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Editing and design by Inís Communication – www.iniscommunication.com Primary Health Care Systems (PRIMASYS) Case study from Ethiopia Overview of Ethiopian primary health care system With more than 90 million inhabitants, Ethiopia is the second mortality rate is 353 per 100 000 live births,3 and in 2015 the most populous country in Africa, after Nigeria. Numbers country’s infant mortality rate was 59 per 1000 live births. of males and females are approximately equal. The rate of On the other hand, in the same year 86.4% of children were population increase is estimated at 2.6% per year.1 In recent immunized, including pneumococcal and rotavirus vaccine.4 years the life expectancy has been increasing, and is now 64 years at birth.2 The population of the country is mostly agrarian Ethiopia allocated US$ 1.6 billion to health care in 2015. Of and rural, with a low per capita income. Pneumonia is the total health expenditure, 14.69% goes to finance primary leading cause of mortality in Ethiopia. Another major health health care (PHC). Households contribute more than one 5 issue in the country is maternal and child health. The maternal third of the country’s health expenditure (Table 1). Table 1. Key demographic, macroeconomic and health indicators, Ethiopia, 2016 Indicator Data Source of information Total population of country 90 076 012 Health and health-related indicators, Ethiopia fiscal year (EFY) 2007 (2014/2015) Distribution of population (rural/urban) 19.4% urban Health and health-related indicators, EFY 2007 (2014/2015) Income or wealth inequality (Gini coefficient) 30 International Monetary Fund Country Report No. 15/326, Federal Democratic Republic of Ethiopia, 2015 Life expectancy at birth 64 Health Sector Transformation Plan Infant mortality rate 59/1000 Health and health-related indicators, EFY 2007 (2014/2015) Maternal mortality rate 353/100 000 Trends in maternal mortality, World Health Organization live births Immunization coverage (including pneumococcal and rotavirus 86.4% Health and health-related indicators, EFY 2007 (2014/2015) vaccine) Total health expenditure as proportion of gross domestic product (GDP)a 2.66% Health Sector Transformation Plan 2015 PHC expenditure as % of total health expenditureb 14.69% National Health Accounts 2011/2012 % total public sector expenditure on PHCc 26.73% National Health Accounts 2011/2012 Per capita public sector expenditure on PHCd 11.57 Ethiopian birrs National Health Accounts 2011/2012 Out-of-pocket payments as proportion of total expenditure on health 36% National Health Accounts 2011/2012 a. Total health expenditure ÷ country gross domestic product x 100. b. Total PHC expenditure ÷ total health expenditure x 100. c. Public health expenditure for PHC units ÷ total public health expenditure x 100. d. Per capita public sector expenditure on PHC: public health expenditure for PHC units ÷ total population. 1 Health and health-related indicators. Addis Ababa: Federal Democratic Republic of Ethiopia, Ministry of Health; 2015. 2 Health Sector Transformation Plan. Addis Ababa: Federal Democratic Republic of Ethiopia, Ministry of Health; 2015. 3 Trends in maternal mortality, 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015. 4 Health and health-related indicators. Addis Ababa: Federal Democratic Republic of Ethiopia, Ministry of Health; 2015. 5 Fifth National Health Accounts 2010/2011. Addis Ababa: Ethiopian Federal Ministry of Health; 2014. Ethiopia Case Study Timeline of health infrastructure but also on a fundamental change in attitudes and values regarding the development of human Modern medicine was introduced to Ethiopia in the resources and the equitability of social services. It remains 16th century during the regime of Emperor Libne Dingel to be seen whether the existing Ethiopian Government can (1508–1540), and was enthusiastically promoted during the maintain momentum in the continuing decentralization reigns of Emperor Menelik II (1889–1913) and Emperor Haile and democratization processes, and create a sociopolitical Selassie (1930–1974). Emperor Menelik invited travellers, environment conducive to bottom-up PHC development. missionaries and members of diplomatic missions to A plan to achieve universal access to PHC was prepared and introduce medicines and provide medical services, mostly embedded in the Health Sector Development Programme III in Addis Ababa, and various programmes and interventions in 2005. This plan aimed to address shortcomings of service ensued. Emperor Haile Selassie established the Ministry of coverage within the health system through accelerated Public Health, and the first National Health Service, in 1947.6,7 expansion and strengthening of PHC services.10 The Alma-Ata Declaration on Primary Health Care (1978), Governance and structure of and its call for Health for All by the year 2000, was welcomed by the Ethiopian Government. However, it was clear that a primary health care in Ethiopia national health policy based on the declaration alone was not sufficient, and in fact implementation of PHC policies Ethiopia’s health service is structured into a three-tier system: was largely unsuccessful at first,8 for the following reasons: primary, secondary and tertiary levels of care (Figure 1). The • The policies and strategies for the specific elements of the primary level of care includes primary hospitals, health PHC were not clearly defined at national level. centres (HCs) and health posts (HPs). The primary health care • Regions and health facilities had limited awareness of unit (PHCU) comprises five satellite HPs (the lowest-level those elements as defined at the central level. health system facility, at village level) and a referral HC. This • There was lack of clarity on health policies in most regions is the point where PHC is administered and primary services as a result of poor and inadequate dissemination of facilitated under the health service delivery structure. information on the policies. A primary hospital provides inpatient and ambulatory services to an average population of 100 000. A primary The development of PHC in Ethiopia