ETHIOPIA Program for Results for Strengthening Primary Health Care Services Technical Assessment Revised July 2022 1 ABBREVIATIONS AND ACRONYMS ANC Antenatal Care CBHI Community Based Health Insurance CIARP Conflict Impact Assessment and Response Planning CMNNDs Communicable, Maternal, Neonatal, and Nutritional Diseases CPR Contraceptive Prevalence Rate CPS Country Partnership Strategy CRVS Civil Registration and Vital Statistics CSA Central Statistical Agency DALY Disability-Adjusted Life Years DHIS District Health Information System DHS Demographic and Health Survey DLIs Disbursement Linked Indicators EHSP Essential Health Services Package EPHI Ethiopian Public Health Institute EPSS Ethiopian Pharmaceuticals Supply Service ESAP Ethiopia Social Accountability Program ESPES Enhancing Shared Prosperity through Equitable Services FTA Transparency and Accountability GDP Gross Domestic Product GFF Global Financing Facility GGHE General Government Health Expenditure GTP Growth and Transformation Plans HCF Health Care Financing HCI Human Capital Index HEP Health Extension Program HEWs health Extension Workers HHM Health Harmonization Manual HMIS Health Management Information Systems HPN Health, Population and Nutrition HPs Health Posts HSDP Health Sector Development Programs HSTP Health Sector Transformation Plan IFA Iron Folic Acid IMR Infant Mortality Rate JCCC Joint Core Coordinating Committee JCF Joint Consultative Forum JFA Joint Financing Arrangement JSC Joint Steering Committee MDG Millennium Development Goals MMR Maternal mortality Rate/Ratio MOH Ministry of Health NHFS National Health Facility Survey OOP Out-Of-Pocket PDO Program Development Objective 2 PFM Public Financial Management PforR Performance for Result PHC Primary Health Care PHCUs Primary healthcare units PHEM Public Health Emergency Management PPMED Policy, Plan, Monitoring and Evaluation Directorate RHBs Reginal Health Bureaus RMNCHY+N Reproductive, Maternal, Newborn, Child, Adolescent and Youth and Nutrition SARA Service Availability and Readiness Assessment SDGs Sustainable Development Goals SHI Social Health Insurance UHC Universal Health Coverage UNICEF United Nations Children's Fund VAS Vitamin A Supplementation VERA Vital Events Registration Agency WASH Water, Sanitation, and Hygiene WDA Women Development Army WHO World Health Organization 3 Table of Contents I. Context and Scope .............................................................................................................. 5 A. Background/Context.......................................................................................................... 5 B. Program Scope................................................................................................................... 9 II. Strategic relevance of HSTP II ............................................................................................ 9 IV. Soundness of Government Program .............................................................................. 24 IV. Governance structure and Institutional Arrangement................................................... 26 V. Assessment of Monitoring and Evaluation Arrangements ............................................ 35 VI. The Expenditure Framework .......................................................................................... 39 VII. Program Economic Evaluation....................................................................................... 45 4 I. Context and Scope 1. This technical assessment was carried out as part of the preparation of the proposed Ethiopia Program for Results (Hybrid) for Strengthening Primary Health Care Services. The assessment focusses on the country context, strategic relevance of this support, the technical soundness, and the governance structure including the country partnership platform. The most recent data from various sources have been utilized including the Health Sector Transformation Plan (HSTP) I evaluation report 2019, Health Extension Program evaluation report 2020, the mini Demographic and Health Survey (DHS) 2019, Demographic and Health Survey 2016, the Service Availability and Readiness Assessment (SARA) 2018, and the 7th or 6th National Health Accounts, analyses from various health care financing studies including Public health Expenditure 2020, and comprehensive assessment of Civil Registration and Vital Statistics (CRVS) system report (2020). Furthermore, various overarching and sub strategies of health and CRVS sectors have been reviewed and key challenges and identified gaps have been taken into account in the assessment. A. Background/Context 2. Ethiopia is one of a few countries in Sub-Sahara Africa that has made consistent progress towards the achievement of health outcomes over decades. The country has achieved Health Millennium Development Goals (MDG) and continuous progress in improving the health of the population in the post-MDG era. The progress is a result of two decades of a continued strategic framework, implemented through the Health Sector Development programs (HSDP) 1996 -2015 and followed by Health Sector Transformation Plan (HSTP I and II) 2015-2025. This framework is a key component of both phases of Ethiopia’s Growth and Transformation Plans (GTPI and II), demonstrating the government’s support for prioritization of human development, allocation of resources to high-priority primary health care (PHC) interventions, and a robust community ownership approach built upon an extensive Community Health Workers program- the Health Extension Program and the Health Development Army. 3. The government of Ethiopia has embarked on a multi-sectorial approach, especially at the lower level, to address lagging dimensions of health outcomes and improve the very low Human Capital Index (HCI). Over the past decade, the Government of Ethiopia has invested a significant portion of its resources to ensure that its people have access to basic services such as Health, Water, Sanitation, and Hygiene (WASH) and Education. Ethiopia has made progress in recent years in critical human capital outcomes. It achieved the MDG on child mortality three years ahead of target and has made progress in child survival rates and primary education enrollment.1 However, these improvements in human capital come from a low base of essential health, education, agriculture, and WASH services and Ethiopia ranks among the bottom 21 of the 174 countries included in the HCI. The 2020 Human Capital Index (HCI) estimates that a child born in 1 National Planning Commission and the United Nations in Ethiopia. October 2015. Millennium Development Goals Report 2014 Ethiopia: Assessment of Ethiopia’s Progress towards the MDGs. Addis Ababa, Ethiopia. https://www.undp.org/ethiopia/publications/ethiopia-mdg-report-2014 5 Ethiopia today will only reach 38 percent of his or her potential, against a benchmark of full health and complete education.2 Like other low-income countries, Ethiopia’s HCI score is pulled down by a high stunting rate and poor child learning outcomes. 4. Despite the overall progress in health services delivery, Ethiopia still falls short of the targets for universal health coverage (UHC). In 2019 the UHC service coverage index was still very low at 38%.3 The index is based on tracer interventions for reproductive, maternal, newborn and child health, infectious diseases and noncommunicable diseases. In addition, the overall UHC service coverage indices vary across regions. Some key RMNCAYH-N outcome indicators are still low. The neonatal mortality rate remains consistently high at about 33 per 1000 live births (The risk of mortality during the neonatal period contributes 54.5 percent of the total risk of death during the first five years of life among Ethiopian children. This is the result of lack of access to high quality maternal care services during the perinatal period. Additionally, 189,000 under-five children still die from preventable childhood diseases every year (EDHS, 2019).4 5. Rapid population expansion sets significant challenges for the health system and the economy. With a population of above 110 million in 2020, Ethiopia is the second most populous country of Africa and ranks 12th in the world. In spite of increasing contraceptive prevalence rate and declining fertility the population is expected to increase to over 130 million people by 2050 (of which young people are expected to comprise over 50 percent), mostly due to previous high fertility rates. The country is characterized by rapid population growth (2.6%), young age structure, and a high dependency ratio, with a high rural-urban differential. Ethiopia has a high total fertility rate of 4.1 births per woman (3.2 in urban areas and 4.5 in rural areas).5 The broad base of the population pyramid indicates that Ethiopia’s population is young, which is typical of countries with low life expectancies and high fertility rates (figure 1). Development prospects for the youth in terms of their education, skills development and ability to find a job, are strongly linked to their health. 2 World Bank. 2020. The Human Capital Index 2020 Update: Human Capital in the Time of COVID-19. World Bank, Washington, DC. https://openknowledge.worldbank.org/handle/10986/34432 License: CC BY 3.0 IGO 3 World Health Organization. 2022. Global Health Observatory Data Repository. https://data.worldbank.org/indicator/SH.UHC.SRVS.CV.XD?locations=ET 4 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 5 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 6 Figure 1: (A) Population pyramid, EDHS 2019 (B) Trends in Total Fertility Rate, 2000-2019 Total fertility rate for the 3 years before each survey 7 6 5 4 3 2 1 0 2005 EDHS 2011 EDHS 2016 EDHS 2019 EDHS Total Rural Urban The TFR has declined in Ethiopia over time, from 5.4 children per woman in 2005 to 4.1 children per woman in 2019, a decrease of 1.3 children. The TFR among women in rural areas declined from 6.0 to 4.5 children over the same period, while the TFR among urban women rose from 2.4 to 3.2 children. 6 6. The health system is at risk due to COVID-19 and the recent security situation in the country makes the provision of basic and essential health service at all level very difficult. As of November 15, 2022, over 494,185 cases and more than 7,572 COVID-19 fatalities were registered in Ethiopia, with a sharp acceleration in the months of May and June.7 Considerable efforts and improvements have been made to expand the COVID-19 response while ensuring the continuity of essential health services through a concerted effort of Government and partners on the ground. Despite all response efforts, the pandemic has posed an overall socio-economic impact that has interrupted the delivery and utilization of RMNCAH and other essential health services. According to the Ministry of Health (MOH), nationally, there was an overall 10 percent reduction in out- patient attendance which is a proxy measure of the reduction in the overall health seeking behavior of the community. Maternal and child health services and follow-up of chronic care has been most affected. On average, there is a 12 percent reduction in contraceptive service uptake and a three percent reduction in the institutional skilled delivery in August 2020 compared to the pre COVID period. 7. The COVID-19 pandemic has affected the delivery of essential health services more in pastoralist regions compared to the agrarian ones. According to UNICEF8 the coverage of ANC4 services decreased from 23 percent in January 2020 to 21 percent in July 2020, with a sharp decrease to 19 percent in April 2020. Likewise, coverage of diarrhea and pneumonia treatment services fell from a 21 percent and 19 percent coverage respectively in January 2020 to a 13 percent and 10 percent coverage in July 2020. Penta coverage also decreased from 21 to 17 percent 6 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 7 WHO COVID-19 Dashboard. Geneva: World Health Organization, 2020. Available online: https://covid19.who.int/ (last cited: 16 November 2022) 8 UNICEF: Primary Healthcare level RMNCH service delivery monitoring survey. 2020 7 between January and April 2020 and increased again to 20 percent by July 2020. Overall child health services provision seems to have been the most affected among essential health care services. Lack of essential supplies, staff absenteeism, poor availability of quality service delivery, and supply chain information further aggravated an over stretched health could be said to be among the top reasons essential health service delivery was interrupted during COVID. 8. The recent Conflict Impact Assessment and Response Planning (CIARP) has shown that the conflict has adversely affected access, availability, and provision of essential health services, and negatively impacted health and nutrition outcomes. It is estimated that close to 24 million people have been adversely impacted in the conflict-affected areas and estimated 5.7 million people were forcibly displaced at various stages of the conflict across Tigray, Amhara, Afar, Oromia, Benishangul Gumz and Southern Nations, Nationalities and people’s Region regions.9 The readiness of the health system to deliver essential health services has been hampered due to the damage caused to health infrastructure, widespread looting of medical equipment and medicines, insecurity, and displacement of households and health workers. Available reports showed that 3,217 health posts, 709 health centers, and 76 hospitals were partially or completely damaged in the six conflict- affected regions.10 9. The physical damage to health infrastructure, and looting of medical equipment, medicines and medical supplies, especially in the Afar, Amhara and Tigray regional states, was extremely devastating. The damaged/looted health facilities were only partially functional or not functional during the time of the CIARP assessment. The damage to the public health infrastructure was not limited to health facilities; based on available reports, zonal health departments, woreda health offices, ambulances, EPSA stores, and oxygen plants were also either damaged or looted during the conflict. The health workforce also suffered greatly due to the conflict estimated more than 9,888 health workers had fled from their duty stations.11 9 Ministry of Health-Ethiopia. 2022. Ethiopia Conflict Impact Assessment and Recovery and Rehabilitation Planning (CIARP): Final Health Sector Report and Costs. Addis Ababa, Ethiopia. https://e-library.moh.gov.et/library/wp- content/uploads/2022/07/Health-Sector-report-CIARP_-July-30-_2022.pdf 10 Ministry of Health-Ethiopia. 2022. Ethiopia Conflict Impact Assessment and Recovery and Rehabilitation Planning (CIARP): Final Health Sector Report and Costs. Addis Ababa, Ethiopia. https://e-library.moh.gov.et/library/wp- content/uploads/2022/07/Health-Sector-report-CIARP_-July-30-_2022.pdf 11 Ministry of Health-Ethiopia. 