Strengthening Human Resources for Health 2012- 2019

Project Accomplishments

1 This document is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the Cooperative Agreement AID-663-A-12-0008 “Strengthening Human Resources for Health (HRH) in Ethiopia.” The contents are the responsibility of Jhpiego and do not necessarily reflect the views of USAID or the United States Government.

Photos credit: Beruk Weldeyesus for Jhpiego

March 2019

2 CONTENTS

CONTEXT 5

PROJECT RESULT FRAMEWORK AND A SNAPSHOT OF HIGH LEVEL

ACCOMPLISHMENTS 8

MAJOR ACCOMPLISHMENTS BY INTERMEDIATE RESULT AREA 10 Improving Human Resources for Health Management 10 Increasing Availability of Midwives, Anesthetists, Health Extension Workers and Other Essential Health Workers 14 Improving Quality of Pre-service Education and In-service Training of Health Workers 20 Generating Research and Program Learning Evidence on HRH 30

SUMMARY 32

WAY FORWARD 33

TESTIMONIES FROM KEY STAKEHOLDERS 34

MESSAGE FROM CHIEF OF PARTY 35

3 4 CONTEXT In 2011, despite having made significant progress in previous years, the maternal mortality ratio in Ethiopia was 676 per 100,000 live births, and the under-five mortality rate was 88 per 1,000 live births1, which was among the highest in the world. Among communicable diseases, HIV/AIDS, tuberculosis, and malaria were the most serious public health problems−1.5% of the adult population was infected with HIV2, and the country had the seventh highest burden of tuberculosis in the world3. One of the underlying reasons for the poor health outcomes was the lack of access to quality health care. This was best illustrated by the 10% skilled birth attendance rate4, the lowest in the world. Ethiopia’s aspirations to achieve its health development targets, which were aligned with the Millennium Development Goals (MDGs), required improving access to quality health care, which in turn depended on improving the availability, accessibility, acceptability, and quality of its health workforce. However, Ethiopia had several workforce challenges, including, but not limited to, shortages, rapid turnover, uneven distribution, and poor quality. According to the World Health Organization, countries needed a minimum of 2.3 doctors, nurses, and midwives per 1,000 population to achieve the health MDGs5, but in 2012 Ethiopia’s health worker density of 0.76 per 1,000 was no where close to this number, even when health officers and health extension workers (HEWs) were included in the numerator6. The shortage of health workers was further compounded by high attrition and inequitable geographic distribution. For example, the physician-to-population ratio varied from 1:3,056 in the capital city, Addis Ababa, to 1:98,258 in the Afar Region7. There were also serious national concerns about the quality of education of health workers, which was partly a result of the rapid scale-up in the number of institutions providing training for health workers. In-service training (IST) was also plagued with poor planning, coordination, and quality8. To address the substantial health workforce challenges, in May 2012, the United States Agency for International Development (USAID), awarded the Strengthening Human Resources for Health (HRH) Project, an investment of up to $55 million to support the efforts of the Government of Ethiopia to improve health outcomes for all Ethiopians.

1Ethiopian Demographic and Health Survey, CSA, 2011 2 Ethiopian Demographic and Health Survey, CSA, 2011 3 https://apps.who.int/iris/bitstream/handle/10665/137094/ 9789241564809_eng.pdf?sequence=1 4Ethiopian Demographic and Health Survey, CSA, 2011 5The world health report 2006 – Working Together for Health. Geneva, World Health Organization, 2006:10–13. 6 Health and Health Related Indicators. FMOH, 2004 E.C 2011/12 G.C 7 Health Sector Development Program IV 2010/11–2014/15, October 2010, FMOH 8 Health Workforce in Ethiopia, 2012, World Bank 5 6 The HRH Project had four result areas: 1. Improved human resources for health management. 2. Increased availability of midwives, anesthetists, HEWs, and other essential cadres. 3. Improved quality of education and training of health workers. 4. Generated research and evaluation evidence.

