Health Financing Quarterly Newsletter. Volume 2 No. 4. July 2015

HSFR/HFG Ends Second

Successful Year, Will Build

on Achievements in Year 3

Leulseged Ageze, HSFR/HFG Chief of Party/Project Director, says

the project had a great year that , collaborating with its partners,

had achieved successes in working towards putting better health

system in place

The HSFR/HFG Project in Ethiopia recently ended its second year

(July 1, 2014–June 30, 2015) with achievements in its major pro-

gram areas, health care financing (HCF) and health insurance initi-

atives. Activities included building the capacities of frontline person-

nel in implementing HCF reforms and community-based health

insurance (CBHI).

Health Financing (HF), the project’s quarterly newsletter, recently

asked Leulseged Ageze, HSFR/HFG Chief of Party/Project Director,

to highlight project achievements and challenges last year and to

identify focus areas for the coming year. The answers have been

edited for length.

What was the focus of the project in the past

fiscal year?

The project has supported the wide range of health finance

and governance reforms that the Ethiopian FMOH [Federal

Ministry of Health] continues to initiate and implement. We

built on previous years’ achievements in consolidating the

first generation of health care financing reforms throughout

the country. However, the major focus has been preparation

for universal health coverage through financial risk protection.

IN THIS ISSUE

Dr. Ariel Pablos-Mendez Praises Ethiopia’s

CBHI Program …. Page 4

Health Care Financing Updates …. Page 5

Community Based Health Insurance

Updates …… Page 6

Social Health Insurance

Updates ..… Page 10

Our approach in the progression from first to the second gener-

ation reforms was balanced and systematic. As part of the con-

solidation of first generation reforms, health facilities that per-

formed well and demonstrated the capacity to run these re-

forms without any or with only minimal project support were

selected, recognized, and graduated from our support. For

health facilities and regions that embarked on these reforms

more recently, including Afar, Gambella, and Somali regions, we

focused on building reform implementation capacity.

Our HCF team worked very closely with the FMOH Medical

Services Directorate on implementation of HCF reforms in fed-

eral referral and teaching hospitals. The necessary legal, organi-

zational, and operational frameworks have been put in place.

Some of these hospitals have already begun implementing differ-

ent reform components.

With regard to the second generation reforms, we have been

supporting the government in expansion of CBHI and making

the necessary preparation for launching SHI [social health insur-

ance]. We finalized CBHI pilot evaluation through reiterative

validation and review of the draft report with Breakthrough

International Consultancy, the firm that led the evaluation, and

the EHIA [Ethiopian Health Insurance Agency]. We finalized,

printed, and disseminated the report. The report is an invaluable

source of evidence for different policy and program initiatives.

Based on the recommendation of the CBHI pilot evaluation

report and through consultation with EHIA, FMOH, and other

key stakeholders, we drafted the CBHI scale-up strategy that has

the target of covering 80 percent of woredas and up to 80 per-

cent of eligible households by 2020. While we are working on

finalization of the scale-up strategy, CBHI expansion is underway

in 185 woredas, more than our initial plan of 161.

We have been supporting EHIA in its preparations for launching

SHI in the current fiscal year. In this regard, we updated the

financial sustainability analysis by taking into account more up-to

-date socio-economic data and other policy variables.

We provided different capacity building and have seconded full-

time staff to the agency, both at central office and in selected

branch offices.

In addition to successful execution of our routine project activi-

ties, we were privileged to take part in key policy processes that

have paramount importance for the Ethiopian health sector in

general and health financing in particular. We took part in con-

sultations about and development of Ethiopia’s health policy,

specifically, the Health Care Financing Strategy and Health Sec-

tor Transformation Plan (HSTP). We were one of the key play-

ers on the Health, Clean and Safe Hospitals initiative at central and re-

gional levels. We are glad to work with Ras Desta Damitew Hospital as

sponsors and key partners. We are always grateful to FMOH, EHIA, and

RHBs [Regional Health Bureaus] for these opportunities and for their

continued confidence and trust in our team.

How do you assess the project’s performance

during the past year?

As I mentioned above, HSFR/HFG had another great year. First genera-

tion reforms are better institutionalized in all health centers and hospi-

tals throughout the country. Our support to the FMOH in institutional-

izing HCF reforms in federal referral and teaching hospitals makes imple-

mentation of these reforms across the country more complete.

Our capacity-building efforts through training of health facility govern-

ance, management, and finance teams continued with a focus on new

health facilities and newer regions. We trained around 445 persons (343

men and 102 women) on HCF reform implementation and an additional

155 persons (117 men and 38 women) on financial management. We

have also been strengthening accountability through institutionalization

of regular auditing of health facility finances – we trained 28 auditors.

We supported strengthening of health facility governance and we

trained 977 health facility governing board members on HCF reform

components, on their duties and responsibilities, as well as on their

working relations with health facility management. All preparatory steps

have been taken to provide legal and operational basis to implement

HCF reforms in federal and teaching hospitals.