2022. Ethiopia Conflict Impact Assessment and Recovery and Rehabilitation Planning (CIARP): Final Health Sector Report and Costs. Addis Ababa, Ethiopia. https://e-library.moh.gov.et/library/wp- content/uploads/2022/07/Health-Sector-report-CIARP_-July-30-_2022.pdf 8 B. Program Scope 10. The Health Sector Transformation Plan (HSTP) II provides the overarching strategic framework for the health sector and reflects Government of Ethiopia’s commitment to achieve the national transformation plan and global health Sustainable Development Goals (SDGs). The scope of the PforR operation will be within the sector main framework proved by the HSTP II through the Sustainable Development Goal Pool Fund (SDG PF) that is a non-earmarked harmonized support to the sector using country systems. The HSTPII is a continuation of HSTPI and part of the long-term vision “envisioning Universal Health Coverage through the primary health care� that have provided strong guidance on key areas resulting in consistent progress in health outcomes over the last two decades. The HSTP II is in line with Ethiopia’s 10 years Prosperity plan (2020/21-2030/31). The various Sector Strategy has translated GTPII goals into concrete directions for the improvement of coverage, equity and quality of essential health services, while enhancing implementation capacity of the health sector at all levels of the system. The Strategy’s focus on quality and equity requires a shift in the status quo to maintain the maternal, child health and nutrition outcomes that has been attained in the past decades and health system that is under greater stress due to the ongoing COVID19 and security situation and ultimately to drive improvements at the national scale over the next five years. The Proposed financing to the program will receive resources from IDA, the Global Financing Facility in Support of Every Woman and Every Child (GFF). II. Strategic relevance of HSTP II 11. There is a strong strategic relevance for Government to focus on key maternal, neonate, child, adolescent and nutrition services. Ethiopia has made remarkable progress in its health outcomes over the past few decades. The country achieved the fourth MDG—reducing child mortality— three years ahead of target, and it made great progress toward achieving MDG 5 — improving maternal health and continuous progresses have been observed in the post MDG/in the last five years. Despite the progresses that have been made so far, there remains an important unfinished agenda. Some key RMNCAYH-N outcome indicators are still low. The neonatal mortality rate remains consistently high at about 30 per 1000 live births. This is the result of lack of access to high quality maternal care services during the perinatal period. Additionally, 189,000 under-five children still die from preventable childhood diseases every year.12 The prevalence of stunting remains stagnant and very high with about 37 percent of children under the age of 5 stunted in Ethiopia nationally, and four regions with stunting rates about 40 percent. 12. The HSTP is aligned with the Country Partnership Strategy (CPS), and the proposed operation is fully aligned with CPS indicators and sector milestones. It continues to leverage the efforts of partners and use of country systems. The proposed financing has a strong focus on building systems that will cushion the poor against health expenditure shocks which is consistent with the Africa Region Strategy principles. A critical outcome under this pillar is increasing access to quality health and education services. The proposed operation is also consistent with the foundations of good governance and state building: improving public service performance management and responsiveness; enhancing space for citizen participation in the development 12 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 9 process; and enhancing public financial management (PFM), procurement, transparency, and accountability. 13. Ethiopia has effectively harmonized support from its development partners. As a signatory of the International Health Partnership Compact, Ethiopia is exemplar in mobilizing resources in support of government priorities. The SDG PF continues to be supported by 12 development partners under the management of the Federal MOH.13 The Health Harmonization Manual and joint financing agreements have been revised to address changing context and enable the sector to effectively facilitate the harmonized support of its partners. 14. HSTP II (2021-2025) aims to achieve UHC through expanding access to services and improving the provision of quality and equitable comprehensive health services at all levels . Reproductive, Maternal, Newborn, Child, Adolescent and Youth (RMNCHY) health will continue to be the major focus areas under the HSTP through expanding the high impact services based on the recently revised Essential Health Services Package (EHSP) and implementing the recently revised Health Extension Program (HEP) Road Map to make services more accessible to the population.14 Hence, Ethiopia will not be able to realize HSTP II, and the long-term vision “envisioning Universal Health Coverage through the primary health care� and Human Capital Development agenda without investing on the lagging RMNCH and nutrition agenda. These agenda are the top priority areas for the country to improve the health of its population, develop the human capital as well as to reduce the health-related economic cost. Women and Child Health 15. Ethiopia has made remarkable progress in reducing maternal and child health outcomes over the past few decades. The country achieved the fourth MDG—reducing child mortality— three years ahead of target, and it made great progress toward achieving MDG 5 —improving maternal health. Under-5 mortality rates declined from 123 deaths per 1000 live births (2005 DHS) to 55 per 1000 in the 2019 DHS (see Figure 2). Similarly, a steady decline is observed in Infant Mortality Rate from 77 (2005 DHS) to 43 (2019 DHS). The decline in neonatal mortality rate has been modest between 2005 and 2016, from 39 (2000 DHS) to 29 (2016 DHS) and there has been a slight increase in neonatal mortality since 2016, from 29 to 33 deaths per 1,000 live births.15 13 UK FCDO, UNICEF, EU, GAVI, The Netherlands Government, Spanish Development Cooperation, UNFPA, Irish Aid, WHO, Italian Cooperation, Bill and Melinda Gates Foundation, Korea International Cooperation Agency (KOICA)and the World Bank. Millennium Development Goals Pool Fund was renamed Sustainable Development Goals Pool Fund. 14 Ministry of Health Ethiopia. 2021. Health Sector Transformation Plan II (HSTP II). Addis Ababa, Ethiopia. https://e- library.moh.gov.et/library/wp-content/uploads/2021/07/HSTP-II.pdf 15 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 10 Figure 2: Trends in Childhood Mortality, 2000-2019 16. The changes in the maternal and child health outcomes are a result of significant improvements in the coverage of key reproductive, maternal and child health services; prevention and control of communicable diseases and health system strengthening efforts. Ethiopia has implemented a set of effective maternal and child health interventions, including family planning, Antenatal Care (ANC), skilled-birth attendance, postnatal care and immunization. The government has also emphasized prevention and control of infectious diseases, including human immunodeficiency virus (HIV), tuberculosis and malaria. A service provision assessment in 2014 found that more than 90% of the primary hospitals and health centers provided the full package of services related to maternal and child health, HIV, tuberculosis and malaria prevention and control. More than 80% of health posts provided child health, family planning and antenatal care services. As a result, health services coverage of priority programmes increased significantly between 2000 and 2019 (Fig. 3). 17. There are improvements in key services such as skilled birth attendance including in three low performing regions (Afar, Somali and Oromia) antenatal care, utilization of modern family planning methods and child vaccination coverage while low progress is reported in the prevalence of stunting (37 percent). Modern contraceptive use by married women has steadily increased over the last 15 years, from 14 percent in 2005 to 41 percent in 2019. Similarly, the percentage of women receiving antenatal care from a skilled provider has increased from 28 percent in 2005 to 74 percent in 2019, an increase of 46 percentage points over the 14-year period that reduces morbidity and mortality risks for the mother and child during pregnancy, delivery, and the postnatal period (see figure 2 and 3).16 18. Pneumonia and diarrhea remain the major killers of under-five children contributing for 16.4 percent and 8 percent of deaths, respectively. The prevalence of stunting remains stagnant and very high with about 37 percent of children under the age of five stunted in Ethiopia nationally, and four regions with stunting rates about 40 percent17. Furthermore, there are stark differences 16 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 17 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 11 in health and nutrition outcomes among different income groups and geographic regions. Large variations were reported in 2019 EDHS: the Contraceptive Prevalence Rate (CPR) ranges from three percent in Somali up to 50 percent in both the Amhara Region and Addis Ababa. According to the 2018 Service Availability and Readiness Assessment (SARA) survey, nationally 95 percent of facilities offered family planning services however only 47 percent of facilities in Somali region were likely to provide that service. Greater focus also needs to be given to adolescent health and nutrition, building on the national strategy. Only 60 percent of facilities offered adolescent friendly health services in 2019, out of which only 30 percent had staff trained in this technical domain18. 19. Quality of antenatal care as measured by the content of care received during antenatal care visits stood out as an important factor that influences both facility delivery and postnatal care. The percent of women who with a live birth during the 2 years preceding the survey who received a postnatal check in the first 2 days after giving birth had been doubled between 2016 and 2018. This percent has steadily improved in the last decades and DHS 2019 reported that 38% of mothers who received postnatal care within two days of delivery compared to 17% in 2016.19 Among mothers who attended four or more antenatal care visits and delivered at home, the content of care received during ANC visits was the only factor that showed a statistically significant association with receiving postnatal care. Newborns delivered in a health facility were much more likely to receive a postnatal health check from a skilled provider within 2 days than those delivered elsewhere (62% versus 2%). Infants born to urban women (48%) were more likely than those born to rural women (30%) to receive a check-up within the first 2 days of birth. The percentage of newborns receiving check-ups within the first 2 days increases with increasing mother’s education. Twenty-two percent of babies born to women with no education received a postnatal check-up, as compared with 70% of babies born to women with more than a secondary education. 20. Maternal health remains a challenge, but there are clear signs of positive trends. Maternal Mortality Ratio has declined from 871 per 100,000 births (2000 DHS) to 412 per 100, 000 (2016 DHS).20 Between 2000 and 2019, Contraceptive Prevalence Rate increased from 8 percent to 41 percent; Total Fertility Rate declined from 5.5 to 4.1 children per woman; and births attended by skilled attendants increased from 6 percent to 50 percent. Ethiopia’s attainment of MDGs for child health years ahead of the target date is a reflection that human development and achievement of the SDGs are top priorities in the country’s development targets. 18 Ethiopian Public Health Institute (EPHI) and Federal Ministry of Health of Ethiopia (MoH). 2018. Ethiopia Service Availability and Readiness Assessment (SARA) 2018 Final Report. Addis Ababa, Ethiopia https://www.ephi.gov.et/images/pictures/download_2011/Ethiopia-Service-Availability-and-Rediness-Assessment- SARA-report-2018.pdf 19 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 20 The 2011 DHS refers to births in the last 7 years before the survey (i.e.2004-2011) while the 2016 DHS refers to the period 2009-2016. It is likely that there were even fewer maternal deaths in the more recent years. 12 Figure 3: Trends in Maternal Health Care, 2000-2019 DHS 74% 62% 50% 48% 34% 27% 28% 28% 26% 6% 6% 10% 5% 5% 10% ANC by skilled provider Birth attnded by skilled provider Birth occurred in health facility EDHS 2000 EDHS 2005 EDHS 2011 EDHS 2016 EMDHS 2019 Table 1. Progress of Key Health Indicators Indicator 2000 2005 2011 2016 2019 Infant Mortality Rate (per 1000 live births) 97 77 59 48 47 Under Five Mortality (per 1000 live births) 166 123 88 67 59 Total Fertility Rate (per woman) 5.9 5.4 4.8 4.6 4.1 Maternal Mortality Ratio (per 1000 live births) 871 - 676 412 - Skilled birth Attendance 6 6 10 27.7 50 Anemia among women of reproductive age - 27 17 24 - Antenatal Care from a skilled provider (percent) 26.7 27.8 33.9 62 74 Antenatal Care from a Skilled Provider 4 visits (percent) - - - 32 43 IFA 90+ supplementation for pregnant women (percent) - - 1 5 11 Children receiving penta3 by 12 months of age (percent) - - 34.7 53.2 60 Children 0-5 months exclusively breastfed (percent) 55 49 52 58 59 Children fed a minimum acceptable diet21 (percent) - - - 7 11 Children under five stunted (percent below -2 SD) 58 51.3 44.4 38 37 Vitamin A Supplementation for children 6-59 mo (percent) 56 46 53 45 4722 Contraceptive Prevalence Rate (percent) - 13.9 27.3 35 41 21 Minimal Acceptable diet is calculated according to breasfeeding status, number of food groups consumed, and number of times fed 22 Note that the 2019 mini-DHS used the age group 6-35months for VAS (rather than 6-59 months) 13 21. The COVID-19 pandemic, climate shocks and civil conflict have severely impacted the wellbeing of Ethiopia’s people. Ethiopia has had the second largest number of COVID-19 cases and fatalities in Sub-Saharan Africa with almost half a million cases and 8,000 deaths since March 202023. About 7 million children are at risk of learning losses due to the prolonged and interrupted school closures during the early days of the pandemic. Severe repeating droughts and flooding in 2021 further impacted the livelihoods and food security of over 12 million people.24 There are over half a million people currently displaced due to drought, conflict, seasonal and flash floods, landslides, swampy land, strong winds, volcanos, and fire.25 To add to this, the civil conflict which started in November 2020 in Tigray and spread to Amhara and Afar regions has left 9.4 million people in dire need of humanitarian assistance.26 Access to Equitable Quality Services 22. Equity and quality in primary health care service delivery are at the center of Ethiopia’s current health policy, inaugurated in 1993. The policy has five pillars: (i) democratization and decentralization of the health system; (ii) preventive and promotive health services; (iii) access to health care for all the population; (iv) intersectoral collaboration; and (v) enhancing national self- reliance by mobilizing and efficiently use of resources for health. During HSTP-I, the 1993 health policy was revised to respond to current sociodemographic, epidemiologic, and economic changes in Ethiopia. The revision also took into account the government’s vision of becoming a middle- income country and the national commitment to UHC and the SDGs. The policy document has undergone a series of consultations and expected to be finalized and endorsed in 2022. 