The HRH Project was implemented by a Jhpiego-led consortium that included Management Sciences for Health, Ethiopian Midwives Association, Ethiopian Association of Anesthetists, Open University UK, and Project Mercy. The Project was awarded in May 2012 and closed in June 2019. To achieve its objectives, the HRH Project supported and strengthened the Federal Ministry of Health (FMOH), the 11 regional health bureaus (RHBs), the then Food Medicine and Healthcare Administration and Control Authority (FMHACA), the Federal Ministry of Education (FMOE), the Higher Education Relevance and Quality Agency (HERQA), the Technical and Vocational Education and Training Agency, regional occupational assessment and certification agencies, 52 government universities and colleges (28 universities and 24 regional health science colleges- RHSCs), over 40 private colleges, and nine health professional associations.

7 8 9 MAJOR ACCOMPLISHMENTS BY INTERMEDIATE RESULT AREA

Improving Human Resources for Health Management

10 Upgraded filing system in the HRM Unit in Felege Hiwot Referral Hospital, Amhara Region

uman resources (HR) are a critical component of health systems and links with other building blocks in the health system. Yet numerous challenges affected HRH management in Ethiopia’s public sector. These included poor attention to HR management, Hweak HR structures and staffing, absence of professional development opportunities for HR staff, lack of HR plans and budgets, erratic awareness and implementation of HR policies, a weak HR information system and poor inter-sectoral collaboration. In response to these gaps, the HRH Project supported: • The FMOH to develop a National HRH Strategic Plan (2016–2025). RHBs were also assisted to develop strategic and operational plans tailored to their local needs. This resulted in improved planning capacity and increased budgets for HR activities. • Restructuring of HR units and creation of 1,307 new government- funded HR management (HRM) positions at different levels of the health system. This improved the capacity of the health sector to effectively carry out HRM functions. • The RHBs HR processes with the recruitment and orientation of 67,070 new health care providers by drafting or updating job descriptions, position announcements, and determining need- based allocation and deployment of these professionals. • Training of 2,950 HR managers and officers based on a nationally approved curriculum, which improved knowledge and performance of HR managers and staff. The preparation of 60 master trainers created local capacity to sustain the training. • Development and utilization of a staff orientation manual or employee handbook to facilitate smooth integration of new hires into the sector and raise awareness about HR policies. • Improvement in knowledge and utilization of HR policies by identifying, collating, and distributing HRM policy and procedure documents at different levels of the health management system. • The FMOH and RHBs to determine the stock and distribution of the health workforce (see page 32). This support was critical to inform planning, deployment, and monitoring of progress in the absence of a robust HR information system.

11 • RHBs to update personnel files of 130,938 health workers. The Project also collaborated with United States Centers for Disease Control and Prevention (CDC) and Tulane University to support RHBs to institutionalize the Human Resource Information System (HRIS) and update the profiles of health workers nationwide. • FMHACA to strengthen regulation and governance of health workers by developing scopes of practice for 15 health occupations, ethics code of conduct, and directive for continuing professional development (CPD). • Establishment of national and regional HRH partnership forums to improve strategic collaboration and communication. The forums are led by the FMOH at national level and RHBs at regional level and include ministries of education, civil service, and finance; higher education institutions; professional associations; and development partners. • Improvement in leadership, management, and governance capacity and practices at FMOH, RHBs, and regional hospitals by training 313 leaders and managers during a nine-month leadership, management, and governance (LMG) program to help them achieve greater equity and quality of health services.

