Reaching the Health MDGs in Ethiopia - oecd.org · 5 Health Expenditures in Sub-Saharan Africa 0...
Transcript of Reaching the Health MDGs in Ethiopia - oecd.org · 5 Health Expenditures in Sub-Saharan Africa 0...
Reaching the Health MDGs in Ethiopia
Financing Challenges and Prospects
OECD Global Forum on Development
Aid Effectiveness in Health
4 December 2006, Paris
Tedros Adhanom
FMOH
2
Country Profile
1.1 million sq.km
77.3 million population
Population growth rate: 2.7% /year
Rural population:85%
Federal government :– 9 Regional States, and 2 City
Administration
– 624 Woredas (districts)
– 15,000 kebeles (villages)
Part 1 - Challenges:Mobilizing Domestic Resources and
Improving Execution of External Funding
Overview of Health Expenditures
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He
alt
h E
xp
en
dit
ure
s in
Su
b-S
ah
ara
n A
fric
a
01
020
30
40
50
Countr
y
Buru
ndi
Dem
ocra
tic R
epublic
of
Congo
Lib
eria
Rw
anda
Sie
rra L
eone
Eth
iopia
Eritr
ea
Madagascar
Guin
ea-B
issau
Nig
er
Centr
al A
fric
an R
epublic
Mozam
biq
ue
Tanzania
Mala
wi
Chad
Ghana
Mali
Togo
Maurita
nia
Uganda
Burk
ina F
aso
Congo
Benin
Kenya
Gam
bia
Sudan
Zam
bia
SS
A A
vera
ge
Guin
ea
Nig
eria
Côte
d'Iv
oire
Senegal
Cam
ero
on
Zim
babw
e
Djib
outi
US
$ p
er
cap
ita
Ethiopia still among the lowest spenders …
SSA Average Ethiopia
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The share of donors and NGOs has increased while the share of government and households has decreased
Ethiopia Health Expenditures 2001/02-2004/05
33%
16%
36%
10%
4%
31%
19%
31%
19%
1%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Government World (public) Household NGO (international& local)
Private(employers &
others)
2001-2002 2004-2005
7
Budget Execution of Capital Budget by Source of Financing
62%
106%
68%
87% 89%
76%
88%
74%
5%13%
18%
37%
23%21%
12%5%
10%
26%
1991 1992 1993 1994 1995 1996 1997 1998
Domestic External Loan External Assistance
Execution rates of capital budgets markedly lower for external assistance compared to domestic sources
Audited Values Unaudited Values
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What explains the low execution rates of donor funds?
Fragmentation– Large number of accounts with different rules
Donor Procedures– Different and cumbersome reporting systems
Capacity
SOLUTION: MDG Performance Fund– Early experience of PBS as a financing instrument has
been positive, but there are huge disappointments with management procedures and procurement systems
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Strengthening the MDG Performance FundGeneral Revenue Protecting Basic Services
MOFED
FMOH
Bilaterals, UN agencies, Global Funds etc
Central Procurement and Logistics Agency
: drugs and equipment
(in kind)
BOFED
WOFED
Budget Flow (channel 1A)Sector Specific Assistance Flow (channel 1B)Purchasing flow
(in kind)
(in k
ind)
Health Center
Health Post/ Community
PBS BLOCK Grant
Health MDG Performance Fund
Capacity Building TA, training
Strenghthening procurement/
logistics
International commodities (vaccines, contraceptives,malaria drugs,TB drugs, ITNs, HSEP drugs)
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The Three Key Questions
How to increase the share of domestic funding as a share of total public spending?
How to improve the execution rate of donor funds?
How to improve the public reporting systemto better capture the efficiency and equity of health spending?
Scaling up: what can be achieved and at what cost?