23. Ethiopia’s Health Extension Programme (HEP), launched in 2003, has remained to be the key platform to address equity in access and utilization of key health services closer to the community. The programme has enabled Ethiopia to achieve significant improvements in key maternal and child health; prevention and control of communicable diseases; hygiene and sanitation behaviors; and community engagement. Despite these successes, the programme has faced challenges, including resource gaps; absence of a well-established referral system; high turnover of health extension workers; and community complaints about inadequate curative care and delivery services. These challenges remain to be addressed for progress in UHC. Guided by the HEP optimization roadmap, the HEP remain to the mainstay platform for community participation and an effective service delivery for households during the 2021-2024 through improving PHCUs’ readiness to provide quality care to their catchment population; expanding emergency obstetric and surgical care services the health centers; ensuring strong PHCU linkage and strengthening multi-sectoral collaboration. 23 Ministry of Health, “COVID-19 report,� April 26, 2022. 24 Reliefweb, 2021: https://reliefweb.int/disaster/dr-2015-000109-eth; and https://reliefweb.int/sites/reliefweb.int/files/resources/ethiopia_drought_update_january_2022.pdf 25 International Organization for Migration (IOM) (2021), Ethiopia National Displacement Report 10 (Addis Ababa, Ethiopia: IOM). https://displacement.iom.int/sites/default/files/public/reports/DTM%20Ethiopia%20National%20Displacement%20Rep ort%2010_For%20uploading.pdf. 26 United Nations Office of Humanitarian Affairs (OCHA) (2022), “Ethiopia – Northern Ethiopia Humanitarian Update (Situation Report)� last updated, February 2022, United Nations (website). https://reports.unocha.org/en/country/ethiopia/card/5EhBh4Xf5z/?gclid=EAIaIQobChMI_LjAyr379QIVFQaICR26FQ9aE AAYASAAEgJmzvD_BwE. 14 24. Despite the Government’s notable progresses in HSTP I, access to quality health services remains unequal, both geographically and socioeconomically. Total Fertility Rate has reached a below replacement level at 1.7 births per woman in Addis Ababa, the capital city, while remaining highest at 6.4 children per woman in the Somali region (which reflects the combined effects of demand side barriers to family planning as well as the non-availability of services).27 For example, the coverage of modern contraceptives among the highest wealth quintile is twice as high as the one of the lowest quintile in 2014 (53.6 vs. 27.1). Data also show high inter-Woreda inequalities especially in SNNP, Amhara and Oromia.28 For skilled birth delivery, a gap of 50 percentage points remains between the poorest and the wealthiest. Data from the latest DHS 2016 shows that the national level of skilled birth attendance is at 27.7 percent nationwide but ranges from 16.4 in Afar to 97 percent in Addis Ababa. 25. Quality of services is a major challenge as identified by the Government in the HSTP II . Health sector performance for the period of HSTP I (2014/15-2019/20) has concluded that quality of health care is still sub-optimal. HSTP II aspires to achieve UHC through expanding access to services and improving the availability, readiness, and provision of quality and equitable comprehensive maternal and newborn health services at all levels. The national health-care quality strategy has had promising results; and the use of a community�based collaborative quality improvement initiative, which has improved postnatal care services in rural Ethiopia. Data from the 2018 SARA indicates large differences in availability of quality basic services, including readiness to provide basic emergency and essential obstetric and neonatal care. Data show that, among health facilities that provide delivery services, only 4 percent of the health facilities had all the 25 tracer items for Basic Emergency and Essential Obstetric and Newborn Care Service with worrying intra- regional differences: zero percent in Afar, Oromia and Benshangul Gumz to 16% in Addis Abeba.29 As shown in Figure 4, the probability of dying during the early childhood period (per 1000 live births) is considerably higher in some regions compared to others. 27 Ethiopian Service Provision Assessment Plus data 2016. 28 Mekkonen Y; Family Planning in Ethiopia: An Analysis of Successes, Challenges and Future Direction; World Bank, Ethiopia. May 2016. Draft. 29 Ethiopian Public Health Institute (EPHI) and Federal Ministry of Health of Ethiopia (MoH). 2018. Ethiopia Service Availability and Readiness Assessment (SARA) 2018 Final Report. Addis Ababa, Ethiopia https://www.ephi.gov.et/images/pictures/download_2011/Ethiopia-Service-Availability-and-Rediness-Assessment- SARA-report-2018.pdf 15 Figure 4. The probability of early childhood deaths by time of death and regions, 2019 26. The results of the 2019 mini-DHS showed that coverage with RMNCH services is consistently lower in rural areas and special support regions as compared to that in urban areas and non-special support regions. The widest urban-rural disparity in maternal health service utilization occurred in health facility delivery. The use of modern family planning methods varies significantly across regions. In 2019, the contraceptive prevalence rate (CPR) (modern methods) ranged from 3.4% in Somali Region to 49.5% in Amhara. Vaccination with all basic vaccines varied from 18.2% in Somali Region to 73.0% in Tigray and 83.3% in Addis Ababa. In 2019, the under-5 mortality rate was 59 deaths per 1,000 live births, ranging from 26 in Addis Ababa to 101 in Somali.30 Similarly, utilization of RMNCH services largely varied by educational status and wealth quintiles. Individuals and households with higher educational status and in the higher and highest wealth quintiles had consistently better health service utilization indicators compared to their less educated and poorer counterparts (Firew Tekle Bobo, 2017) 27. Overall, there are pressing needs to address geographic and regional disparities in health services access, utilization, and outcomes. Major challenges include inconsistency in priorities, limited contextualization of health service delivery systems, low community awareness and utilization of available services, mal-distribution and wrong placement of health workers, and inadequate infrastructure. Addressing these challenges will require context-specific, innovative solutions to tackle the root causes. Ensuring equity in delivery of quality health services based on the recently revised EHSP, through which different high impact interventions will be made available for each respective level of care, by creating high-performing primary health care units, ensuring active engagement of the community in service delivery, and continually improving clinical care outcomes. 30 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 16 Women and Children’s Nutrition Outcomes 28. Ethiopia faces many challenges in ensuring that investments that impact future learning, skills, and labor productivity are made in the early years of life. The first 1,000 days—from a woman’s pregnancy until her child reaches two years of age—is the fastest period of human growth and cognitive development. Evidence shows that good health, adequate nutrition, responsive caregiving, early stimulation, and social protection are essential during this period to lay the foundation for a healthy and productive life.31 In fact, the early years of life is when the most labor productivity potential is attained.32 Having a young, productive workforce can drive economic growth faster than population growth to realize the demographic dividend—especially when synergized with women and girls’ empowerment and reproductive health interventions. Even though early childhood development and nutrition interventions yield high returns and can break the intergenerational cycle of poverty, they are not being implemented at scale, in a coordinated way, to benefit children across the continuum of care. In fact, only 1 percent of Ethiopian children under two years of age have simultaneous access to health care, food security, and WASH. The MOH has championed multisectoral efforts to move forward the early years agenda, but there is still limited accountability,33 budget, and capacity for other sector ministries to carry out their roles and responsibilities as defined in national policies and strategies (see section below)34. 29. Nearly one third of pregnant and lactating women are anemic, which is a significant public health problem that impacts their own health and that of their children. Ensuring that women of reproductive age are well-nourished sets the stage for their children to achieve optimal nutrition outcomes. Women’s age and number of children are among the most important factors that affect maternal nutrition, especially in countries like Ethiopia where child marriage is common. Early marriage, limited use of contraceptives, and low education levels contribute to high rates of unwanted pregancies. Furthermore, inadequate consumption of diverse foods during adolescence and pregnancy, particulary animal-source foods, also contributes to poor nutrition outcomes. An estimated 29 percent of adolescents (15-19) and 22 percent of women of reproductive age (15-49) are undernourished (Body Mass Index less than 18.5 kg/m2). Nearly 24 percent of women have anemia and 29 percent of pregnant and lactating women are anemic. Only 11 perecent of pregnant women take the recommended regimen of Iron Folic Acid (IFA) supplementation.35 Encouraging women to eat an adequate, diverse, iron-rich diet and adhere to IFA for the full 90+ days are critical to alleviate the serious risks associated with anemia during pregnancy—low birth weight, premature birth, and maternal mortality. One of the key barriers to improving IFA coverage is poor nutrition counseling during antenatal care and lack of follow-up on adherence and management of side effects. 31 WHO, UNICEF, World Bank Group, Nurturing Care Framework for Early Childhood Development, 2018 32Investing from pregnancy to an early age is essential as early childhood is when most of the productivity potential of an individual can be reached; beyond the early years, some of the damages are irreversible (e.g. stunting). Investment in early childhood has the highest cost-benefit ratio and the highest return per dollar invested: 7% to 16% annually (see Heckman, J., Moon, S., Pinto, R., Savelyev, P. and Yavitz, A. 2009. A New Cost-Benefit and Rate of Return: Analysis for the Perry Preschool Program: A Summary. (Policy Paper N° 17). IZA, Germany). 33 Irish Aid, et al. (2020) Multisectoral Nutrition Policy and Program, Design, Coordination and Implementation in Ethiopia 34 34 UNICEF, et al (2021) Operational research on Ethiopian Multisectoral Approaches for Nutrition (draft report) 35 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 17 30. More than one third of children are chronically undernourished or stunted.36 Despite a significant decrease in stunting prevalence from 58 percent in 2000 to 37 percent in 2019, signifiant inequities persist. Four regions had rates above 40 percent in 2019 (Figure 5). Stunting was substantially higher in rural areas (41 percent) compared to urban areas (26 percent) and was correlated with mother’s education and household wealth quintile. The key drivers of stunting37 are poor nutritional status of women during pregnancy, low dietary diversity during complementary feeding, poor hygiene practices (leading to child diarrhea)38 and inadequate access to quality health care, food security, and water and sanitation.39And with the ongoing COVID-19 outbreak and security situation, there is significant risk that chronic undernutrition (stunting) will increase over time and acute undernutrition (wasting) will escalate, which will have a multiplicative impact on child mortality.40 To improve nutrition outcomes, more targeted interventions are needed at the lowest level of service delivery to simultaneously address the key drivers of undernutrition (both within and outside the health system). Families also require more frequent contact with service providers and community agents at critical stages of development to address social norms and promote optimal nutrition behaviors using multiple channels of communication. Figure 5. Stunting rates vary greatly by residence, region, and socioeconomic status 41 50 49 43 41 42 42 41.7 45 40 41 41 40 40 37 36 36 35 35 35.4 33 35 31 30 26 25 24 25 18 19.0 20 17.0 14 15 10 5 - Female Urban Harari National Amhara Fourth No education Rural Tigray Affar SNNP Somali Primary Secondary Higher Male Gambela Ben-Gumz Highest Oromiya Dire Dawa Lowest Middle Addis Abeba Second Sex Residence Region Wealth quintile Mother's Education 36 Stunting refers toa child who is too short for his/her age; it is a manifestation of chronic undernutrition associated with impaired cognitive development, delayed school enrollment, low educational attainment, and decreased adult earnings. 37 Tasic, Hana & Akseer, et. al. (2020). Drivers of stunting reduction in Ethiopia: a country case study. 10.1093/ajcn/nqaa163. 38 Changes in Child Undernutrition Rates in Ethiopia, 2000-2016, Hiroven et al, April 2018. 39 All Hands-on Deck: Reducing Stunting through a Multi-Sectoral Approach in SSA and Ethiopia, Emmanuel Skofias, 2018, World Bank. 40 Myatt M, Khara T, Schoenbuchner S, et al. Children who are both wasted and stunted are also underweight and have a high risk of death: descriptive epidemiology of multiple anthropometric deficits using data from 51 countries. Arch Public Health. 2018;76:28. Published 2018 Jul 16. doi:10.1186/s13690-018-0277-1 41 Ethiopian Public Health Institute (EPHI)[Ethiopia] and ICF. 2021. Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. https://dhsprogram.com/publications/publication-FR363-DHS- Final-Reports.cfm 18 31. Coverage of child nutrition interventions is below the level necessary to accelerate stunting reduction.42 Access to quality nutrition services delivered through the health system remains a barrier in regard to availability of trained health providers, nutrition commodities, quality nutritional counseling, and preventative care services. Only 11 percent of children 6-23 months receive a minimal acceptable diet,43 and merely 14 percent consume an adequately diverse diet. The prevalence of diarrhea is highest among children 6-11 months when complementary foods and other fluids are introduced (which increases the risk for growth faltering). Only 17 percent of children with diarrhea received a combination of both Oral Rehydration Solution (ORS) and zinc (the recommended treatment). About 45 percent of children received Vitamin A Supplementation (VAS) in 2016, but that declined from 53 percent in 2011. This drop was not surprising given the Government’s commitment to transitioning from campaign-based VAS distribution to more sustainable routine service delivery. However, continued VAS disruption, exacerbated by COVID-19 and insecurity, is of concern because it is one of the most cost-effective and efficacious public health interventions known to reduce child mortality, morbidity, and undernutrition in developing countries. Some of the key barriers to VAS delivery found in a recent formative research study include lack of demand for routine services, stock-outs, and poor recording.44 Recommendations to overcome these challenges, including strengthened community outreach, will be piloted and assessed for scale-up as part of ongoing operations research led by the MOH with technical support from UNICEF. 