Before Intervention After Intervention

POLICY Number of national HRH 0 strategic plan 1

Recruitment 1,600 Number of HR staff 5,030 at all levels

Training 65 Number (%) of HR staff who 3,015 received on-the-job training (4%) in HRM at all levels (60%)

Partnership Forum Number of national or regional 0 HRH partnership forum 12

Health Workforce 114,362 Number of professionals in the 243,602 health sector 12 Upgraded HR filing system in Tigray Region Health Bureau, Tigray Region

Magnifying HR functions as a key component of the health sector performance “With improved capacity at zonal and woreda health offices, the HR staff at those levels are effectively managing HR issues and have avoided unnecessary travel to the RHB for health workers. This has increased health workers’ satisfaction by reducing delays related to HR decisions. In addition, the pressure and workload on the RHB human resources staff has reduced, thereby giving them time to perform system strengthening activities such as mentoring and coaching of HR staff at lower levels.” Wossen Gizachew, Acting Head of the HRM Support Process, SNNP RHB ~***~ “Health workers’ recruitment and deployment at the woreda health offices used to be open for corruption. However, it improved significantly in the last four years, with HRM training and follow up by the RHB and the HRH Project. Now, we strictly follow the regional civil service rules and regulations to hire health workers which increased speed, transparency and accountability”. Redwan Hassen, HRM Officer, Woreda health office, Silte Zone, SNNPR ~***~ “Health workers had difficulties to access their own personnel files, and sometimes, they incurred additional cost and time to come to the RHB for a number of HR services.” Tesfaye Dadi, HR Officer for the Oromia RHB ~***~ “Improved HR structure and increased staff in district and woreda health offices ensured proper performance of HR duties such as employment, transfer and promotion. As a result, the number of staff coming to the RHB for complaints and grievances has decreased in the past four years. Besides, discussions with health professionals during supportive supervision and review meetings showed that their satisfaction with HR support functions has improved over the same period.” Habtamu Demissie, Former Head of HR Development and Administration Support Process, Oromia RHB, now Director, Human Resources Administration Directorate, FMOH ~***~

13 Increasing Availability of Midwives, Anesthetists, Health Extension Workers, and Other Essential Health Workers

14 lthough Ethiopia had severe workforce shortages across all health care occupations, the needs were greater for some cadres. For instance, in 2012, Ethiopia had only 4,709 midwives, 252 anesthetists, and 28,994 HEWs serving its population Aof over 849 million. Thus, the HRH Project supported efforts of the government to improve the availability of midwives, anesthetists, HEWs, specialist nurses, emergency medical technicians, biomedical technicians and public health specialists. The HRH Project interventions focused on supporting higher education institutions to expand existing programs and open new ones for the priority health cadres while maintaining quality. In addition, the Project supported professional associations to play a greater role in the education of health professionals. Overall the Project: • Contributed to the graduation of 48,923 health workers, including 1,508 anesthetists, 15,552 midwives, 13,849 Level III and 14,593 Level IV HEWs, 1,277 emergency medical technicians (EMTs), and 474 biomedical technicians. • Supported scale up of education of anesthetists, midwives, HEWs, EMTs, and BMTs by providing the necessary technical and material assistance to FMOH and higher education institutions. • Developed and disseminated messages to inform and attract prospective midwifery and anesthesia students. • Assisted with development of trainings for seven nursing specialties in 24 universities. • Supported establishment of postgraduate (MPH) programs in HRH management in three education institutions and health economics (HE) in four education institutions, which graduated 119 students since the programs were launched in 2014. • Strengthened the capacity of the Ethiopian midwifery and anesthesia associations to play a central role in supporting and strengthening the education of midwives and anesthetists.

9 CSA, 2004 EFY

15 Midwifery students of Harar Health Science College practicing antenatal care in Jegol Hospital, Harari Region The HRH Project contributed to the Ethiopian Government’s effort to train and increase availability of selected priority health cadres.

18,000 HRH Project Achievements Compared to LOP Targets 2013-2018

16,000 15,552 LOP Target for All Cadres = 38,891 14,419 14,593 Six Year Achievements = 48,923 14,000 13,849 13,500 LOP Targets 6 Years Acheivements

12,000

10,000

8,230 8,000 Number of Graduates Number of

6,000

4,000

2,000 1,508 1,551 1,415 1,277

478 582 474 178 89 119 - Anesthetists Midwives HEWs Level IV HEWs Level III Emergency Medical Specialized Nurses Biomedical Technicians Postgraduates in Technicians HE and HRM Target Cadres