Our technical support was instrumental to expansion of CBHI program

to 185 new woredas, more than the originally planned 161. We provid-

ed a motorbike and a computer and printer to each CBHI scheme. This

was a huge procurement and we are very glad that these essential items

are available to the schemes. We developed the CBHI scale-up strategy

based on the lessons learned from the 13 pilot schemes. The strategy

was reviewed through stakeholders’ policy consultation workshop and

the revised version was submitted to EHIA; we expect it to be submit-

ted to and endorsed by the FMOH . We also supported recruitment

and training of 353 CBHI executive staff to new schemes. Moreover, we

trained over 8,000 kebele leaders, who are critical for effective imple-

mentation of the CBHI initiative. We also trained relevant government

staff: 571 from woredas , 401 health service providers, and 47 from

EHIA .

Furthermore, the CBHI pilot schemes evaluation revealed impressive

coverage under the pilot schemes (over 50 percent of eligible house-

holds); increased health service utilization among CBHI beneficiaries, an

average of 0.7 per beneficiary per annum visit to health providers and

2

3

more than double of the 0.3 national average; and improved finan-

cial protection of members and their beneficiaries. So far, financial

protection has been provided to over 6 million Ethiopians through

the pilot and expansion CBHI schemes.

In other areas of program learning, we have been supporting

FMOH, RHBs, and EHIA on generation and use of health financing

evidence in policy decision making. Early in the year, we produced

a summary note showing that health resources are inadequate to

buy quality health, which the ministry reviewed, refined, and circu-

lated to the Ministry of Finance and Economic Development, the

Prime Minister’s Office, and parliamentarians. Finalization of the

CBHI evaluation and its policy use is another major achievement in

the year. Despite our focus on the CBHI expansion effort, we also

managed to make supervision visits to 686 health facilities (30 hos-

pitals and 646 health centers). Supervision visits were also made to

CBHI schemes; 17 visits were made to pilot schemes and 224 to

expansion schemes, which shows some schemes were visited more

than once. Such supervision events are critical to provide on-the-

spot technical support, and they also are an important source of

information for policy decision making and for gauging progress of

reforms

I think it is also worth mentioning field visits that we organized to

health facilities and CBHI schemes. This year we had more visibility

through visits by the FMOH as well as the U.S. Government and

other development partner delegations. The visits enabled us to

showcase the achievements of HCF reforms and to share lessons.

In addition to our quarterly newsletter, we produced success sto-

ries and policy briefs with wide circulation including through HFG

website. Project achievements were presented at the World

Health Systems Research Symposium and International Health

Economics Association Congress. We also supported experience

sharing and networking among regions, health facilities, and CBHI

schemes within the country.

Any challenges you would like to highlight?

Generally speaking, many of the challenges are addressed by gov-

ernment. We also have the support from our client and home

office. However, there are still some challenges, most of which are

the same ones I mentioned last year.

The first challenge is related to high government staff turnover.

We keep on observing this in health facility governing boards,

health facility management and finance staff, and CBHI executive

staff. Retaining key health facility staff is particularly challenging in

the regions that recently started HCF implementation, such as

Afar, Gambella, and Somali. Strengthening consolidation and gradu-

ation of health facilities in regions that started reform early and

thus are more advanced is a strategy that we believe will enable us

to put more effort into newer and weaker health facilities. However,

it is always difficult to sustain gains partly because of the high turno-

ver of staff and health facility board members.

Expansion of the CBHI initiative into 185 additional districts in the

past year was a huge undertaking. We also received requests for

support and have conducted some preparatory activities in Benshan-

gul-Gumuz Region and Addis Ababa City Administration to jump

start CBHI initiative. While it is good news that momentum and

interest exist, this will also be a challenge for project staff to provide

the required technical support.

Our HCF reform implementation experience, specifically, CBHI

implementation, showed that local government leadership and com-

mitment is critical to the success of these initiatives. Creating com-

mitment in new woredas and maintaining momentum in existing

ones is a huge challenge.

The CBHI pilot took place in 12 rural woredas and only one urban

center. I believe expansion of CBHI into urban settings will be a

challenge. It also will be difficult to introduce CBHI in pastoral areas,

where access to and provision of health services remains a challenge.

What will the project’s focus be in the coming

Fiscal year?

Definitely, our main focus and priority for the coming year will be

supporting implementation of CBHI in the 185 expansion woredas

and further expansion of the CBHI initiative into new woredas in the

four largest regions (Amhara, Oromia, SNNP, and Tigray) as well as

initiating CBHI in other regions such as Benshingul Gumuz and Addis

Ababa City Administration. We will work with the EHIA and RHBs

to put in place the necessary legal and operational frameworks as

well as on creating the necessary capacity.

Launching and successfully implementing SHI will also be a focus. As

a new area for the project and the country, we believe its success

will require a huge amount of staff time, external technical assistance,

and resources.