32. Poor access to quality WASH services negatively impacts nutrition outcomes. Nearly 9 out of 10 diarrheal deaths among young children are linked to unsafe drinking water, inadequate access to sanitation, and poor hygiene practices.45 In Ethiopia, 69 percent of households have access to an improved source of water, yet only 7 percent of households use an appropriate method to treat their water. According to the 2019 DHS, only 20 percent of Ethiopian households use improved toilet facilities—42 percent in urban areas and 10 percent in rural areas. Handwashing with soap and water is the most effective intervention to prevent diarrhea and reduce the spread of infectious disease. And yet only 28 percent of urban households and 7 percent of rural households have soap and water.46 Table 2: Nutrition and nutrition-related indicators, Ethiopia DHS 2000-2019 DHS DHS DHS MDHS DHS MDHS2 2000 2005 2011 2014 2016 019 Stunting, children 0-59 months47 58 47 44 40 38 37 Wasting, children 0-59 months 11 11 10 9 10 7 Underweight, children 0-59 months 47 38 29 25 24 21 Households with access to improved source of water - - 54 53 65 69 Households with access to improved sanitation - - 8 4 6 20 42 Ethiopia: An Investment Framework for Nutrition, Eozenou and Shekar, 2017, World Bank 43 Minimal Acceptable diet is calculated according to breasfeeding status, number of food groups consumed, and number of times fed 44 Oxford Policy Management (2021): Formative Research on Key Nutrition-Specific Interventions in Ethiopia, draft report 45 Stepping up Early Childhood Development: Investing in Young Children for High Returns, World Bank, October 2014 46 Central Statistical Agency (CSA) [Ethiopia] and ICF. 2016. Ethiopian Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF. https://dhsprogram.com/publications/publication-FR328-DHS-Final- Reports.cfm 47 Proportion of children 0-59 months with height-for-age z-score (HAZ) below - 2 SD 19 Infants exclusively breastfed (under 6 months) 38 49 52 - 58 59 Children fed minimum acceptable diet (6-23 months) 4.3 - - 4 7 11 Vitamin A Supplementation (VAS) – 6-59 months 56 46 53 - 45 - Adolescent and Maternal Nutrition Anemia – women of reproductive age - 27 17 - 24 - Anemia – pregnant and lactating women 48 - 30 19 - 29 - Iron Folic Acid (IFA) 90+ pregnant women - - 1 - 5 11 BMI – women of reproductive age (15-49 years) 30 27 27 - 22 - BMI – adolescent Girls (15-19 years) 38 33 36 - 29 - 33. Ethiopia’s commitment to allocate and use resources to end maternal and child undernutrition is reflected in the Government’s development plans. This includes the 10-year Development Plan: Pathway to Prosperity (2021-2030) that identified human capital development as one its key focus areas that aims to accelerate nutrition outcomes such as reducing stunting from 37 percent to 13 percent and decreasing anemia among women reproductive age from 24 to 12 percent. Additionally, the five-year HSTP II has a major strategic initiative on nutrition that includes scaling-up comprehensive integrated nutrition services during the first 1,000 days; increasing micronutrient supplementation (such as Vitamin A supplementation) for children and pregnant and lactating women; expanding lessons from the “Seqota Declaration�49 in collaboration with other sectors to end child undernutrition; and strengthening multisectoral coordination linkages and nutrition coordination platforms across Food and Nutrition Policy implementing sectors. 34. In 2019, the Government launched the Food and Nutrition Policy to create a legal and institutional framework to improve national food security and nutrition outcomes. It builds on the multisectoral approach of the National Nutrition Program II (2016-2020) and nutrition governance structure piloted in the “Seqota Declaration� (2016). The recently launched National Food and Nutrition Strategy (2021-2030) provides the roadmap for the Food and Nutrition Policy, including nutrition-specific strategic objectives to prevent and control micronutrient deficiencies with ambitious targets such as improving VAS coverage from 45 percent to 95 percent in 2030. The MOH also developed a Health Sector Strategic Plan for Early Childhood Development (2020-2025) to integrate nurturing care interventions such as early stimulation and positive caregiving into existing maternal and child health and nutrition services. Adolescent Girls Agenda 35. Adolescents and youth (ages of 10-29 years) constitute approximately over 42 percent of the estimated total population of 110 million. Data show that this age group has remained underserved with regard to receiving appropriate health care. Approximately 30 percent of women marry by age 15, and the 2016 DHS shows that about 13 percent of women aged 15-19 have had a birth or were pregnant at the time of the survey. Young women and men face barriers to health services – data show that 40 percent of women aged 15–19 living in urban areas use a modern contraceptive method, as compared to only 17 percent of those living in rural areas. Given that age at sexual debut is still quite young, and that married adolescents have the highest unmet need for 48 World Bank estimate based on the numbers reported on DHS 2005 (unweighted) and 2011 (weighted). 49 The Seqota Declaration is a government commitment to end child undernutrition that is being rolled-out in selected food insecure, water-stressed woredas that have a high stunting prevalence in the northern regions. 20 contraception for spacing purposes and is the group with the greatest demand for family planning, it is critical to strengthen services to reach and address the needs of this age group. In addition, other issues such as Female Genital Mutilation, Gender Based Violence, especially in child marriage, increases their risk of adverse health outcomes such as unintended pregnancy, HIV and other sexually transmitted infections (STIs). Gender Aspects Affecting Health Outcomes 36. Ethiopia suffers from some of lowest gender equality performance indicators in sub- Saharan Africa. The Global Gender Gap report 2016 ranks Ethiopia at 109 out of 144 countries in terms of the magnitude and scope of gender disparities.50 Ethiopian women still face cultural practices and behaviors such as early marriage, abductions, female genital mutilation, as well as physical, psychological, and sexual violence, all of which are harmful to their health and that of their children. Young Age at Marriage 37. Early marriage and childbearing, limited use of contraceptives, and limited access to reproductive health information and education contribute to the high rate of unwanted adolescent pregnancies.51 One of the major reproductive health challenges faced by adolescents in Ethiopia - with 54 percent of pregnancies to girls under the age of 15 years being unwanted. Polygamy is a widely accepted practice in southern parts of Ethiopia and five percent of women in their teens and eight percent of women between the ages of 20 and 24 years are married to men who have more than one wife. This practice is partly related to low socioeconomic and cultural status of women and exposes young women to an increased risk of contracting sexually transmitted diseases.52,53 The legal age at marriage in Ethiopia is 18 years for both males and female but data from the 2016 DHS indicate that 30 percent of women aged 25-49 were married by age 15. Obstetrics Fistula 38. Obstetric Fistula is another condition affecting women in Ethiopia. Reliable data on obstetric fistula are hard to come by because of the stigma associated with the condition, but the WHO estimates that at least 8,000 Ethiopian women develop new fistulas every year. This is a result of multiple factors such as prolonged and/or obstructed labor, practices like early marriage and teenage pregnancy, malnutrition, scarcity of healthcare units in rural areas and a low rate of skilled care during pregnancy and delivery. In 2014, a five-year strategy to eliminate obstetric fistula was launched by the Government of Ethiopia in collaboration with local and international NGOs.54 Domestic Violence 39. Domestic violence in Ethiopia is of great concern though reliable data on this is very hard to come by. The summary findings from DHS 2016 shows that more than 35 percent of ever married women have experienced physical, emotional or sexual violence from their husband or partners; 50 Analytical summary - Gender and women's health: WHO/AHO: AFRO 51 2016 DHS indicate that 30 percent of women aged 25-49 were married by age 15, which usually translates into early childbearing and adverse health consequences for both the mother and her newborn. 52 http://www.aho.afro.who.int/profiles_information/index.php/ethiopia: 53 http://www.aho.afro.who.int/profiles_information/index.php/ethiopia: 54 Sonny I; Married as Children, Women With Obstetric Fistulas Have No Future: PRB 21 24 percent experienced emotional violence; 25 percent physical violence and 11 percent sexual violence. This is higher among older women, formerly married women, and those living in rural areas. High regional variations are also observed (higher in Oromia, Amhara and Harar).55 Human Resources for Health 40. Increasing access to competent, motivated and compassionate health workers was one of the transformation agendas of HSTP-I, and the government sought to increase the availability of health workers. In 2018, health worker density was estimated at 1.0 per 1,000 population, considerably lower than 4.5 per 1000 population standard proposed by WHO to achieve UHC. WHO estimates that countries with fewer than 23 health care professionals per 10,000 population (counting only physicians, nurses and midwives) will be unlikely to achieve adequate coverage rates for the key primary health care interventions. The inadequate number and skill mix of health professionals; persistent high staff turnover and poor motivation has been a persistent challenge for the health sector. A new incentive package for health workers that is allocated based on pre- identified exposure level of risk. Interventions need to continue during HSTP-II to build and sustain a competent, motivated, and compassionate health workforce, with adequate number and skill mix. Moreover, evidence based human resource management and human resource management and leadership capacity at all levels has to be further improved to retain a motivated health workforce and increase productivity of health facilities. 41. The Health Extension Program and the Health Development Army have brought together groups of women to mobilize the community and promote healthy behavior. This is believed to have led to significantly improved access to Primary Health Care services, particularly for the rural poor. Under the HSTP II period, the government planned to revitalize the HEP based on the newly revised HEP roadmap where more essential health services will be expanded to make services more accessible to the population. Expanding the HEP service package to meet the ever-growing needs of the community, addressing gaps in quality of care provided by health extension workers (HEWs), revising the number and mix of health professionals, strengthening HEP infrastructure to allow the provision of more comprehensive and improved services are priority areas of strengthening the role of HEP in enhanced performance of PHC services in Ethiopia under the HSTP II period. During the HSTP II period, the HEP will be more tailored to the pastoralist population and urban settings. Table 3: Distribution of Human Resources for Health (to be updated 2020) Region Physicians Health All Midwives Health (GPs, Officers Nurses extension specialists workers Afar 26 76 632 52 1006 Tigray 176 620 3797 627 2253 Amhara 406 1480 8718 1178 9849 Oromia 424 1805 13679 3324 16561 Somali 65 606 2748 655 1586 55 Central Statistical Agency (CSA) [Ethiopia] and ICF. 2016. Ethiopian Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF. https://dhsprogram.com/publications/publication-FR328-DHS-Final- Reports.cfm 22 Benshangul 21 99 837 112 1283 Gumuz SNNPR 172 1390 9624 1390 9286 Gambela 0 71 324 64 358 Harari 26 56 408 51 76 Addis Ababa 191 651 3276 409 - Dire Dawa 32 79 375 60 78 Central/Federal 157 - - - National 1696 6933 44418 7922 42336 Source: Health and Health Related Indicator MOH 2013/14-2014/1529. 42. Ethiopia needs to intensify efforts in developing and managing its workforce to cope with the increasing demand of the society, changing epidemiology, help achieve the Sector Strategy, SDGs and targets and to address the equity, quality and transformational agenda. Procurement of Pharmaceutical Products 43. The HSTP-I mid-term review (2018) documented relatively increased availability of essential medicines, successful integration of vaccines supply management into the Integrated Pharmaceuticals Logistics System, reduction of pharmaceuticals wastage, and establishment of electronic supply management system at the central Ethiopian Pharmaceutical Supply Agency (EPSA) and its hubs. According to a WHO African Region report, Ethiopia had a health product score1 of 0.51, which was slightly higher than the regional average of 0.48. With the need to shift from product-oriented to patient-oriented services, several initiatives were carried out during HSTP-I, including rollout of auditable pharmaceutical transactions and service (APTS) in 200 health facilities, introduction of clinical pharmacy and drug information services, and increased emphasis on anti-microbial resistance (AMR). 44. Despite the impressive progress that has been made, previous reviews of implementation of the Government’s strategies noted challenges. These included stocks out, over stock and short expiry dates, and the ability to meet the growing demands are the key challenges. Progress on plans to reduce pharmaceuticals wastage rate to less than 2% and increase the contribution of local manufacturers in supplying EPSA to 60% are far behind 2020 targets. There is a challenge in last-mile delivery of medical supplies and challenges related to procurement, maintenance, and inventory management of medical equipment, along with a gap in testing the efficacy of generic drugs produced in Ethiopia, due to lack of bioequivalence. The mean availability of essential medicine tracer items is at 28% in 2018 with significant inter regional gaps, level of health facility and urban rural. 45. Business Process Reengineering was initiated to address the challenges that have been identified. This will help guide the transformation of pharmaceutical supply chain with the view of ensuring health commodities security at all levels of healthcare delivery system, ensuring 100 percent availability of vital and essential drugs with no stock outs and less than 2 percent wastage rate. In the HSTP-II period, actions including proper quantification and forecasting, reduced procurement lead-time should continue to ensure an uninterrupted supply of quality-assured medicines and supplies, to avoid stockouts and ensure timely access to essential medicines and health products. 23 IV. Soundness of Government Program 46. The design of the HSTP is based on the international experience of factors and strategies used to effectively tackle the identified challenges, adapted and refined from the experience of the past decades of implementing previous strategies. The HSTP has three key features: quality and equity; universal health coverage; and transformation. The HSTP sets out four pillars of excellence which are believed to help the sector to achieve its mission and vision. These are: 1) Excellence in health service delivery; 2) Excellence in quality improvement and assurance; 3) Excellence in leadership and governance; and 4) Excellence in health system capacity. These four areas of excellence are further decomposed into objectives, strategic directions and initiatives. . The strategic objectives are linked with each other in a cause-effect relationship and every strategic objective has a set of performance measures and strategic objectives. 