2012 2018 1.36 2.52 Health workers Health workers per 1,000 per 1,000 population population 7 new nursing specialties in neonatal care The number of nursing, operation room The number of midwifery training nursing, emergency and anesthesia training institutions increased critical care nursing, institutions increased from 42 to 47 and the pediatrics and child from 14 to 29. number of graduates health nursing, surgical jumped by 24%. nursing, psychiatric As a result, annual nursing, and ophthalmic graduation output In just five years, the nursing opened in 24 increased by 251%, density of midwives institutions. from 98 in 2012 to 344 nationwide has in 2018. doubled from 0.07 As of September per 1,000 population 2018, over 1,551 had The number of in 2013 to 0.17 per graduated and 4,117 anesthetists in the 1,000 in 2018. additional students have public sector grew from enrolled. 252 in 2012 to 1,201in 2018. These specialized nurses are expected to help address the growing demand for higher quality care.

Source: Annual Performance Data Collection Report, Strengthening Human Resources for Health in Ethiopia, 2013-2018 16 Strengthened the Role of Professional Associations in Improving the Health Workers Education and Training Professional associations play key roles in advancing education, practice, and regulation. Through the technical and financial support of the HRH Project, the Ethiopian Association of Anesthetists (EAA) and the Ethiopian Midwives Association (EMwA) have: • Raised the profile of their profession among members and in the public by conducting annual meetings and celebrating the International Day of Midwives. • Disseminated promotional messages through brochures, radio and television to attract prospective students to the field. • Contributed to development of accreditation standards, curricula, scope of practice, and national licensing examinations. • Trained faculty and preceptors. • Developed institutional capacity to design and provide CPD by developing 16 courses. • Participated in practice analysis studies. • Strengthened their organizational capacity - EAA by hiring 7 staff and increasing its membership from 226 to 2,150, and the EMwA established three additional chapter offices and created a database to track practicing midwives.

Handover of new vehicles to EAA and EMwA

17 18 Level IV 1st year anesthesia students learning using airway management models donated by the HRH Project, Harar Health Science College, Harari Region

19 Improving Quality of Pre-Service Education and In-Service Training of Health Workers

20 Second year medical students learning neurological examination in a skill laboratory using a model donated by the HRH Project, Debre Tabor University, Amhara Region

thiopia had made significant strides in scaling up education of health workers. However, there were major concerns about quality of education due to the rapid scale-up, which outpaced the availability of required faculty and infrastructure. In addition, 66 Eregulatory mechanisms to assure the quality of education—such as accreditation and national licensing examinations—were not well Curricula established. Developed and Reviewed Based on the Pre-Service Education Conceptual Framework, the HRH Project strengthened institutional capacity of more than 90 public and private higher education institutions and regulatory agencies to produce competent graduates.

Pre-Service Education Conceptual Framework

FLUENCING FACTO IN RS OUTCOMES

ctice Pra Stude cal s nts ini ite Cl S INFLUENCING FACTORS

/

s

r Health Long Term

o DEPLOYMENT C COMPETENCE t u u s Intermediate Impact r T r Outcomes r / o i s t c r p

REGULATION Outcomes u e lu h ce m ac re Te P

I REGULATION nfrastr re and uctu Management

REGULATION Overall 13,183 instructors and preceptors from public and private higher education institutions benefited from faculty development courses, including, but not limited to, effective teaching skills, student assessment, simulation-based training, problem-based learning, instructional design skills, and quality improvement. In addition, 66 curricula were developed or re-designed to maximize competency based learning.

21 In 52 public higher education institutions: • Use of simulation training was strengthened through training and coaching of skills laboratory assistants, donating simulators and medical equipment to institutions, and expansion of skills centers. • Clinical practicum for students was improved through expanding practice sites, training of preceptors and formalizing relationships of the education institutions with the practice sites. • Health Science Education Development Centers (HSEDCs) were established to lead education quality improvement. • Regular self-audits of programs were conducted using national standards and audit results were used to inform quality improvement activities.