Strengthening consolidation and graduation of health facilities in the

early starter regions is a strategy that we believe will enable us to

focus our effort on the newer health facilities. The project will con-

tinue graduating health facilities from its regular support in collabora-

tion with our government counterparts. We will continue providing

training and other forms of support focusing mainly in new health

facilities, and late starter regions.

Finalizing the federal legal framework and supporting operationaliza-

tion of health finance and governance in federal hospitals will also be

a major undertaking in this fiscal year.

We will keep on working on evidence generation and knowledge

4

Dr. Ariel Pablos-Mendez Praises Ethiopia’s CBHI Program

management to enhance evidence-based policy making and program

learning. We will keep on conducting periodic supportive supervi-

sion of health facilities and CBHI schemes. Efforts will also be made

to institutionalize HCF indicators and supervision instruments in

the FMOH, EHIA, and RHBs. We will support the FMOH in con-

ducting health expenditure tracking for the sixth round, and for the

first time using the System of Health Accounts 2011 framework.

This round of resource tracking will be more government led, as a

unit to institutionalize resource tracking is established in the minis-

try’s Resource Mobilization Directorate. The project will provide

technical support, while funding of training, data collection, analysis,

and report writing and dissemination is expected from the [Bill and

Melinda] Gates Foundation. The FMOH is also soliciting funding

from other sources, to conduct full-fledged health services utiliza-

tion and expenditure surveys of households and people living with

HIV.

In conclusion, how do you see your overall performance

and collaboration with different stakeholders?

Overall, we had another great year of success and remarkable

achievements. I would like to take this opportunity to thank the

project team and the strong backstopping support of the home

office. The overall leadership and support from our client, USAID,

was as usual superb. We also had strong collaboration and part-

nership with our government counterparts at all levels. We are

also grateful to all health sector partners that worked with us.

(Contributed by Habtamu Bogale)

Dr. Ariel Pablos-Mendez, USAID Assistant Administrator for

Global Health, and Dr. Kebede Worku, State Minister of the

Ethiopian Federal Ministry of Health, visited one of Ethiopia’s

first community-based health insurance (CBHI) schemes. Since

its establishment, the Gimbichu scheme has achieved remarkable

results, and is considered among the best-performing schemes in

terms of membership uptake and renewal, and financial sustaina-

bility. Its current enrollment ratio is at 58 percent of the total

eligible households in the district, which has an estimated popula-

tion of 108,255.

In his welcoming speech, Dr. Kebede described the efforts made

by the Government of Ethiopia to initiate CBHI in the four most

populous regions of the country – Amhara, Oromia, SNNP, and

Tigray. “We introduced CBHI in 13 districts at a pilot level four

years ago,” said Dr. Kebede. “By evaluating and monitoring our

strengths and weaknesses, we have taken the lessons from this

pilot to expand CBHI to 185 additional districts. Based on this

good experience, the Ethiopian government’s vision is to estab-

lish CBHI schemes in each of its 900-plus districts by 2020, and

to provide coverage for 80 percent of the population in the agri-

cultural and informal sectors.”

Dr. Kebede also recognized the government and people of the

United States for the continued technical and financial support of

the health insurance initiatives: “On behalf of the Ethiopian Gov-

ernment, I would like to take this opportunity to specially recog-

nize and thank the American people and government for their

continued support in initiation and implementation of Ethiopia’s

CBHI initiative.”

Dr. Pablos-Mendez addressed the gathering by reminding the audience

of his visit to Ethiopia four years ago: “As a public health professional, I

appreciate the progress the Ethiopian government has made in health

care financing reform and implementation of health insurance. Health

insurance was a new concept for the country at the time of my first

visit.” He said the government’s introduction of insurance has produced

significant achievements.

The visit enabled Dr. Pablos-Mendez to hear from local beneficiaries

about the changes they have witnessed since the establishment of CBHI

in their villages, and its impact on their lives.

Mrs. Kumele Cherenet, a community member with three children, told

the visitors about her experience with the new insurance scheme.

“Before implementation of CBHI in our village, we used to borrow up

to 1,000 Birr when we got sick and had to repay double the amount of

this loan. Now, by contributing an affordable

A warm welcome to Dr. Palos-Mendez in Gimbichu

5

amount, we are getting quality health services both at the health

center and the hospital. Women in our villages have witnessed many

positive changes since the introduction of CBHI.”

Mr. Chalchisa Megersa, a farmer, said “among the villagers here,

before being CBHI members, at least one of us has sold our cattle

to solve our health-related problems. But now, thanks to CBHI,

each household can get comprehensive health care services without

the need to pay at time of seeking these services.”

Dr. Pablos-Mendez noted success of Gimbichu’s CBHI pilot scheme

demonstrates that Ethiopia will be a model country in health insur-

ance, and is moving towards achieving universal health coverage.