47. The HSTPII reiterates that Primary Health Care remains the core health system during its implementation period and beyond. Past experience revealed that the country’s flagship program, which focuses on primary health care, high impact health services interventions, has been a key vehicle in expanding access to essential health services packages to all Ethiopians, with specific focus on women and children. The Government’s long-term vision has played a pivotal role for the progress that has been made in reducing child mortality and improving maternal health programs in the last decade. The design of the HSTPII also builds on the success that has been gained and strives more to meet increasing demand of the population as well as scaling up of existing high impact interventions whose population coverage lags behind the target through the revitalized Health Extension Program. 48. Five priority issues were identified as part of the transformation agenda for HSTP-II. Key interventions will be implemented to address these priority issues to transform the health system and to achieve health for all. The transformation agenda are: i) Quality and Equity: ensuring quality and Equity in services by creating high-performing primary health care units, ii) Information Revolution: to significantly improve methods and practices for collecting, analyzing, presenting, using, and disseminating information that can influence decisions; iii) Motivated, Competent and Compassionate Health workforce: ensuring equitable distribution and availability of an adequate number and skill mix of health workers who are motivated, competent, and compassionate to provide quality health services; iv) Health Financing: reforming public financial management and health financing to improve efficiency and accountability, while pursuing the agenda of sustainable domestic resource mobilization for health; and v) Leadership: enhancing leadership and governance mechanisms at all levels of the health system to drive attainment of the national strategic objectives through activities to ensure alignment and harmonization, thereby creating an enabling environment for the translation of plans into results. Box 1: Key health sector targets for 2024/25 24 Improve the health outcomes of citizens through provision of equitable, accessible and quality health services, enhance awareness of the public. 1. Increase life expectancy from 64 in 2014/15 to 69 by 2019/20. 2. Universal Health Coverage (UHC) Index from 0.43 in 2020 to 0.58 in 2024/25 3. Reduce maternal mortality rate (MMR) from 420/100,000 live births in 2016 to 279/100,000 live births by 2024/25. 4. Reduce under 5 child mortality rate from 55/1000 live births in 2019 to 43/1000 live births by 2024/25. 5. Reduce infant mortality rate from 44 in 2014/15 to 20 per 1000 live births by 2019/20. 6. Increase modern contraceptive prevalence rate from 41 percent in 2019/20 to 50 percent by 2024/25. 7. Increase high performing PHC facilities from 5 percent in 2020 to 35 percent in 2024/25 8. Increase Total Health Expenditure (THE) per capita from US$33 to US$42.2 49. The key challenge for Ethiopia is making progress towards maternal, neonatal health outcomes, providing equitable and quality health services. The HSTP critically analyzed the challenges and gaps in previous implementation in delivering maternal, neonatal, child and adolescent health services; and providing equitable and quality services. Accordingly proposed strategies and actions that have a strong evidence base to improve maternal, neonate health outcomes as well as equitable and quality health services were well articulated in Sector Strategy. 50. The Sector Strategy has the critical building blocks required for a program that can deliver results. These include: 51. A technically sound and costed strategic plan well aligned with Ethiopia’s Economic Development policies and strategies, and SDG. It was validated by Joint Assessment of National Strategy tool that was developed by International Health Partnership Plus-WHO; well established processes and tools for evidence-based planning and efficient use of resources on a sustained basis; 52. Clearly defined and costed set of evidence-based interventions. These are supported by a results framework with multi-year financing plan; one health tool was employed to come up with two scenario resource requirements for implementation of the Sector Strategy; 53. Highest level political commitment: Defined through various high-level strategies to achieve the health SDG; 54. Clearly defined governance structures: These involve key stakeholders; and strong donor coordination and aid harmonization governed by the International Health Partnership Plus compact, previous Sector Strategies harmonization manual, and Joint Financing Arrangement. 25 IV. Governance structure and Institutional Arrangement Government structure and institutional arrangement 55. The proposed operation will use existing institutional and implementation arrangements. Ethiopia follows a decentralized federal structure of administration and the Constitution provides for shared responsibility for health policy making, regulation and service delivery between the MOH, Regional Health Bureaus and Woreda Health Offices. Proclamation No. 475/1995 of Federal Democratic Republic of Ethiopia defines the powers and duties of executive agencies. The MOH has a mandate for national health policy formulation, expansion of health services, establishment and operation of national referral hospitals and national level study and research centers, determining standards and operational protocols, regulation of health services and professional education in public health, and prevention, control and eradication of communicable diseases. This requires a smooth coordination between MOH and RHBs to maximize impact. 56. The Government of Ethiopia has established multi-sectoral coordination mechanisms to address nutrition policy and technical issues. Nutrition policy issues are coordinated and monitored by the National Nutrition Coordinating Body, chaired by the State Minister of the Federal MOH and co-chaired by the State Ministers of Agriculture and Education. The Director of the Maternal and Child Health Directorate acts as the Secretary. Additional sectors in the National Nutrition Coordinating Body include finance and economic development; water and energy; and women, children and youth affairs. Technical issues in coordination and monitoring are managed by a Nutrition Technical Committee, comprised of representatives from all nine line ministries and nutrition partners. The National Nutrition Coordinating Body is chaired by the MOH and co-chaired by the Ministry of Agriculture and Ministry of Education. The Nutrition Case Team in MOH acts as the Secretary. This nutrition coordination structure extends from sub-district level up to Regional level through layers of coordination bodies consisting of representatives across several key sectors. 57. The MOH will be responsible for planning, budgeting and reporting funds released from the Pooled Fund, through which IDA funding will be disbursed under the PforR operation. The Joint Consultative Forum (JCF), which is the highest governance body for dialogue, decides, guides, oversees and facilitates the implementation of HSTP-II. This dialogue forum is chaired by the MOH and co-chaired by one of the partners in the sector that will focus on sector policy and reform issues between Government of Ethiopia its partners and wider stakeholders. Similar to the preceding PforR operations, disbursement will be made directly to the pool fund, SDG PF, that supports the priority needs of the health sector, and verification protocols will be agreed upon according to the identified list of Disbursement Linked Indicators (DLIs). 58. MOH has 26 functional Directorates following the nationwide health sector reform. The Directorates were established based on their functions, under the Office of the Minister and the State Minister that include Policy, Planning and Monitoring and Evaluation (M&E); Public Relations and Communication; Internal Audit; Women, Children and Youth Affairs; Ethics and Anti- Corruption; Medical Services; Clinical Services Maternal Child Health and Nutrition; Disease Prevention and Control; Health System Strengthening and Special Support; Health Extension and Primary Health Service; Partnership and Cooperation; Finance and procurement; Human Resource Administration; Asset Management and General Service; Public Health Infrastructure; Health Information Technology; Reform and Good Governance; Pharmaceutical and Medical Equipment; 26 Legal Affairs; Hygiene and Environmental Health; Health Professionals' Competency Assessment and Licensure; Health and Health Related Institutions Regulatory; Emergency, Injury, and Critical Care; Human Resource Development; and Health Service Quality. 59. The Policy, Planning and M&E Directorate is in charge of policy formulation and review tasks, strategic and operational planning, monitoring and evaluation and stakeholders engagement coordination. 60. Partnership and Cooperation Directorate is mandated to develop and lead the implementation of Health Care Financing Strategy; assess and ensure cost-effectiveness of new and existing interventions; conduct resource mapping, alignment, allocation and ensuring efficient utilization of financial resources; monitor and manage grants of the health sector; generate evidence through health economics and financial analysis. 61. Maternal and Child Health Directorate is responsible for directing RMNCAHN & Seqota Declaration programs, interventions and activities and implementing major priority programs for all aspects of maternal, child health and nutrition issues throughout the country 62. Disease Prevention and Control Directorate is in charge of coordinating communicable and non-communicable disease programs; coordinating the designing and development of national strategies, policy guidance, technical guidelines, protocols, Standard Operating Procedures, and intervention packages; ensuring the availability and uninterrupted supply of commodities for the programs, in collaboration with the Ethiopian Pharmaceuticals Supply Agency (EPSA). 63. Health Extension and Primary Health Service Directorate is responsible for ensuring the realization of universal health coverage through support and follow-up of primary health care activities by developing the necessary guidelines and strategies as well as giving the necessary support to all regions in Ethiopia. 64. Health System Strengthening and Special Support Directorate is responsible for addressing inequities/geographic disparities (socio-economic, demographic, gender, people with special needs) by providing technical assistance, financial and logistic support for the disadvantaged groups on health system building blocks & people; coordinating health interventions with other line ministries; building resilient health system, and improving the state of inequities in the country. 65. The Medical Service Director General coordinates development of standards for curative care and monitoring their compliance at hospitals and health centers. 66. MOH has seven agencies that are responsible for guiding and implementing health and health-related activities, including: o The Ethiopian Public Health Institute (EPHI): is responsible for public health- and nutrition- related surveys and researches, quality laboratory systems, and public health emergency management o Armauer Hansen Research Institute (AHRI): primarily responsible for generating and delivering scientific evidence, developing new tools and methods through biomedical, clinical, and 27 translational research; and serves as a hub for technological transfer and capacity building in medical research and training o HIV/AIDS Prevention and Control Office: primarily responsible for coordination of multi-sectoral HIV prevention and control activities o Ethiopian Health Insurance Agency (EHIA): primarily responsible for establishing and implementing an efficient, effective health insurance system; undertake studies and take measures to ensure the financial sustainability of health insurance system. o The Ethiopian Food and Drug Authority (EFDA): is responsible for assuring the safety, efficacy, and quality of health and health-related products and services through control and supervision of food safety, pharmaceutical quality, tobacco and tobacco products, cosmetics and related products, and other regulatory activities. o Ethiopian Pharmaceuticals Supply Agency (EPSA): is responsible for ensuring a sustainable supply of quality assured pharmaceuticals to health facilities at an affordable price o National Blood Bank: responsible for ensuring the availability of blood and blood products in Ethiopia 67. The MOH also supports regions in systems development and developing health sector programs and plans which are aligned with national plans and goals. It mobilizes additional resources to improve service delivery and creates appropriate platforms for mutual accountability, information flow and efficient use of resources. 68. The Regional Health Bureaus are responsible for delivering health services . Services are provided based on national health policy, for health service delivery within the region including all types of hospitals, licensing health facilities, and for ensuring adequate supply of safe and affordable medicines and other supplies. The Woreda Health Offices manage and coordinate the primary health care units (primary/district hospital, health centers and health posts) and are responsible for planning, financing and monitoring the health progress and service delivery within the Woreda. Governance and institutional capacity s 69. Good governance is crucial in the realization of the principles of the HSTP-II, and in ensuring that the outlined activities are executed in an efficient and accountable manner. There are well established governance structures at different levels of the Ethiopian health system to effectively plan and use these resources. There is strong recognition that over the years the health systems in most developing countries have become increasingly complex due to changes in international aid architecture and responding to ad-hoc needs resulting in vertical program and duplication. The Government’s strategies have aimed to create an open and transparent mechanism of governance for health sector activities, rationalize these structures and improve overall governance in the health sector to ensure effective harmonization as well as better accountability. The International Health Partnership Plus also provides strong impetus for this. 28 70. In the HSTP-II period, MOH will conduct preparatory activities for establishing semi- autonomous professional and facility regulation through the involvement of professional associations and other stakeholders. The Health Harmonization Manual (HHM) has been revised in 2020 to further strengthen coordination and accountability and for eventually moving towards “full� harmonization with “one plan, one budget, and one report�. Accordingly, the coordination and implementation of the HSTP-II will have an institutional framework built on consultation and review, to enhance the dialogue between the MOH and health development partners to obtain effective development assistance to the health sector. The principles for such dialogue are ownership by the Government of Ethiopia, alignment of partners to the government, harmonization among partners, mutual accountability between the Government and partners, and financing for results. The overall governance and implementation arrangements that are clearly outlined in the HHM include: 71. The JCF, the highest governance body for dialogue is chaired by the Minister of Health and co-chaired by the lead partner in the sector. It is the platform for dialogue and consultations on the overall policy direction, reform and institutional concerns about the health sector between Government of Ethiopia, development partners and wider stakeholders. The JCF plays a leading role in expanding the involvement of the private and NGO sectors in health service delivery which will be chaired by the Minister of Health, co-chaired by Health, Population and Nutrition (HPN) chair, and the secretariat will be the Policy, Plan, Monitoring and Evaluation Directorate (PPMED). High level federal government bodies, HPN development partner groups (multilateral and bilateral development partners), NGOs, the private sector, and health professional associations are represented in this forum. Its functions will be revitalized through processes for collaborative agenda setting and close follow-up of planned actions. JCF meetings are held on a regular basis between MOH, donors and other stakeholders. 