These improvements have enhanced the quality of education, as demonstrated by an 82.7% pass rate in Certification of Competence (COC) examination in 2018 among graduates from vocational programs (up from 62.6% in 2014). A pre-post intervention study using objective structured clinical examination has also documented a significant increase in competence scores among midwifery (51.8% to 56.6) and anesthesia (61.5%- to 65.7%) students.

22

HSEDC Focal Person organizing reports of quality audit, currculum and learning materials review and training provision in the HSEDC Innovation Learning from the experiences of other countries, Health Science Education Development Centers (HSEDCs) have been established at 52 higher education institutions to serve as internal quality assurance hubs. Though they are each at various stages of becoming institutionalized and fully functional, they are all supporting faculty to conduct regular self-audit of programs, using HERQA’s quality improvement standards and using results for improvement purposes. They also conduct faculty development, curricular review, and other quality improvement activities. Key Functions of HSEDCs

Faculty Development

Educational Quality Curriculum Assessment Strengthening HSEDC

Educational Student Research Assessment

Simulation Center

Overall, in 52 training institutions a total of: • 155 academic programs audited using national standards. • 1,336 faculty trained using local resources. • 188 curricula reviewed. • 345 course syllabi, learning modules and guidelines developed. • 197 competency based assessment tools, 24 exam blueprints and 18 item banks developed.

Establishing a HSEDC at HEIs is an effective, efficient and sustainable mechanism to nurture a culture of continuous quality improvement. Strong advocacy that resulted in HSEDCs leveraging their internal resources and university leadership support ensured the use of results after program self-audits, helped address prioritized gaps at the institutions, and will facilitate sustainability.

23

HSEDC Focal Person organizing reports of quality audit, currculum and learning materials review and training provision in the HSEDC D O N A T I O N S

13 BUSES

12,844 BOOKS 49,722 MODULES

1,190 COMPUTERS

1,384 SKILLS LABORATORY MATERIALS (Simulators and medical equipment)

18,429 OFFICE SUPPLIES 24AND FURNITURE D O N A T I O N S

13 BUSES Remla Miftah, Gender Focal Person counseling a student, Zufan Girmay, in the Gender Office in Dr. Tewelda HSC. Tigray Region A Gender Focal Person counseling a student in Dr. Tewelde Health Science College, Tigray Region

Fostering Gender-Responsive Education in Health Science Education Despite the Federal Ministry of Education’s affirmative action programs designed to close the gender gap, women have been under-represented in 12,844 pre-service education programs for health professionals, with significantly BOOKS lower performance and graduation rates than their male counterparts. Many factors contribute to the gender gap, including an unfavorable teaching and learning environment for women, poor academic background, sexual 49,722 harassment, peer pressure, and financial problems. Proactive interventions MODULES 13, 207 are needed to give female students an opportunity to realize their full Students potential, achieve gender equity in health professional education, and Received ultimately to increase women’s share in the growing health care workforce. Gender Office Support In collaboration with the FMoE and Federal Ministry of Women and Children’s Affairs, the HRH Project strengthened gender offices and established new ones in 44 health education institutions to address gender gaps in educational outcomes. The gender offices provided 11,735 female 1,190 students and 1,472 male students with a variety of gender transformative COMPUTERS interventions, such as, life skills training, counseling, tutorial and financial assistance, that reduce female students’ dismissal and dropout rates, particularly in their first year, which is a critical milestone for success in 24 higher education. RHSCs Gender offices trained teachers in gender-responsive pedagogy, adopted Introduced sexual harassment policies, and challenged harmful gender norms and Gender stereotypes on campus community through awareness creation events. Interventions for These interventions have improved performance and retention of female 1,384 the First time students. SKILLS LABORATORY MATERIALS “Previously, getting copies of learning materials was a nightmare for me because my family could not afford it. Now, I can get the copies (Simulators and medical equipment) and study them thanks to the 100 birr stipend I get monthly from the gender office. Because of that, I performed the best this year and got the annual award for my academic performance” Banchiaymolu Damte, first year medicine student and winner of the 2015 best performing student award, Arbaminch University

The actionable commitment of health education institutions’ leadership to gender issues, including formalizing gender office functions, and assigning 18,429 dedicated office, personnel, and budget, is key for sustainability. OFFICE SUPPLIES AND FURNITURE 25 Strengthening Regulation of Health Workers Education At the national level, the HRH Project improved systems for regulation of health workers’ education through development of accreditation and quality improvement standards for 17 education programs (Eleven BSc and six TVET programs).