After hearing the testimonies of the CBHI member community rep-

resentatives, Dr. Pablos-Mendez pointed out that “residents of Gim

bichu are not only beneficiaries of CBHI, but also part of the

change that the world strives to see: equity in health by achieving

universal health coverage.” He also reassured the gathering that the

American people and government will be by their side to ensure

this change.

The visit of Dr. Pablos-Mendez was an important event for commu-

nities in Gimbichu. The public gathering was attended by more than

400 people including community representatives, and federal, re-

gional, zonal, and district governmental officials. A large number of

CBHI beneficiaries also attended. Community leaders thanked dele-

gation members for their visit, and their continued support. As a

gesture of gratitude and respect, they presented Dr. Pablos-

Mendez and other guests with gifts of traditional costumes.

The dignitaries were accompanied on the visit by senior officials

and experts from the FMOH, the Oromia Regional Health Bureau,

the Ethiopian Health Insurance Agency, and USAID Ethiopia.

Visitors wore traditional dresses and were blessed by

elders

Mrs. Kumele Che-

renet, a CBHI mem-

ber, explaining

about benefits of

CBHI for women

Health Care Financing Updates

The HSFR/HFG project collaborated with government counterparts

during the last quarter of the project year (April-June 2015) to pro-

vide training in health facility governance, health care financing (HCF)

reform implementation, and financial management throughout the

country. These trainings and other activities are critical to the con-

solidation of first generation HCF reform components including

revenue retention and utilization (RRU), health facility governance

structures, establishment of private wings, reform of fee waivers and

exempted health services, user fee settings and revision, and out-

sourcing of non-clinical services. The following articles highlight the

major HCF training conducted during the quarter.

Trainings on HCF reform implementation

In April, the project team in the central office and for Oromia, Hara-

ri, and Dire Dawa collaborated with the respective regional health

bureaus (RHBs) to provide basic and refresher trainings on HCF

reform implementation for 173 (131 men, 42 women) health facility

staff in Adama and Harar towns. HSFR/HFG also provided technical

support for the trainings.

In Adama, the Addis Ababa City Administration Health Bureau

organized the training into three rounds (April 6-8, 9-11, and 17,

20, and 21). The training covered HCF reform, CBHI, leadership

management and governance, the Clean and Safe Hospitals

(CASH) initiative, and professional ethics. Sixty-five hospital sen-

ior management staff (41 men and 24 women) attended the train-

ing.

The project team for Oromia, Harari, and Dire Dawa, in collabo-

ration with the RHBs in the three regions as well as the Clinton

Health Access Initiative (CHAI), organized HCF training for nine

new hospitals on April 15-22. The training, which took place in

Harar town, focused on HCF, Business Processing Reengineering,

Balanced Score Card, the Ethiopian Hospitals Reform Implemen-

tation Guideline, Hospital Performance Monitoring Indicators,

and the Health Development Army. A total of 108 (90 men, 18

women) personnel attended the training.

6

Training on financial management

The project team in Amhara organized an eight-day (April 17-25)

financial management training for new health centers implement-

ing HCF reform. The training, which took place in Woldia town,

covered government accounting reform; gave an overview of HCF

reform including health insurance; and discussed directives for

RRU, facility governance, and implementation of the new fee waiv-

er system. Twenty-eight key finance staff (19 men and 9 women)

from health facilities in six zones of Amhara participated in the

training.

Consultative workshop to revise HCF legal

framework and operational manual

The project provided support for a consultative workshop held

June 5-8 in Adama town to discuss the findings of HCF supportive

supervision. The heads of the RHB and Bureau of Finance and

Economic Development (BoFED) made opening remarks empha-

sizing the need to increase the health sector budget and assess

trends in utilization, availability of essential drugs, client satisfac-

tion, and other aspects of health care. Subsequent to the presen-

tation, participants were divided into groups to discuss the issues

and each group presented its proposal for resolving the issue.

Participants commented and consensus was reached on the ap-

propriate way to implement HCF reform. A total of 145 partici-

pants (119 men and 26 women) attended. Workshop participants

were the head and deputy head of the Addis Health Bureau, CPSP

owners, responsible officials and experts from the BoFED, deans

of teaching hospitals, CEOs, medical directors, and directors of

Planning and Budget from one medical college, five hospitals, and

10 sub-city administrations.

Training on health facility governance

During the reporting quarter, the project trained 151 (121 men and

30 women) health facility governing board/body members drawn

from referral and teaching hospitals in Addis Ababa, hospitals in

Southern Nations, Nationalities and Peoples’ (SNNP), and new health

centers in Amhara region. The training topics included: a background

on HCF reforms, components of HCF reforms (RRU, health facility

governance, fee waivers and exempted health services, user fee set-

ting and revision, establishment of private wings in hospitals, and

outsourcing of non-clinical services), and the roles and responsibili-

ties of the facility governing board/body, management committee,

and facility finance and administration staff.