72. The Joint Consultative Forum also oversees the allocation, implementation and use of the Pooled Fund, the Global Fund, Gavi, the Vaccine Alliance and other multilateral and bilateral donor supported projects ensuring effective linkages between support provided by different partners, regional bureaus and other sectors. 73. The Joint Core Coordinating Committee (JCCC) is the technical arm of the JCF which is chaired by the Director of Policy, Plan, Monitoring and Evaluation Directorate (PPMED). The JCCC is responsible for following up the implementation of the decisions of the JCF and the recommendations of the review missions (mid-term and annual review meetings, and final evaluation) and organizing the review, conducting M&E, and coordinating operational research and thematic studies. PPMED, staff, and senior members from the HPN Group, are members of the JCCC. With the ongoing revision and full implementation of the HHM, the functioning of the JCCC will be revitalized by revising its composition (implemented by the JCF) and by developing performance accountability measures among federal and regional government levels and with development partners. 74. MOH-RHBs Joint Steering Committee (JSC): The Minister of Health chairs this forum that meets every two months to facilitate smooth, effective implementation of HSTP priority activities. The State Ministers of Health, Regional Health Bureau Heads, heads of departments/services of the Ministry, director generals, M&E heads of MOH Agencies and Plans, and M&E heads of RHBs participate in this meeting. The meetings focus on the implementation and progress of the plan and challenges faced during the course of its implementation. The committee is also responsible for 29 updating the plan; introducing new initiatives, policy guidelines, and programs; and creating systems and mechanisms for communication and information/experience sharing. 75. Management Committee (MC) and Executive Committee (EC): The MC that is composed of the Minister, State Ministers, and Directors of all Directorates, will meet regularly to guide and follow the implementation of HSTP. The Executive committee, which is composed of the Minister, state ministers, Director Generals of agencies, will meet regularly to guide and follow the implementation of the plan. Regional/Zonal/Woreda-level management committee and partner forums will be established and will monitor the implementation of HSTP at each level. Program specific advisory groups and technical working groups will be established as deemed necessary. 76. There are strong institutional capacities at the Federal level that are demonstrated by the effective use of evidence-based policy making and focus on development and implementation of high impact interventions. Ethiopia has achieved the goals of the GTP and these achievements were made possible due to the implementation of high-impact interventions, primarily through flagship community-based programs such as the Health Extension Program (HEP) that continues to make significant contributions towards improved health indicators in the country. During the HSTP- II period, the Health Extension Program (HEP) will continue to be an effective program for community participation and an effective service delivery platform to reach individuals, families, and communities with a comprehensive package of PHC services. The HEP will be revitalized based on the newly revised HEP roadmap where more essential health services will be expanded to make services more accessible to the population. The program will scale up implementation of the HEP optimization roadmap to address evolving community needs for quality health services and fully embrace emerging public health challenges. 77. Under the HSTP-I, Women Development Army (WDA) mechanism was expected to play a key role in organizing community, families, mainly women, to scale-up best practices gained from the Health Extension Program, sustaining the gains of the Health Extension Program and ensure wider community participation in facilitating community ownership and in rolling out the second generation Health Extension Program. However, in recent years, the functionality of these structures has shown signs of decline. According to the 2019 National HEP Assessment, WDA leaders did not demonstrate model behaviors due to low capacity and acceptability among WDA leaders and low acceptance by community members. Overdependence on the WDA structure has resulted in underutilization of other community resources, including those of men, religious leaders, and traditional leaders56. 78. The HSTP-II recognizes community engagement, empowerment, and ownership as a foundation of service delivery as it ensures active participation and engagement of the community in planning, implementation, monitoring and evaluation of health and health related activities. It puts communities at the center of the government’s strategy to increase control over their lives through creating health literacy and decision power and improve health service delivery at the local level. In this strategic period, re-designing, testing, and implementing a package of alternative approaches tailored to address emerging challenges to the existing community engagement strategies will be a key milestone to advance community engagement and ownership and accelerate the progress towards UHC. In particular, the community awareness about their 56 Ministry of Health, The national assessment of the Ethiopian Health Extension Program (HEP), 2020 30 entitlements for basic service delivery can be strengthened and so is their voice in demanding the same including that of vulnerable groups through creating appropriate, systematic and context specific avenues for constructive dialogue between service providers and the citizens. The expected result of this direction is to achieve a community with improved health behavior, health outcomes, and improved accountability. 79. The Woreda-based national planning introduced by MOH and Regional Health Bureaus help in evidence-based and results-oriented Top-down and bottom-up planning to achieve the Sustainable Development Goals. Estimates are based on the indicative resource envelope provided by MOH and Regional Health Bureaus. These plans are aggregated at the regional level by the respective Regional Health Bureaus and compiled into the national plan by MOH. 80. The assessment carried out for the proposed operation shows that citizen engagement and social accountability mechanisms exist in several aspects of service delivery in health . Patients, communities, providers and health authorities engage on a continuous basis and some beneficiary feedback is flowing between the different stakeholders. During the HSTP-II period, the sector plans to strengthen existing social accountability mechanisms such as community scorecard (CSC), town hall meetings and increase participation of the community in health facility governing boards to enhance accountability and transparency of the health system to the public. 81. The World Bank has been supporting the sector under the AF to Health SDGs PforR since 2017 for the development and implementation of the health sector CSC, which is a feedback mechanism where citizens rate the performance of their local health service on a regular basis, to promote inclusiveness and citizens’ feedback on service delivery. Through this support, the health sector CSC directive was developed and the Ministry designed, piloted and full-scale implementation was initiated between 2017-2019. As verified by independent review, the number of districts that implemented the CSC has reached to more than 200 districts in June 2019. The implementation of CSC has made health facilities to be responsive to citizen’s feedback and has brought improvements in health service delivery. Improvements in the management of Ambulances, construction of waiting areas and improvements in the cleanliness of health facilities are among the improvements observed following the implementation of CSC. A CSC technical working group (TWG) has also been established which is comprised of technical members drawn from government and partners (UNICEF, Yale University project, World Bank- ESAP MA). The TWG meets regularly to review the implementation of the CSC scale up and address the technical challenges. 82. There were, however, implementation challenges as identified during the course of program implementation (2017-2021) including technical challenges in measuring the quality of CSC implementation at the district level; lack of formal organizational structure at the sub national level to host and make accountable for its implementation; and lack of standardization in the implementation across and within regions. 83. For example, beneficiary feedback flows between the different stakeholders do exist. However, given the oral nature of these engagements, it is impossible to assess the strength of the feedback flows and extent to which grievances are handled in some regions with pastoralists’ populations that were the focus of the original program (Gambella, Somali, Afar, and Benishangul- Gumuz), and systematic engagement with the communities remains very limited and might require support. In addition, the assessment found that while systems are in place and cover both upstream 31 and downstream engagement, these are ad-hoc and mostly conducted orally. The lack of documentation on the engagements between service providers and citizens, as well as on the management of related grievances makes it difficult to assess the nature and the extent to which grievances are resolved, or how potential problems are left undiscussed or unresolved at every level (national, regional, zonal, Woreda, Kebele level). Therefore, one of the key areas for improvement is to systematically record discussions, grievances and agreements at every level and the way these are addressed with some basic performance measurement of monitoring grievances management. 84. The strategic plan for HSTP-II 2021-2025 identifies the strategic direction/program on community engagement to achieve the targets laid out in sector plan through ensuring community engagement and ownership. Community engagement has been a primary principle and strategy for achieving the strategic objectives of HSTP-I. The government also highlights that the presence community-based health extension program and community engagement platforms and community engagement mechanism in developmental activities including health is a strength and an opportunity to influence the performance of the health sector. o Enhance Community Ownership: through community representation at health facility governing boards and regular town hall meetings and public conferences o Enhance Good Governance by: i) Facilitating gender equity in the leadership and gender mainstreaming; ii) Providing special and targeted support to developing regions to reduce the state of inequality; iii) Enhancing implementation of patient and citizen charters and track progress; iv) Strengthening town-hall meetings of health facilities to promote engagement of the public; v) Strengthening accountability and transparency through performance measurement, engagement of the public and civil societies (e.g. Citizen scorecards). o Improve Community Participation and Engagement by: i) Strengthening the Health Development Army to contribute to better health outcomes and climate resilient green economy through empowering individuals, families and communities; and ii) Increase health literacy and health system literacy of the public to improve quality of Care) Strengthen accountability of the health system to the public by implementing strategies to build trust and credibility with communities that their input is honored and acted upon. 85. At the national level, the Public Wing and the complaint handling system for the Pharmaceuticals Fund Supply Agency and infrastructure-related issues are the three main engagement mechanisms. As a forum where users and providers’ associations discuss strategic planning and performance topics (including patients’ satisfaction surveys) with the Federal MOH, the Public Wing seems effective. However, there is no evidence that the Pharmaceuticals Fund Supply Agency complaints handling system is effectively used by bidders, a weakness which had been highlighted in the earlier assessment. Similarly, there was no documentation on the way the complaints related to infrastructure were recorded and handled. These are critical steps towards ensuring that the views of potentially affected individuals are taken into consideration in the decision-making process and need to be addressed in the AF. 86. At the local level, several citizen engagement mechanisms are in place: (i) Health Governing Boards composed of community members and facility employees (for hospitals and health centers) address any issue related to health facility, (ii) Discipline Committees, addressing patients’ complaints about health personnel mistreatments at the Woreda level, (iii) Health Center Management Committees, discussing community contributions (financial, material or immaterial) 32 to carry out small infrastructure projects (such as waiting rooms), (iv) Infection Prevention and Patient Safety Committees (usually has patient representation at the Kebele level only). These are all established in hospitals but they are less active in health centers; (v) “Town hall� {meeting} called by health governing boards (usually every three months for hospitals; every 6 months for health centers) where community members discuss issues with health centers leaders such as scarcity of medicines, how medical staff treat patients etc. The implementation status and effectiveness of all the mechanisms including the Kebele Health and HIV/AIDS committees remain unclear due to the lack of information and documentation. 