These standards, which are being used for self-evaluation and external quality audit in public and private health education institutions, will 17 guide and encourage institutions to improve the quality of their Academic education. A national pool of assessors was prepared through training Programs have of 300 experts on accreditation and 534 on quality audit processes. accreditation The Project also supported establishment of national licensing standards examinations for university graduates and strengthened existing certification of competence tests for vocational graduates. These examinations are expected to protect the public from incompetent health care providers and incentivize education quality improvement.

About 20,000 students have taken the new licensing examination. The fact that the FMOH created a dedicated directorate, Health Professionals Competency Assessment and Licensure Directorate, guarantees ownership and sustainability of the initiative beyond the life of the HRH Project.

The HRH Project strengthened examinations. It supported TVET Agency to develop and review COC examinations policy and procedure manuals. The HRH Project also supported regional occupational assessment and certification agencies to train writers and assessors.

After years of waiting, Yisak Kaba was finally able to take a COC test at the Gambella Regional COC Center, which was established with the support of the HRH Project.

26 Institutionalization and Standardization of In-Service Training In-service training (IST) has been a key mechanism for improving the performance of health workers in Ethiopia and a considerable amount of money has been invested on training; but the FMOH had serious concerns about its quality and sustainability. Training programs suffered from poor planning, coordination, and quality. Training providers were also largely international non-governmental organizations, which raises concerns about sustainability.

Integrated Community-based Case Management (ICCM) training provided for HEWs in IST center, Arbaminch Health Science College, SNNPR

The HRH Project supported the development of guidelines and directives to standardize and institutionalize IST. Using instructional design training provided by the Project, FMOH’s IST unit was able to review and standardize102 IST packages developed by various FMOH directorates and partner organizations and approved 56 of them for national use.

IST coordinator positions were created at national and sub-national levels to monitor and supervise health sector IST programs. The Project equipped 35 IST centers with electronic equipment and furniture, and provided technical support (including capacity building and supportive supervision) to all 50 IST centers. As of 2018, 49 IST centers were functional and have trained more than 100,000 health workers. The IST centers have so far generated grants in excess of 210 million birr, which is encouraging progress towards sustainability.

27 Support FMOH to Develop and Manage Needs-Based CPD All health workers are expected to be lifelong learners to maintain and enhance their competence. However, the FMOH did not have a system to manage and regulate CPD of health workers. There were no incentives to encourage nor sanctions to enforce participation in CPD.

In the last six years, the HRH Project supported the FMOH, FMHACA, IST centers, professional associations, and others to develop national framework for CPD. The following interventions were completed:

• National CPD guidelines and directives for health professionals were developed, printed, and disseminated. • Advocacy workshops for CPD were organized for different stake holders. • CPD promotion and sensitization was supported via national television and during annual meetings of professional associations. • Development of CPD standard operation procedures, guidelines for accreditation, and monitoring and evaluation framework for CPD were supported. • More than 200 FMOH and professional associations’ staff were trained in effective teaching and Instructional design courses. • Orientation of 73 CPD providers on the CPD program and its requirements were supported. • Health professional associations were supported to develop CPD courses.

CPD courses developed by professional associations: • Anesthetists Association: 9 courses • Midwifery Association: 7 courses • Medical Association: 12 courses • Society of Internal Medicine: 2 courses

Despite delays, the FMOH has approved the CPD directive and established a national CPD committee. The committee has begun reviewing applications of CPD accreditors.