Table 1. Number of Health Facilities Governing Board/Body Mem-

bers Trained on Facility Governance

Note: HC=health center

Region

# Participants

# Facilities

Men Women Total

Amhara

28

0

28 14 new HCs

Central

13

15

28

5 hospitals

SNNP

80

15

95

24 hospitals

Total

121

30

151

The report from community-based health insurance

(CBHI) implementing regions indicates that as of June 30,

2015, 1,374,325 households (1,077,301paying and 297,024

non-paying) were enrolled in the schemes both in pilot

and expansion woredas.

The overall enrollment rate is 33.1 percent (45.9 percent

in pilot and 31.8 percent in expansion woredas) of eligible

households. The schemes generated 196,234,599.27 Birr

(41,831,485.69 Birr in pilot woredas and 154,403,111.58

Birr in expansion woredas) from members’ contributions

Community-Based Health Insurance Updates

(i.e., excluding general and targeted subsidies). In pilot

woredas, 909,214 visits were made to health facilities

(792,789 in health centers and 116,425 in hospitals) from

April 2011 through June 2014. During 2014/15, 431,659

visits were made in health facilities (359,867 in health cen-

ters and 71,792 in hospitals). Of these visits, 86 percent

were made to health centers, 14 percent to hospitals.

7

CBHI schemes in expansion woredas enroll

around1.2 million households; collect 154.4 mil-

lion Birr in premiums

There are 123 CBHI expansion woredas in Amhara and Oromia (64

in Amhara and 59 in Oromia); 75 of them (49 in Amhara and 26 in

Oromia) have officially established CBHI schemes. (An “officially

established” scheme is one that has begun enrolling members and

collecting premium payments and is reimbursing contracted health

care providers for providing services to scheme beneficiaries.)

There are 1,199,739 households (932,185 paying and 267,554 non-

paying) enrolled in these regions. The total amount collected in

premiums is 154,403,113 Birr.

Of the 64 expansion woredas in Amhara region, 49 have officially

established schemes. Table 2 summarizes the numbers of Amhara

households enrolled in a CBHI expansion scheme. Of the total

1,177,325 eligible households in the region’s expansion woredas,

304,380 paying households were enrolled in 2013/14 and 267,176

paying households were enrolled in 2014/15 for a total of 571,556

paying household enrollments. In addition, 84,255 indigent house-

holds were enrolled, for a grand total of 655,811 member house-

holds over the two years.

The two-year average enrollment rate in the 49 schemes was 33.4

percent of eligible households. The highest enrollment rate was

reported in South Wollo zone (45 percent), followed by Oromia

zone (42.2 percent) and West Gojjam (38.6 percent). Over the two

years, the schemes generated a total of 94,911,006.00 Birr.

A total of 130,835 Amhara households renewed their membership

in 2014/15. The highest household membership renewal was in

West Gojjam, South Wollo, and South Gondar, the least in Wag

Himra and North Gondar.

Table 2: Household Enrollment in Schemes and Amount of Premi-

um Collected in CBHI Expansion Woredas of Amhara Region Dis-

aggregated by Zone. 2013/14-2014/15

In Oromia region, all 59 CBHI expansion woredas started

member enrollment and contribution collection in the final

quarter of 2013/14. Of these, 26 have established CBHI

schemes. Only 12 schemes (three each in North Shoa and

West Shoa, two in West Arsi, and one each in East Shoa, Arsi,

West Arsi, and East Harargie) reported the number of paying

and indigent households and the contribution collected. The 59

expansion woredas have enrolled 543,928 households (360,629

paying and 183,299 indigent) (Table 3). The highest enrollment

rate is in Finfine Special Zone (50.6 percent) followed by North

Shoa (42.8 percent), Guji (37.0 percent), and Arsi (36.3 per-

cent). The schemes generated 59,492,107.58 Birr from member

contributions.

Table 3: Household Enrollment in Scheme and Amount of Premium Collected in CBHI Expansion Woredas of Oromia Region Disaggregat-ed by Zone

Health service utilization by beneficiaries of

CBHI expansion schemes

In Amhara’s 64 CBHI expansion woredas, 35 schemes reported

that beneficiaries made 664,463 visits to contracted health facil-

ities (615,396 to health centers and 49,067 to hospitals) and the

schemes reimbursed 27,841,728.80 Birr to those facilities in

2014/15. Over the time that these schemes have been operat-

ing, their beneficiaries have made a total of 792,413 visits

(737,245 to health centers and 55,168 to hospitals) and the

schemes have reimbursed 32,158,948.81 Birr to the providers.

Note: HH– household

8

In Oromia region, 18 of the 26 established schemes start-

ed providing health care services in 2014/15. Ten schemes

reported on the number of beneficiary visits in the year

(81,271 visits, 75,156 of which were to health centers,

6,115 to hospitals). Nine reported on reimbursements,

which totaled 3,689,415.08 Birr.