87. Current social accountability tools and other citizens’ engagement mechanisms target all basic sectors including the health sector. These are Protection of Basic Services 3 (Financial Transparency and Accountability (FTA), Grievance Redress Mechanisms (GRM) and Ethiopia Social Accountability Program (ESAP II) and Enhancing Shared Prosperity through Equitable Services (ESPES)) are contributing to achieve significant results to address quality and equitable access issues in health service delivery in woredas where the health sector is covered. The power of these approaches lies in their complementarity as they address both the supply and demand side of citizen engagement. 88. On the supply side, the government has pushed for greater budget transparency, in particular through FTA which has enabled capacitated citizens in budget literacy and enabled them to access budget and expenditure information at the woreda and kebele level. On the demand side, with support from civil society, ESAP II and ESPES have aimed to strengthen the capacity of citizens and communities to become increasingly aware of their service entitlements, undertake participatory service needs assessments and engage the authorities in budget discussions and develop, finance and monitor the implementation of ‘joint action plans’ to resolve potential service delivery issues at the woreda and kebele levels. 89. In the health sector, preliminary results of ESAP have shown that such mechanisms have initiated a behavioral change for citizens and providers (more respectful and ethical patient- health worker relationship). They have strengthened patients and providers’ ownership of health facilities based on a better understanding of budgets, service standards, linkages with policies; and they have contributed to better service delivery (greater availability of essential drugs, higher staff attendance, joint community-government mobilization of resources for the renovation of facilities, etc.). 90. Administrative data and results of internal assessment by the ESAP2 management agency indicates notable progress: As a result of interface meetings between service providers, citizens representatives through social accountability committees, 94 qualified health personnel were added in existing health centers, 53 water and sanitation facilities were constructed and/or maintained in health facilities, 48 renovations were made to create a more conducive environment for basic service delivery (wards, waiting rooms ) and several Pharmacies were equipped with the necessary drugs following citizens demands. The citizens and service providers provide anecdotal evidence that this has led to improvements in service provision and an impact evaluation underway will provide additional information on the results and impact story. 91. Posting of budget and expenditure information which includes basic service sectors including health has continued in more than 95 percent of woredas. The pre-budget discussion forum which has been designed to identify and prioritize community needs at the local levels before 33 budget is allocated and help citizens to voice their concerns during the planning and budgeting process of basic services including health have started in 37 percent of woredas in FY 2008 (2015/2016) and this is expected to increase in the coming years. More than 60 percent of basic service facilities including health centers are now posting their plans and performances to enable citizens understand the type of services that they provide. 34 V. Assessment of Monitoring and Evaluation Arrangements Health Management Information Systems (HMIS) 92. Ethiopia has multiple data sources that can be used to effectively monitor and evaluate results under the PforR. The proposed PforR will draw on data sources used to monitor results under the preceding PforR program, plus additional sources of data that will become available during the course of implementation. One of the transformation agenda under the Health Sector Transformation Plan II (2020/21–2024/25) is the information revolution required to transform the way information is collected, analyzed presented and disseminated. 93. Various platforms were put in place by the Government to strengthen key decision-making, including performance monitoring teams, review meetings, a JSC, and planning forums. The District Health Information System (DHIS2) platform was customized and fully scaled up with user-friendly data use features. Other service recording systems for logistics, regulatory system, and other functions were also introduced. An electronic Community Health Information System (echoes) application was developed and implemented; and, several other applications are in development including a Master Facility Registry, electronic HRIS, and a National Health Data Dictionary (MOH, 2019)57. Regarding public health surveillance information system, list of reportable diseases, including maternal and perinatal death surveillance and response, are included in the disease surveillance system. A national database center was created at EPHI to handle the Public Health Emergency Management (PHEM) information system. 94. The 2019 HMIS performance assessment including the newly deployed system DHIS2 identified the following weakness which are relevant to using the routine DHIS for reporting DLIs • A total of 189 indicators were identified to track the performance of HSTP I. The indicators were categorized by input (12%), output (38%), outcome (37%) and impact (14%) based on the M&E logic framework. Majority of the indicators were aligned with the then SDGs, WHO and other global indicators and based on country’s priorities. However, the M&E did not specifically address how the index indicators were to be measured. • The HSTP II MTR report reveals that majority of the targets set were ambitious, with no clear data source and frequency of reporting and analysis. Thus, some indicators were not measured throughout the HSTP I period. • The ministry also conducted DQR in 2016 and 2018 to assess the data quality and HIS system. According to the 2018 DQR facility report completeness improved from 72% in 2015/16 to 92% in 2018/19 while proportion of health facilities that meet data verification within 10% range for skilled delivery improved from 71% in 2015/16 EFY to 82% in 2018/19. Despite efforts in improving data quality, the level is still sub-optimal which requires continued and sustained investment. 57 MOH. (2019). Health and Health Related indicators 2011EFY (2018/19). Addis Ababa, Ethiopia: MOH . https://e- library.moh.gov.et/library/wp-content/uploads/2021/07/Health-and-Health-Related-Indicators- 2011.pdf 35 Household Surveys 95. Household surveys that provide information on health include the Demographic and Health Survey and Multiple Indicator Cluster Survey. It was undertaken in Ethiopia only once in 1995. The country has, since 2000, been undertaking standard DHSs almost every five years (2000, 2005, 2011 and 2016). A mini-DHS was undertaken in 2014 and 2019 to collect data to support the monitoring and evaluation needs for Phase IV of the Ethiopia HSDP (2010/11–2014/15) and the first HSTP (2015-2020), respectively. The data from the DHSs undertaken in Ethiopia has allowed monitoring of health outcomes and analysis of trends from 2000 to 2019. The 2016 results were used as a key baseline data source for four DLIs (on deliveries, pregnancy care, immunization and contraception) for the AF of the Ethiopia Health MDG PforRs and the 2019 mini-DHS allowed for the monitoring of progress made in the DLIs. 95. Demographic Health Survey: The DHS uses a standard methodology and results re generally regarded internationally as one of the most reliable measures of population-based coverage information. The Central Statistical Agency (CSA), an entity independent of the MOH, has conducted DHSs nationally and regionally representative household surveys that provide demographic, heath service utilization and basic health status information with technical support from ICF Macro. Mini DHSs have been conducted to collect a core/ subset of the full DHS data in 2014 and 2019. The most recent full DHS and mini-DHS were completed in 2016 and 2019. The DHS 2020 was not conducted due to the ongoing COVID19 outbreak and the security situation of the country. Health Facility Surveys 96. Health facility surveys that have been undertaken include the Ethiopia National Health Facility Survey (NHFS) undertaken in 2005 the Ethiopia Service Provision Assessment Plus Survey undertaken in 2014, and the SARA undertaken in 2016/17. The objective of the NHFS was to obtain information on the operating capacity of the health care facilities and to measure the capacity of the health care infrastructure to respond to the HIV epidemic. The survey was undertaken in all hospitals and from a sample of health centers and higher private clinics. The Ethiopian Service Provision Assessment Plus survey collects information on the availability and delivery of health care services in Ethiopia and assesses the preparedness of facilities for provision of quality health services both of which will be critical to the DLIs in the preceding PforR AF. The information collected are in the following areas: child health, maternal and newborn care, family planning, sexually transmitted infections, HIV and AIDS, and tuberculosis. It is a cross-sectional study, combining Service Availability and Readiness Assessment and Service Delivery Indicator. The survey collects information from all hospitals in the country and from a representative sample of health centers and clinics. Population and Housing Censuses 97. Ethiopia has undertaken three population and housing censuses in 1984, 1994 and 2007, following the United Nations standards for undertaking censuses. The census collects demographic, social and economic characteristics of the population, including information on mortality and fertility. It also collects information on the housing characteristics of all households 36 in the country. Census data have many uses, including provision of denominators required for the calculation of health indicators such as CPR and immunization rates; provision of data at low levels of geography as a basis for population projections; and provides sampling frame for surveys such as the DHS. Plans were underway to undertake another census since 2017, which have not yet materialized in consideration of security/political instability in the country. Civil Registration and Vital Statistics (CRVS) 98. Reliable statistics from a well-functioning CRVS system is key for the country’s development and transformation efforts to improve the well-being of the population. In 2012, Ethiopia enacted a comprehensive law governing the institutional and operational framework of CRVS system through Proclamation 760/2012 making the registration of vital events compulsory in the country. The country established the Federal Vital Events Registration Agency (VERA) in 2013 under the Ministry of Justice to direct, coordinate and support the registration of births, deaths, marriages and divorces at national level. Regional vital event registration agencies (RVERAs) were also established in the nine regional states and the two city administrations by the regulation of the respective regions. The country launched the official registration of births, deaths, marriages and divorces in August 2016. Following the country’s reform initiative in 2018, VERA was merged with the Main Department for Immigration and Nationality Affairs to form Immigration, Nationality and Vital Events Agency (INVEA) by the regulation of the Council of Ministers No.449/2019 which is accountable to the Ministry of Peace. The registration of vital events is carried out at the kebele level using a manual paper-based system, to be computerized progressively from the federal office to the regional and local offices. In 2017, the proclamation 760/2012 was revised (Proclamation 1049/2017), stipulating the role of the health sector in notifying births and deaths occurring in health facility and community levels and recording causes of death. The CSA is authorized to collect, compile, analyze and disseminate vital statistics data from civil registration system at national and sub-national levels. 99. Good progress has been made in strengthening the CRVS system since 2016, mainly with resources from the government, complemented with financing and technical assistance from development partners mainly the World Bank and UNICEF. Civil registration currently takes place in 90 percent of the total registration centers (19,020) nationally and in all 32 refugee centers. Birth registration increased from 12 percent in 2016 to 20 percent in 2019 while death registration increased slightly from 11 percent to 13 percent. Major challenges affecting the low registration coverage and considerable differences across regional states include absence of functional registration councils at different administrative levels; existence of manual/paper-based registration system; no standard, interoperable CR information system for civil registration process; lack of long-term training scheme for officials assigned at different levels; shortage of resource to undertake CRVS operations at different levels; registration fee for issuance of certificates; absence of competent and experienced registration officers at all levels; lack of awareness among the public on the importance of registration; and poor coordination between the health sector and INVEA structures at lower levels. 100. Aside from the implementation challenges, the COVID-19 outbreak in the country since March 2020, the ongoing civil unrest since October 2021 and the associated factors have severely affected the performance of CR system in the country. This ongoing challenging situation has disrupted the registration services due to the suspension of registration of vital events and closure of all civil registration offices in the aftermath of the outbreak and during the conflict in some parts 37 of the country; reduction in operating hours of civil registration offices; reduction in demand for civil registration services from members of the public; difficulties in distribution/supply of registration materials to subnational offices; delays in transmission of registration returns; and disruption/slowdown of registration offices at all levels. 101. The proposed operation will contribute to addressing the existing implementation challenges and ensuring operational continuity during COVID-19 and enhancing the system for continued production of comprehensive vital statistics in the country. To institutionalize the CRVS system in the country, INVEA and the health sector needs to collaborate and implement their respective CR activities in an integrated and harmonized manner. Hence, the proposed new health PforR operation will support INVEA and the health sector to undertake CRVS activities through the provision of technical assistance and capacity building activities including digitization of CRVS system, training and awareness raising activities, strengthening coordination and collaboration with key stakeholders, amending legal and policy framework, monitoring and evaluation 102. The health sector has developed an M&E framework to guide monitoring and evaluation of HSTP II implementation. The logic model is based on the Ethiopian health system framework and adaptation of the recent WHO’s Monit oring and Evaluation framework. It includes the logical relationship from health system inputs to outputs and outcomes and then ultimately to impact. See the framework below Figure 6: Monitoring and Evaluation Framework of HSTP II 38 VI. The Expenditure Framework 103. The expenditure framework of this operation is defined by the government program and program boundary which is the HSTP II and the SDG PF, respectively. The proposed operation will contribute to the reduction of the financing gap under the HSTP using a hybrid PforR with the inclusion of an Investment Project Financing (IPF) component. The largest proportion (US$321 million) of the proposed operation will be allocated to the PforR with US$124 million allocated to IPF component. The program boundary for the PforR operation is the SDG PF which has a strong focus on reproductive, maternal and child health interventions through strengthening of primary health care services. The SDG PF is a pooled fund that is managed by MOH using GoE procedures. It provides complementary resources, consistent with the “one plan and one budget� concept, to fill resource gap to implement evidence based high impact RMNCH services and strengthen the overall health system with a strong focus on primary healthcare units. 