28 29 Generate Research and Program Learning Evidence on HRH

30 here was limited research and evaluation evidence to inform national HRH policies and programs. With support from the HRH Project, twelve (nine national-level and three regional-level) Tstudies were conducted. Research Conducted 1. Human Resources for Health Rapid Situational Assessment on 12 Prioritized Geographic Areas, 2012 studies 2. HRH Comprehensive Baseline Study, 2013 conducted 3. Competency Assessment of Graduating Midwifery and Anesthesia Students in Ethiopia (baseline), 2014 4. Job Satisfaction and Factors Affecting Health Worker Retention in Ethiopia’s Public Health Sector, 2014 5. Task Analysis of Midwives, Health Extension Workers and Anesthetists, 2014 6. Competence of Midwives in Provision of Care during Labor, 13 Childbirth and Immediate Postpartum Period in Tigray and Research Amhara Regions, Ethiopia, 2015 Papers 7. Task Analysis of Medical Doctors, Health Officers, Nurses, published Pharmacy Professionals, Medical Laboratory Professionals, 2015 8. Health Professionals Regulation in Ethiopia, 2015 9. Evaluation of the Effectiveness of Interventions to Improve Quality of Midwifery and Anesthesia Education: a Pre-Post Quasi- experimental Study Design (end-line), 2018 10.Study on Magnitude, Distribution, Performance and Challenges of Staff Secondment in Ethiopia’s Public Health Sector, 2018 12 11.Assessment of Rural Health Extension Workers’ Competence on Program Reproductive, Maternal, Child and Newborn Health Services in Learning Oromia Region, Ethiopia, 2018 Reports 12.Magnitude, Distribution, Performance and Challenges of Staff Secondment in Ethiopia’s Public Health Sector: a Cross-sectional Produced Study, 2018

• Results from the studies informed development of the HRH Strategic Plan, the regulatory sector transformation plan, curricula, national licensing examinations, and CPD courses promoting a culture of evidence-based practice.

Workers • Thirteen peer-reviewed journal articles were published. Study

Performance ofPerformance Health

Regulation & Retention & Regulation Quality of Education findings were also widely disseminated through reports and presentations at local and international conferences. • Twelve program learning reports were generated to inform future HRH program design. Research • The research capacity of government counterparts and national Themes professional associations was built by involving them in study protocol development, fieldwork, and manuscript writing.

31 Summary The combined improvements in health workers production and HRM contributed to increase Ethiopia’s workforce density by 85%, from 1.36 per 1,000 population in 2012 to 2.52 in 2018.

National and Regional Health Workforce Density Per 1,000 Population 2012 and 2018 10.00

9.00 8.83 8.37 8.00

7.00 2012 2018 6.49

6.00

5.00 4.18 3.97 4.00 3.45 3.44 3.33 3.00 3.06 3.00 2.46 2.52 2.26 2.07 1.99 1.81 1.91 2.00 1.57 1.32 1.32 1.29 1.36 1.15 1.00 0.46 0.00 Addis Ababa Harar Gambela Benishangul Dire Dawa Tigray Afar SNNP Amhara Oromia Somali National Gumuz

Source: Population Projection Ethiopia 2014-2017. Addis Ababa, Central Statistics Agency, 2018, Annual Statistical Abstract 2012. Addis Ababa, Central Statistics Agency, 2013 Baseline survey Report, Strengthening Human Resources for Health in Ethiopia, March 2013 Annual Performance Data Collection Report, Strengthening Human Resources for Health in Ethiopia, 2013-2018 Health and Health Related Indicators. FMOH, 2004 E.C 2011/12 G.C and 2009 EFY (2016/17) 2010 E.C 32 Way Forward

The Project’s recommendations for future areas of HRH investment in Ethiopia include:

• Improve functionality of HRIS. • Increase motivation and retention of health workers. • Professionalize HR staff. • Increase production to meet needs and demands for health workers. • Improve quality of education. • Strengthen CPD implementation. • Improve culture of research and data use for decision making.