Original CBHI pilot schemes enroll

766,516 members, collect ETB 41.8 mil-

lion Birr in premiums

The CBHI program in Ethiopia started in April 2011 with

13 pilot schemes in Amhara, Oromia, SNNP, and Tigray

regions. These 13 original schemes had enrolled 766,516

households by the end of June 2015. Of these 17,033

households (12,748 paying and 4,285 non-paying) were

new in 2014/15; in the same year, 95,727 households re-

newed their membership. The schemes generated

24,858,068.58 Birr in contributions from new and renew-

ing members in the year. Since the establishment, the

schemes enrolled 174,586 households (145,116 paying and

29,470 non-paying) and generated 41,831,485.69 Birr from

new and renewing member contributions. The average

household enrollment rate is 45.9 percent; the highest

enrollment rate is reported in Tehuledere (85.5 percent),

followed by Gimbichu (65.2 percent), Kilte Awlaelo (57

percent), and South Achefer (55.7 percent) (Table 4).

The three schemes in Amhara enrolled 2,986 new paying

households in 2014/15. They also enrolled six non-paying

(indigent) households; however, they lost 62 non-paying

households in Fogera Woreda, for a net loss of 56. A total

of 27,910 households (11,936 in Tehuledere, 11,464 in

South Achefer, and 4,510 in Fogera) renewed their mem-

bership in the year. The schemes generated 4,504,626.00

Birr. The average enrollment rate in the region was 50.4

percent, the highest being in Tehuledere (85.5 percent)

and the lowest in Fogera (31.9 percent).

The four schemes in Oromia enrolled 11,472 new house-

holds (7,339 paying and 4,133 non-paying) and 20,958

households renewed their membership. The regional en-

rollment rate is 41.9 percent of eligible households, the

highest being 65.2 percent in Gimbichu.

The three pilot schemes in SNNP region enrolled 21,356

households (20,139 paying and 1,217 non-paying) and gen-

erated 3,521,776.08 Birr from April 2011 through June 2015. The schemes

enrolled only 321 new households (113 new paying households and 208

non-paying) in 2014/15; 36,596 households renewed their membership.

From April 2011 through June 2015, the schemes generated 4,600,598.37

Birr; 1,078,822.29 Birr were generated in 2014/15. Currently, the overall

household enrollment rate in pilot woredas in the region is 45.3 percent;

the highest is in Damboya (45.5 percent), but the rate is about the same for

all three schemes.

The three schemes in Tigray enrolled 2,310 new households (477 in Ah-

ferom, 666 in Kilte Awlaelo, and 1,167 in Tahitay Adiabo); the number of

non-paying households remained the same in all the three pilot woredas.

The schemes mobilized 7,529,641.00 Birr from April 2011 through June

2015; of this 1,701,408.00 Birr came during the reporting year. The total

household enrollment rate in the region is 46.9 percent, the highest being

recorded in Kilte Awlaelo (57.0 percent).

Table 4: Number of Households Enrolled in the Original Pilot Schemes, Number of

Beneficiaries, and Contribution Collected Disaggregated by Region and Woreda

Service provision in the original pilot woredas

In 2014/15, CBHI beneficiaries made 431,659 visits (359,867 to health cen-

ters and 71,792 to hospitals) and reimbursed 17,524,989.78 Birr to health

facilities in the four pilot woredas.

Since 2011, Amhara region has ranked first among the four schemes, in

terms of both total number of visits made and amount reimbursed to health

facilities. In 2014/15, 173,896 visits were made to health facilities (157,486

(86 percent) to health centers and 16,410 (14 percent) to hospitals) and

7,148,193.94 Birr was reimbursed; this represents nearly 37 percent of the

9

total reimbursed between 2011 and 2015.

Since April 2011, when the three Amhara CBHI schemes started

providing protection to beneficiaries, 600,111 visits (556,071 in

health centers and 44,040 in hospitals) have been made to contract-

ed health facilities and the schemes have reimbursed the health facili-

ties 20,203,116.85 Birr for services provided.

In Oromia, 77,019 visits (43,166 in health centers and 33,853 in hos-

pitals) were made and the four schemes reimbursed 3,722,023.93

Birr to health facilities in 2014/15. Since April 2011, 217,039 visits

(133,331 in health centers and 83,708 in hospitals) have been made

and schemes have reimbursed the health facilities 8,796,371.00 Birr.

In SNNP region, 92,842 visits (80,856 in health centers and 11,986 in

hospitals) were made and the schemes reimbursed 2,680,440.01 Birr

in 2014/15. Since April 2011, 285,969 visits (256,127 in health cen-

ters and 29,842 in hospitals) have been made and 7,988,314.26 Birr

reimbursed.

