. Number (%) of TB
patients tested for
HIV
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 24
Country TB Profile 2008 Ethiopia
i. Number of HIV
patient in care/ART
per health worker
(doctor, nurse, health
officer, etc.) in
representative health
facilities and trend
Not available
j. Resources available
(host government,
PEPFAR, GF, other) for
ARV drugs
Available for ARVs: 2010 (59 m), 2011 (76 m), 2012 (82 m) [source:HAPCO)
See attached report
k. Resources available
(host government,
PEPFAR, GF, other) for
HRH (in-service
training, pre-service,
salaries, contracts,
incentives, other)
See ‗f‘ below
l. Impact of HIV scale-
up on reduced
hospitalizations,
mortality
EHNRI/GFATM conducting assessment on the effect of ARV‘s on reduced
hospitalization. Results expected in a few months.
Mortality: 65% reduction in mortality reported from a single cohort ; 24-month
survival ranges from 65-74% (ART scale up study)
Figure 2-2. Survival rate of ART patients at, 6, 12
& 24 months
72.564.6
100
78.6
82.276.7
69.4
84.4
79.6
73.5
R2 = 0.9129
0
20
40
60
80
100
120
Baseline 6 months 12 months 24 months
Minimum Survival Adjusted with LTFMaximum Survival
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 25
3a. Actual strength of the health workforce
a. Number of workers
delivering HIV services
(planned and actual);
geographical
distribution; ratio of
patients to providers
(snapshot?); different
cadres; information
about CHWs?
In Ethiopia, however, service is rendered or organized in an integrated way.
There is no HIV specific health worker in Ethiopia. If country level # means
all physicians, HO‘s and nurses in total – please look into the recent survey;
as seen from one hospital and a health center in Addis Ababa, there are a
total of 80 patients to one physician and 45 pts to on HO and 35 pts to one
nurse respectively.
Health Worker Category and density by cadre, 2009, Ethiopia.
Health
Occupational
categories /Cadres
2003/4 2009
Num
ber
HW/
1000
Populat
ion
Number HW/ 1000
Population
Physicians (GP &
specialist)
1,996 0.0281 2,152 0.0272
Specialists 775 0.0109 1001 0.0126
Health Officer 683 0.0096 1,606 0.0205
Pharmacist 172 0.0024 632 0.0081
Pharmacy
technician
1171 0.0165 2029 0.0258
All Nurses 1426
9
0.2009 20,109 0.2576
Midwives 1274 0.017 1379 0.0176
Lab. Tech 2403 0.0338 1957 0.0249
Lab Technologist NA NA 866 0.0110
Health Extension
Worker
0.0000 30950 0.3943
TOTAL 45,8
17
0.6447 66,314 0.8444
Ethiopia, with an aim to reach all rural villages (100% coverage) in the
country with basic health care services by 2008, by training and deploying
at least 2 HEWs per village (5,000 residents), the country has now trained
and deployed a total of 30,950 female health extension workers, bringing
the proportion of 2 HEWs per 5000 population (a village population). The
HEWs, trained for one year and government salaried are the foundation of
the community health care system in the country.
b. Skills, competencies
documented to
provide HIV services,
yes/no, describe
Currently has a well designed and modular training materials based on
competences requirement for the specific health workforce (see
competence list) appropriate and relevant to the various health workforces
in the country. In line with the task-shifting in Ethiopia, training tools are
developed and used for the HEWs.
c. Vacancy rates by
cadre; distribution,
especially to remote
and rural areas;
perceived retention
issues
Current challenge in the country is the high turn-over of staff resulting in
high vacancy rate. Health workers in remote and rural areas don‘t want to
stay and work in remote and rural areas
The government has recently introduced both financial and non-financial
incentive and bonus schemes with emphasis to remote and rural areas of
the country.
Attention is given to the provision of in-service training as well as regular
supportive supervision to health workers.
Provision of required supplies and commodities as well as improving the
working conditions and emphasis to the participatory functions of health
workers in decision-making process is considered as important in puts to
the retention of health workers.
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 26
3b. National HRH system, including HRH plans and strategy
a. Costed-plan
developed and
disseminated (yes/no,
describe - including
status of
implementation)
Currently the country in collaboration with the stakeholders is in the process
of developing a costed HRH strategic plan. However, along with the
development of a medium term costed plan, the country has been
implementing the production of priority and scarce health workforce,
including MDs, health of officers, Midwives and pharmacists. The country has
achieved the required density level on some of the key health workers
including nurses and health extension workers.
b. HRH Plan takes
universal access into
consideration (yes/no,
describe), specific
HRH requirements
(different cadres) for
HIV scale up
The country HRH strategic plan takes into consideration 100% coverage of
primary health care units for the provision of universal access to basic
services. The strategic plan emphasis in its short and medium plan the need to
accelerate training of physicians, health officers, nurses, pharmacists and lab
technicians as the key and scarce health workforce who have direct relevance
to the HIV/AIDS universal access. The need to address the workload at each
level in the various levels of the health care system and the skill mix
requirement.
c. HRM units exists in
the MOH, staffed by
people who are
professionally
qualified in the
discipline of HRM;
strategically aligned
within MOH; able to
negotiate effectively
with MinFin, PSC,
MOE, etc
Ans. Yes, HRM units do exist in the MOH. Currently the MOH in the country is
suffering from an acute shortage of well trained and experienced human
resource managers who could play a vital role in developing strong human
resource management systems that integrate the planning, hiring,
deployment, training, and development of health staff. As part of the HRM
section in the HRH strategic plan being developed, health workforce
motivation and retention schemes that consider maximizing benefits,
provision id integrated supportive supervision; enhancing opportunities for
staff development including in-service training as well designing staff career
development plans are given emphasis. The role of health workers in decision
making and valuing the work of staff as well as reasonable workload are some
of the components strategized in the staff motivation package.
d. Specific plans to
scale-up HR cadres;
describe current
status of plans,
especially focusing on
degree of
implementation and
current actions
The country has short term and priority health workforce production program.