When lives are on the line, confident, well-trained health workers step up. An early investment in their skills pays off.

33 Testimony from Key Stakeholders

Federal Ministry of Health

When the work was designed, the FMOH was involved with USAID from the beginning. Therefore, it was designed in a way that addressed challenges. In my personal evaluation, and as Minister of Health, the Project has solved many problems. The first achievement being the development of the costed HRH Strategy that shows the need in number and skill mix of health workers. The second big achievement is the production of 50,000 health workers of critical shortage. The third milestone is quality of education and CPD by supporting HERQA and FMOH’s HR Development Directorate. The last one is research. Previously, HRH research was developed for masters’ studies but was shelved; because of this project, research was conducted and used for policy formulation and decision making.

H.E. Dr. Amir Aman, Minister, FMOH

ጤና ጥበቃ ሚኒስቴር የሰው ሀብት ልማት ዳይሬክቶሬት

ይህንን ፕሮጀክት ወደ ሀገራችን እንዲመጣ እና ችግራችን በከፊልም ቢሆን እንዲፈታ ትልቅ ጥረት ያደረገውን ዩ.ኤስ.ኤይድን ማመስገን እፈልጋለሁ:: ይህም ፕሮጀክት የሕዝባችን ችግር የኛ ችግር ነው ብሎ በማመን ኃላፊነቱን በጥሩ ሁኔታ ስለተወጣ በጣም ማመስገን እፈልጋለሁ:: ዶ/ር ጌታቸው ቶሌራ - በኢ.ፌ.ዲ.ሪ ጤና ጥበቃ ሚኒስቴር የሰው ሀብት ልማት ዳይሬክቶሬት ዳይሬክተር

USAID Ethiopia After investing much on other building blocks of the health system strengthening in Ethiopia for many years, USAID wanted to design a comprehensive project that addresses the HRH gaps in the country. Human resources is a key component of health system and the number one contribution of this project was to elevate HRH as a critical agenda in the country. The biggest achievement is supporting the Ministry of Health to develop a 10-year strategic plan to guide the country’s overall HRH program. The Project’s interventions were very much aligned with this National HRH Strategic Plan. The HRH Project built the government’s capacity without creating a parallel system, which is fundamental for sustainability and country ownership. So I consider this was a major contribution to the health system.

Dr. Helina Worku, A/Team Leader for Health System Strengthening Team Health, AIDS, Population and Nutrition (HAPN) Office, USAID-Ethiopia 34 Message from the Chief of Party, HRH Project

Dear readers,

I am deeply honored to share the key accomplishments of the HRH Project. The HRH Project has made substantial contributions in improving the number and quality of health workers as well as national HRH management systems.

The Project would not have been successful without the Government of Ethiopia’s strong collaboration and partnership as it was planned and implemented under the leadership of the Federal Ministry of Health and regional health bureaus. The HRH Project also worked very closely with the Federal Ministry of Education (now called Ministry of Science and Higher Education), HERQA, the FMHACA, higher education institutions and professional associations and extends its appreciation to these institutions.

I am extremely grateful to USAID and the American people for their generosity in funding of the HRH Project. The Project also extends its deep appreciation to Tom’s Shoes for their donation of 80,000 shoes which were given to members of the Health Development Army in Addis Ababa, Amhara, Dire Dawa, Oromia and SNNP regions.

As we reflect on the successes of this initiative, we also look forward to new opportunities to build upon the important work HRH has done and continue to support Ethiopia in meeting its health-related sustainable development goals.

Dr. Damtew Woldemariam, Chief of Party, HRH Project

35 For more information: https://www.jhpiego.org/what-we-do/human-resources-health/ Kirkos Sub-city, Woreda 02/03 | House No. 693 | Wollo Sefer/Ethio-China Street, near Mina Building P.O. Box 2881 | Code 1250 Addis Ababa, Ethiopia| Tel: +251(0)115-502-124 | Fax:+251(0)115-508-814

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