In Tigray region, 87,902 visits (78,359 in health centers and 9,543 in

hospitals) were made, and schemes reimbursed 3,974,331.90 Birr in

2014/15. From April 2011 through June 2015, a total of 183,970

visits were made in health facilities (207,127 in health centers and

30,627 in hospitals) and schemes reimbursed 10,507,881.62 Birr.

Workshop on CBHI Scale-up Strategy

HSFR/HFG in collaboration with the Ethiopia Health Insurance Agen-

cy (EHIA) organized a CBHI Scale-up Strategy Consultation Work-

shop. On the first day of the workshop, held June 2-3, 2015 at the

Capital Hotel in Addis Ababa, project staff made three presentations:

Highlights of CBHI pilot evaluation findings and policy recommenda-

tions, by Abebe Alebachew of the consultant firm Breakthrough

International Consultancy, who led the evaluation; HCF reforms in

Ethiopia by Leulseged Ageze, Project Chief of Party; and CBHI con-

cept and global experience, by Hailu Zelelew, a Senior Associate/

Scientist at Abt who is also technical director of HSFR/HFG project .

Jean Damascene Butera, an international consultant working with

HSFR/HFG project, presented highlights of the scale-up strategy. On

the second day, workshop participants critically reviewed the CBHI

scale-up strategy. Based on their institutional affiliation and ex-

pertise/experience, participants were assigned to one of five working

groups: 1) Vision, mission, objectives, guiding principles, scale-up

approach, and road map; 2) strengthening CBHI legal framework and

institutional structure; 3) CBHI financing mechanisms and strength-

ening management systems; 4) strengthening partnerships with

health care providers and strengthening communication and commu-

nity mobilization; and 5) monitoring and evaluation and the CBHI

management information system. Each group reported back in a

plenary

session

on

major issues identified and recommended a course of action. The

project team revised the draft CBHI scale-up strategy based on

these inputs.

The 72 workshop participants (65 men and 7 women) were from

the FMOH, EHIA central and branch offices, Ministry of Labor and

Social Affairs, and RHBs, and were selected CBHI executive staff

and woreda administrators. The workshop was covered by public

and private media outlets, such as the Ethiopian Broadcasting Cor-

poration (EBC), Sheger FM, Radio Fana with its regional links, and

the widely circulated public newsletters Addis Zemen, The Ethiopi-

an Herald, and Addis Lisan.

Training on CBHI

During HSFR/HFG Year II, the project, in collaboration with RHBs

and EHIA branch offices, provided refresher training on CBHI

program implementation and the CBHI Financial Administration

and Management Systems (FAMS). It also conducted training for

health care providers and an orientation for EHIA branch offices in

four regions (Amhara, Oromia, SNNP and Tigray). Overall, the

project trained 8,666 personnel ( 8,030 kebele leaders, 571 per-

sons drawn from woredas, kebeles, and health centers, 353 CBHI

executive staff (286 orientation on CBHI program and 67 on CBHI

FAMS), 401 health care providers, and 47 EHIA branch offices staff.

Above: Leulseged Ageze, Chief of Party, HSFR/HFG Project

addressing the participants. Below partial view of participants,

workshop on CBHI Scale-up strategy

10

Training for CBHI executive staff in pilot and

expansion woredas

As discussed above, the project trained a total of 286

CBHI executive staff (198 in Amhara, 35 in SNNP,

and 53 in Tigray region) in Year II.

The project team in Amhara region organized a three-

days training for CBHI executive staff of the 25 new

woredas preparing to implement the CBHI program.

The training was held in three sites, Kemissie, Wore-

ta, and Dangila. The training topics included: concepts

and basic principles of CBHI, CBHI regional directive,

CBHI FAMS, and medical audits. A total of 198 CBHI

executive staff (170 men and 28 women) attended the

training.

The project team in SNNP region organized a two-

day training for newly recruited CBHI executive staff

of both pilot and expansion CBHI schemes. During

the training, held in Hossana town, the project team

made presentations on topics that included concepts

of health insurance (community-based and social

health insurance), FAMS, managing contracts with

health providers, database management, and staff

roles and responsibilities. The presentations were

followed by practical exercises and questions and an-

swers. A total of 35 persons (27 men and 8 women)

attended the training.

The project team in Tigray region in collaboration

with Health Insurance and Monitoring and Evaluation

(M&E) teams from the central office organized a four-

day training in Wukro town for CBHI executive staff

from both pilot and expansion woredas. Training top-

ics included: concepts and principles of CBHI, when

and how to establish scheme (registration, contribu-

tion collection, ID card preparation and distribution),

effective ways of implementing CBHI program and

lessons from other regions, M&E (basic concepts, indi-

cators and targets, data collection tools, and data

quality assessment), and CBHI FAMS including the

prerequisite for financial auditing of schemes. The project

staff and RHB accountant served as trainers. At the end of

the training, participants said that the training enabled

them to comprehend procedures and approaches in the

implementation of the CBHI program. They also prom-

ised to organize sensitization and mobilization activities

and to facilitate establishment of schemes in their

woredas. Attending were 53 CBHI executive staff (33

men and 20 women): 18 woreda health office curative and

rehabilitative core process staff who serve as CBHI coor-

dinators; 17 CBHI IT staff; and 18 scheme accountants.