These include physicians, HO‘s, nurses and technicians. In short time period
the country has attained a standard density required for specific cadres, such
as the nurses and pharmacists. Currently there is an accelerated training
program for physicians and HO‘s in the country. 14 universities and 22
hospitals are being used to train these health workforces.
e. Link between service
delivery needs and
production including
HRH pre-service
training and trends for
HIV (and which cadre);
plans and reality
the country HRH plan uses the service target method for the projection of
health workforce in Ethiopia. The plan in this sense considers the achievement
of requirements for priority services such as HIV, TB, malaria and MNCH.
Estimating the right number and mix in line with the facility specific workload
pattern (WISN) is considered in the health workforce development plan.
f. National budget for
HRH pre-service
training and trend
The budget for the health sector in total is as depicted in the table. There is
no HRH earmarked budget line in the country.
The health services in Ethiopia are financed from four main sources:
Government (federal and regional)
Multilateral and bilateral donors (grants and loans)
Nongovernmental organizations (NGOs) (international and local)
Private contributions (e.g., out-of-pocket spending)
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 27
Health Care Expenditure, 2009, Ethiopia
Financing sources US$ Per Capita
(US$)
Percent of total
Health
expenditure
Government 145,501,590.74 1.99 28%
Households 160,042,854.70 2.19 31%
Rest of the world
(donors)
192,293,175.25 2.63 37%
Public enterprises 13,796,059.21 0.19 3%
Private employers 6,129,755.76 0.08 1%
Other private funds 3,966,145.77 0.05 1%
Total 521,729,581.43 7.14 100%
g. Specific steps taken to
increase capacity for
pre-service training by
cadre (doctors, nurses,
laboratory, pharmacy,
other)
See above
h. Specific approaches
for retention and
productivity,
workplace safety,
improved morale by
providing services
(ART), including
financial and non-
financial incentives
and work climate
improvement
interventions; any
evidence such
strategies are working
or not-working
The country has introduced schemes that enhance health workforce
motivation and retention with emphasis to remote and rural areas in the
country; these include the mandatory service requirement by graduate health
workforce before they are licensed, different financial and non-financial
incentives schemes for rural and remote areas in the country.
Strengthened supervision, performance management, supply management,
and Information systems.
The country has introduced workplace HIV prevention strategies to minimize
staff infection.
i. Bonding post-training
present, yes/no,
describe
Yes, with states and health facilities to plan and develop on-the-job, skill-
based training.
j. Human resource
information system,
yes/no, describe
Is in the process of revision for standardization and is part of the HMIS scale
up
k. HIV/AIDS
policy/strategy for
HCWs, access to
prevention, care, and
ART
The health policy favoured the workplace programs for HIV prevention,
treatment and care. In line with the task-shifting strategy the is an intent to
realign tasks that health cadres are authorized to perform to allow more
flexibility and efficiency in providing services (see the HRH work-place policy).
HRH implications of scaling up for universal access to
HIV/AIDS prevention, treatment, and care: Ethiopia 28
APPENDIX D: KEY DOCUMENTS REVIEWED
Human Resource for Health Strategic Plan, Ethiopia, 2009-2020. Federal Ministry of Health
(DRAFT)
Guidance for PEPFAR Partnership Frameworks and Partnership Framework Implementation
Plans, Version 2.0, September 14, 2009
Single Point HIV Prevalence Estimate. FMOH Ethiopia, June 2007
Health and Health Related Indicators. FMOF 2000 (E.C.) (2007/08 G.C.)
Human Resources for Health and Aid Effectiveness Study in Ethiopia. The Federal Ministry of
Health, WHO Ethiopia, June 2008
Rapid Scale-Up of Antiretroviral Treatment in Ethiopia: Successes and System-Wide Effects.
Assafe Y, Jerene D, Lulseged S, Oooms G, Van Damme W. PloS Med 6(4): e1000056.
doi:10.1371/journal.pmed.1000056
ART Scale up in Ethiopia - Success and Challenges. The Federal Ministry of Health, January
2009
Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a
cohort of HIV patients. Jerene D, Naess A, Lindtjorn. AIDS Research and Therapy 2006, 3:10
doi10.1186/1742-6405-3-10
Ethiopia: Taking forward action on Human Resources for Health (HRH) with DFID/OGAC and
other partners. Jim Campbell and Dykki Settle, 23 August 2009
Case study on scaling up education and training of health workers. Global Health Workforce
Alliance, World Health Organization, Geneva, April 2009
Multisectoral Plan of Action for Universal Access to HIV Prevention, Treatment, Care and
Support in Ethiopia. HIV/AIDS Prevention and Control Office (HAPCO), December 2007
Human Resources for Health Profile Study in Ethiopia. World Health Organization in
collaboration with the Federal Ministry of Health, 2009
ETHIOPIA – Health Sector Strategic Plan (HSD III) 2005/6 – 2009/10. Federal Ministry of
Health 2005