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Cost of scaling up health servicesincremental cost per capita 2005-2015 for reaching the MDGs
Current Health Expenditures
Step 1
Step 2
Step 3
Step 4
Step 5
0
5
10
15
20
25
30
35
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
US$ (2004 constant $)
Reversed trend in HIV incidence and stabilized trend in HIV prevalence
Decrease in child mortality due to HIV, malaria, diarrhea diseasesReduced HIV transmissionReduced malaria morbidity and mortality
Step 1: Information and Social Mobilization for Behavior change
Reduced child mortality by two third
Decrease in child mortalityReduction in HIV Mother To Child TransmissionReduction of deaths due to pregnancy by 40%Reduce malaria mortality morbidity Reduce Child malnutrition
Step 2: Health Services Extension Program
Reduced malaria mortality by 50%Increase TB DOTS coverage
Further decrease of: Child mortalityMaternal MortalityMalaria, morbidity & mortalityTB
Step 3: First level clinical upgrade
Reduced MM by 75%Further decrease of :child mortalitymaternal mortalityHIV MTC transmission
Step 4: Expansion and Upgrade of Emergency Obstetrical care
Further decrease of :child mortality,maternal mortality,HIV MTC transmissionProvision of HAART , multi-drug resistant TB and severe malaria treatment
Step 5 : Expansion and Upgrade of Referral Care
MDGs reachedHealth OutcomesScale Up Strategy
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Volume, speed and quality
Reduce morbidity attributed to malaria from 22% to 10%
Maintain HIV prevalence at 3.5
Reduce mortality attributed to TB from 7% to 4% of all treated cases
U5MR 123 to 85
IMR 77 to 45
MMR 871 to 600
Outcome
20 million ITNsMalaria
Reach every household
ART 263,000HIV/TB
Immunization > 80%
Child Health HMIS
Logistic system
Financing system
Harmonization
Health Post:
13,635
Health Center:
3,135
Health Extension Workers:
30,000
Health Officers:
5,000
CPR > 60%Maternal Health
BloodlinesVehiclesTargetsFocus areas
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Three implementation scenarios for HSDP3
Scenario 1: Full implementation of the HSEPaccess to health post 100% (13,635 HP, HR, essential inputs)access to health center 80% (2,229 HC, HR, essential inputs, functional B-EOC)
Scenario 2:– Full implementation of accelerated expansion of PHC
access to health post 100% (13,635 HP, HR, essential inputs)access to health center 94% (3,135 HC, HR, essential inputs, functional B-EOC)Increased coverage of clinical services
Scenario 3: No resource constraintsfull implementation of accelerated expansion of PHCfunctional C-EOChigher coverage targets for clinical careall health MDGs achieved
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Facilities, human resources, HIV and malaria drugs represent the largest share of HSDP3 cost
Ethiopia:Cost Items for each HSDP3 scenario
$0.0
$2.0
$4.0
$6.0
$8.0
$10.0
$12.0
Scenario I Scenario II Scenario III
Monitoring, evaluation, technical &institutional supportPromotion + demand creation
Food supplements
Water and sanitation
Transportation
Pre-service training
Insecticide treated nets
New vaccines
Classical vaccines
Malaria drugs
Other drugs and supplies
HIV/AIDS and TB drugs and supplies
Human resources
Health facilities & equipment
Financing outlook
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HSDP III Financing Gap
0%
20%
40%
60%
80%
100%
Scenario 1 Senario 2 Scenario 3
HSDP III Financing Gap with HIV/Aids funding
Government budget Global Fund Bilateral and multilateral GAVI Gap
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Pledges generally cover partially the cost of each component ... When PEPFAR and Global Fund are not included
Source: Health Care Financing Study
Ethiopia: Donor Pledges by HSDP3 component and sub-component (including PBS excluding Global Fund and PEPFAR)
0
10
20
30
40
50
60
70
Fam
ily H
ealth
Ser
vic
es
HIV
& T
B
Ma
laria
Oth
er
com
mun
icab
le
Hy
gien
e an
d
env
ironm
ent
Cur
ativ
e
Phy
sica
l acc
ess,
tran
spor
tatio
n
Hum
an
reso
urce
s
deve
lopm
ent
Str
eng
then
ing
phar
mac
eut
ical
s
sect
or IEC
BC
C
HM
IS/m
anag
em
ent
He
alth
car
e
finan
cing
Cro
sscu
tting
2005-6
2006-7
2007-8
2008-9
2009-10
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But very large amounts for HIV/AIDS treatment distort the picture
Source: Health Care Financing Study
Ethiopia: Donor Pledges 2005-2010 by HSDP3 component and sub-component (including PBS, Global Fund and PEPFAR)
0
50
100
150
200
250
300
350
400
Fam
ily H
ealth
Se
rvic
es
HIV
& T
B
Mal
aria
Oth
er c
omm
unic
able
Hyg
iene
and
env
ironm
ent
Cur
ativ
e
Phy
sica
l acc
ess,
tran
spor
tatio
n
Hum
an r
esou
rces
dev
elo
pmen
t
Str
engt
heni
ng p
harm
aceu
tical
s se
ctor
IEC
BC
C
HM
IS/m
anag
emen
t
Hea
lth c
are
finan
cing
Cro
sscu
tting
2005-6
2006-7
2007-8
2008-9
2009-10
HIV
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Health System receives less attention from donors
1.1 Family Health Services 1.2 HIV 1.2 malaria
1.2 others 1.3 hygiene and environment 1.4 curative
1.service delivery and quality of care 2.physical access, transportation 3.human resources development
4.strengthening pharmaceuticals sector 5.IEC BCC 6.HMIS/management
7. Health care financing 8.crosscutting
HIV
HIV
MCH
Malaria
MCH
Health System
Ethiopia: Donor Pledges 2005-2010 by HSDP3 component and sub-component (including PBS, Global Fund and PEPFAR)
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…but gap still large form child health, malaria and health systems even for scenario 1
Funding Gap per HSDP3 component
0
500
1000
1500
2000
Family HealthServices
Malaria Health System HIV & TB
Th
ou
san
d U
S$
Scenario 1 Scenario 2 Scenario 3 Funding
Source: Health Care Financing Study
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The Three Key Questions
How to mobilize domestic funding –from the current 5% to 10-15% of total public spending? (in line with the Abuja commitment)
How to reestablish some balance between donor funding sources and most efficiently use the large amounts available for HIV/AIDS treatments?
Which resources mobilization strategy to address the heath system and child health gap?
Thank you