Social Health Insurance Update

Review of implementation manual

HSFR/HFG in collaboration with the Ethiopia Health In-

surance Agency (EHIA) organized a one-day consultative

meeting between EHIA central office staff and branch

managers and project staff to review the social health in-

surance (SHI) implementation manual. The meeting, which

took place on May 15, 2015 in Adama , was attended by

26 persons (22 men and 4 women).

The meeting was chaired by Mr. Mulat Tegegne, EHIA

Acting Deputy Director. The project team made a

presentation on the manual’s major topics, which was

followed by discussion. Participants forwarded comments

about how to improve member registration formats, con-

tents of the member ID card, systems for collecting con-

tributions, implementation of different provider payment

mechanisms, and data management and reporting on

member profiles and health service utilization.

The HSFR/HFG Health Insurance team is incorporating

comments and suggestions into the manual, and working

closely with EHIA staff to facilitate endorsement of the

document. Once it is endorsed, the project will print and

distribute the manual to all branch offices and organize

training on it.

11

HSFR/HFG Staff Donates Potted

Plants to Ras Desta Hospital

For the Ethiopian New Year, HSFR/HFG staffs have do-

nated 64 pots of plants to Ras Desta Memorial Hospital, a

well-known public health facility in Addis Ababa city.

HSFR/HFG staff made the gift in recognition of the facility

being a pioneer in implementing health care financing

reforms, and a long-time partner of the project, initially

collaborating with the USAID HSFR project and over the

past two years with HSFR/HFG. The project also is over-

seeing Ras Desta’s implementation of the FMOH’s new

Clean and Safe Hospitals (CASH) initiative.

Central office project staff collect funds to purchase the

plants and deliver them to the hospital. The staff mem-

bers were received by Ato Tilahun Desta, Ras Desta’s

Disease Prevention and Health Promotion process own-

er, who expressed appreciation on behalf of the facility

and its staff. He said the gift exemplifies the project staff’s

relentless effort in providing support in all areas to make

the hospital a better place.

HSFR/HFG project staff delivering/arranging potted plants at

Ras Desta Memorial Hospital

Expanding Access. Improving Health.

Health Sector Financing Reform/ Health Finance and Govern-

ance (HSFR/HFG) project is a continuation of Health Sector

Financing Reform (HSFR) Project which has been working to

support the implementation of the Health Sector Financing

Reform and the Health Insurance Programs at the national,

regional, zonal, woreda and health facility levels.

The overall goal of HSFR/HFG project is

to help the government consolidate and scale up the vari-

ous components of HCF reform,

to increase utilization of health services by further im-

proving their quality and reducing financial barriers that

impede access to them through scaling up risk-sharing

mechanisms (insurance), promoting community participa-

tion to ensure accountability, and supporting the genera-

tion of evidence for program learning and decision mak-

ing.

Implemented by Abt Associates Inc.

In collaboration with

Broad Branch Associates, Development Alternatives Inc.,

Futures Institute, John Hopkins Bloomberg School of Public

Health, Results for Development, RTI international and Train-

ing Resources Group Inc.

Address Central Office

Mexico Square , TadesseTefera Buliding 2nd floor, In Front

of Hotel D’Afrique

Tel: 251 115 501 049, Fax: 251 115 501 556,

P.O.Box 42521, Addis Ababa, Ethiopia

Regional Offices

Hawassa regional Office

Covers SNNPR & Gambella Regions

Areb Sefer, Ali Shemsan Building, 3rd floor

Tel: 251 (046) 221 5003/4854, Fax: 251 (046) 220 4332

P.O. Box 1133, Hawassa

Bahir Dar Regional Office

Covers Amhara & Benishangul GumuzRegions

Kebele 13 House # 179 Around A.D.M School

Tel: (251) 582-262-970/71, Fax: (251) 582-262-69

P.o.Box: 2316, Bahir Dar

Tigray Regional office

In front of Ethio Telecom, semen region, Nilex Plaza

building, 3rd floor,

Tel: 251(344)413479, Fax:251(334)413479, Mekelle

Oromia Project Office

Project Office for Oromia, Harari and Dire Dawa regions

(co-located with central office)

Health Sector Financing Reform/ Health

Finance and Governance (HSFR/HFG) project

Health Financing is Produced by Health Sector Financing Reform/Health

Finance & Governance (HSFR/HFG) Project in Ethiopia

Content & Design: Bethlehem Negash, Editing: Linda Moll For comments contribution and suggestion Write: bnegash@hsfreth.org

Tel: 251 115 501 049, Fax: 251 115 501 556, P.O.Box 42521,

Addis Ababa, Ethiopia