Human Resources for Health Implications of Scaling Up For ...Six countries accepted the invitation...

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


HIV/AIDS prevention, treatment, and care: Ethiopia 1

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



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.



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



(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



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



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)



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



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



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.



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.



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.



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



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



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



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



APPENDIX C: BACKGROUND DATA COLLECTED

1. HIV epidemiology

a. HIV prevalence and

trends

Epidemiological Fact Sheet 2008

on HIV and AIDS (UNAIDS/WHO)



b. Number of PLHA



c. Estimated number in

need of ART (pediatric

and adult)



d. Number of HIV+

pregnant women per

year





e. HIV prevalence in TB

patients

Country TB Profile 2008 Ethiopia

f. Estimated number of

HIV and TB/HIV

deaths, trends





g. HIV prevalence in

most-at-risk

populations – CSW,

IDU, MSM, other

UNGASS Country Report 2008 Ethiopia

h. HIV prevalence in

health workers,

mortality



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)



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)



e. Percent who

understand modes of

HIV transmission





UNGASS Country Report Ethiopia 2008

f. Percent who used

condoms with casual

partner





g. Number (%) of

pregnant women

tested, HIV+

women/infant pairs

who receive ARV

drugs



h. Number (%) of TB

patients tested for

HIV



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



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.



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)



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).



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

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