104. The SDG PF has been the program boundary under the parent and the additional financing project (2013 – 2021) and has contributed for a significant improvement in key RMNCH health outcomes from a very low base. The HSTP-II is the government program where sector priorities and contribution from all stakeholders including government, development partners and community contribution is reflected. The SDG PF supports a subset of the overall Government Program, with a focus on maternal and child health- an area where key indicators are lagging. Limiting the focus of the SDG PF ensures that the most critical interventions which are linked to the achievement of the PDO will receive support. In addition, it also limits the program to a reasonable scope within the larger HSTP. The SDG PF has the following main objectives: i) Supporting HSTP priorities in Maternal and Child Health services; ii) Improving the Primary Health Care units; and iii) Strengthening sector capacity, including human resources, financial management and supply chain management, health management information systems and health technologies. Eligible expenditures are defined as support to priority areas under the HSTP framework (Table 4). The priorities will be agreed annually at the JCF each year at the beginning of the Ethiopia fiscal year with wider sector planning discussions between MOH and DPs. Consistent with the mandate of MOH, as stated in proclamation 1097/2018, the majority of financial expenditure under the SDG PF will be made at Federal levels, with goods and services transferred in-kind and in cash to sub- national levels according to need and disease burden. 105. The IPF component mainly focus on addressing the emergency public health and nutrition response for conflict affected and security constrained areas in Ethiopia and system capacity building which are also among the key priority strategic initiatives under the government’s program. The IPF component have three sub-components aiming to address i) the emergency health and nutrition response need in conflict affected and security constrained areas, ii) strengthen vital events registration agency (VERA) in building a CRVS, which is central to sound maternal and child health information and child marriage; and iii) filling critical capacity building and technical assistance need responding to capacity gaps in fiduciary management; Health Care Financing; Health Management Information Systems, etc. 39 Table 4: Scope and Results Supported by the SDG PF HSTP Priorities Priority Areas Priority Interventions Intermediate Results Outcomes for SDG PF Maintain and • Supply essential drugs and • Increased deliveries Improve RMNCH medical equipment’s for • Increased number of by skilled birth outcomes and treatment of maternal, Health facilities with provider at national accelerate neonatal & childhood improved emergency level and for the progress towards illness obstetric care three bottom HSTP targets. • Supplying contraceptive • Increased number of performing regions and other RMNCH hospitals providing clinical • Increased proportion commodities mentorship to HCs on the of mothers receiving • Supply of vaccine and 7 signals of BEmONC modern conduct vaccination • Increased percent of HCs contraceptive campaigns providing CEmONC method immediately • Capacity building for the services after delivery implementation of • Increased youth friendly • Increase proportion national quality and equity health service of pregnant women strategy at national and with four ANC visits regional level (ANC+4) Transformation • Increased proportion in Quality and of pregnant women Equity receiving iron folic acid tablets • Increased pentavalent 3 immunization for the bottom 3 or 4 performing Regions. • Early Postnatal Care Services, within 2 days (coverage). • Increased proportion of low birth weight and preterm babies receiving Kangaroo Mother Care services Health System • Avail water and electricity Increased # Primary Health • Increased percentage Strengthening infrastructure at PHCUs Care facilities having all of high performing focus on PHCU • Construction of new PHC drugs from the MOH list of PHCU facilities and renovation of essential drugs available public health infrastructure • Community based in conflict affected areas neonatal care services • Expand cold-chain capacity Number of • Pilot Health Posts (HPs) with comprehensive health services. • Develop implementation manual 40 Strengthened • Strengthen/capacity • Mobile health and Increased number of emergency building of mobile Nutrition Team women and children preparedness and emergency health and established in conflict from the conflict response nutrition team and affected areas affected population Disaster Medical • Temporary/ Mobile clinics provided with basic Assistance Team (DMAT) established for IDPs with RMNCH service. • Develop emergency health high population volume • Increased number of and nutrition emergency and linked to working Health facilities that response guidelines facilities to receive free resumed all health services. service to pre conflict • Health facilities with status Physical maintenance of damaged infrastructure • Provide mentorship and • • Transformation medical equipment • Improve implementation Increased proportion of in Health support for primary of the health insurance enrolled HH in CBHs Financing and healthcare units (PHCUs) reforms: governance • Hospitals providing clinical a) Design higher-level • Increased number of mentorship to Health pooling implementation HCs conducting clinical Centers on signals of options, and prepare a audit Motivated, Health System BEmONC manual for higher-level competent, and Strengthening • In-service training of pooling options • National Climate compassionate midwives and other health b) revise CBHI benefit Change Adaptation Plan health workers on emergency package updated workforce obstetric & surgical care; • Automate CRVS system IFA counseling and other. • Conduct Data Quality • All regions have Information • Scale up Community Score Review assessment and developed and revolution Card (CSC) prepare plan of action to endorsed climate • Scale up of Community address the findings. change adaptation Based Health Insurance • Implement SARA/SPA plans (CBHI) and launching of SHI assessment regularly to • Strengthen DHIS2 data improve the availability of • Automate core quality and use of decision robust data for decision function of making making pharmaceutical supply agency 106. The total cost of HSTP II is US$21.89 billion for the next five years, while the available financial resources for the HSTP-II years is projected at $19.7 billion leaving US$3.4 billion (15%) gap. A significant part of this financing gap is for activities that would improve Reproductive, Maternal and Child health, and strengthen the health system with a focus on primary healthcare whose implementation requires US$2.4 billion. The RMNCH interventions are more detailed and elaborated under the Reproductive Health Strategic Plan (2021-2025) and other health system strengthening and primary health care related are given in the national equity and quality strategic plan; health extension revitalization road map, public health infrastructure roadmap and emergency health and nutrition plan which all are nested under the broader government program, HSTP II. The proposed operation will help to reduce the financing gap under the HSTP II and will specifically target the financing gap for maternal and child health services through the PforR operation; and health emergency disaster risk management and other system capacity building financing gap through the IPF component. 41 107. Based on the development partners resource mapping, the expenditure under the SDG PF is projected to be US$620 million from 2019/20 – 2024/25 (Figure 7). As stated in the country IHP+ Compact, the SDG PF is one of the Government’s preferred modalities for providing support to the sector, the others being sector budget support and the block grant system. SDG PF contributors commit resources on a three-year timeframe and support Maternal and Child Health priority gaps under the HSTP framework, upholding the principles of equity and quality. The JCF agrees on key priorities within wider sector planning discussions between MOH and partners. This multi-stakeholder platform also allows key stakeholders (Government, bilateral and multi-lateral financial agencies, foundations, civil society, private sector, etc.) to be involved in the discussions. The JCF is the highest governing body and serves as a joint forum for dialogue on sector policy and reform issues between the Government and key stakeholders and to oversee the implementation of the SDG PF, and other donor-supported projects. The Forum is chaired by the Minister of Health and co-chaired by the Chair of Health Nutrition and Population (HNP) Partners. 108. The number of DPs contributing to the SDG PF has increased to 13 with the inclusion of the Bill & Melinda Gates Foundation (BMGF) and Korea International Cooperation Agency (KOICA). In June 2021, the contributing Development Partners, Ministry of Finance, and MOH has jointly revised the Joint Financing Arrangement (JFA) to reflect the changing sector, country and global dynamics and attract more development partners to the pool fund. Accordingly, it is agreed that majority of the resources from the pool fund to focus on RMNCH service delivery at primary health care units, quality and equity in health service delivery and health system strengthening activities. During the HSTP I period, it is observed that there are high unliquidated advances at implementing entities level due to poor timely absorption of the resources and increased number of implementing entities which some of them are outside of the direct oversight and accountability line of the health sector. Hence, the revision of the JFA reiterated need to maintain majority SDG PF expenditures, which are derived from activities in the annual health sector comprehensive plan, at the federal level and for in kind transfer to sub-national levels and also to limit the implementing entities to MOH, Regional Health Bureau, and Agencies under the MOH. The development of the comprehensive plan is informed by the HSTP II targets for the respective year and annual woreda based indicative core plan which is a bottom-up planning process where priorities and gaps from the regional level are reflected. 42 Figure 7: SDGPF and HSTP Financing (US$ Million) 109. The SDG PF uses country systems for procurement and financial management, both of which have been successfully managed. SDG PF partners have a contributors’ dialogue platform, not only on the management of the pooled resources but also on health sector issues more broadly. SDG PF is part of the strong donor coordination and aid harmonization governance structures defined under the International Health Partnership Plus compact and previous Sector Strategies harmonization manual. Joint Financing Arrangement signed between the Government and SDG PF contributors sets out jointly agreed terms and procedures for SDG PF management. This includes planning, financial management, governance framework and decision-making, reporting, review and evaluation, audit and supply chain management. It also sets out the principle of aligning with the “one plan, one budget, one report� framework by using collectively agreed country -led arrangements for planning, execution and reporting. Signatories also use a common mechanism for any annual process of validation of the sector plan. Ethiopia’s SDG PF partners have committed to using the existing donor harmonization system and structures. There are no additional donor- specific requirements other than the Bank’s in terms of verification, the results framework and audit reports. 110. The cost of the government program (HSTP II) is estimated based on two scenarios, base case and high case, considering resource availability and targets to be achieved. Base case scenario considers existing interventions and similar investments to estimate targets and cost while the high case scenario requires additional investment such as expansion of infrastructure and pharmaceutical supply to achieve a higher target. Considering the macroeconomic impact of COVID-19 and the ongoing conflict on government’s ability to raise revenue from different sources and finance the government plan, the base case scenario for target setting with medium availability of financial resources is found to be the ideal scenario of financing the HSTP II. The medium case scenario projection assumes that government reprioritize health and increases the general 43 government health expenditure (GGHE) as a share of general government expenditure (GGE) by 2%, from 8% in 2020 to 10% in 2024. This scenario envisions a moderate decline in the share of out- of-pocket payment (OOP) for health services as a result of increased CBHI coverage and the start of Social Health Insurance at the fourth year of HSTP-II. External assistance is assumed to follow moderate declining trend, as observed in the development partners resource mapping (Table 5). Table 5: Available resource projection by source (US$ Billon) Financing Sources (US$ Billion) GC Government External Out-of- Health financing assistance Pocket (OOP) Insurance 2020/21 1.15 1.06 0.94 0.06 2021/22 1.38 1.06 0.99 0.06 2022/23 1.67 1.06 1.04 0.07 2023/24 2.03 1.06 1.09 0.15 2014/25 2.46 1.06 1.15 0.15 Total 8.69 5.31 5.21 0.49 111. The trend and composition financing health in Ethiopia have shown progress, but predictability and sustainability of financing remains to be the un-finished agenda. Although the HSTP I target of US$32.2 per capita health expenditure has been achieved, still it is far below the US$86 recommended by WHO to provide a basic package of health services in low-and-middle income countries. Economic growth remains the main driver of the domestic general government health expenditure and between 1999/00 and 2016/17, government spending as a share of total health expenditure has shown progress and filled the additional financing gap created due to decline in external resources during the period of 2014/15 -2019/20. Despite a low level of health expenditure relative to regional figures, the government program and strategies has led Ethiopia achieve a better health outcome than many Sub-Saharan African (SSA) countries. Ethiopia has a much higher level of health-adjusted life years (59 years) than many other countries that spend more or less the same amount as Ethiopia (such as Malawi and Benin) and even much higher than countries that spend more (Uganda, Tanzania, Burkina-Faso, and Togo). Likewise, Ethiopia has achieved a low IMR and MMR in view of its per capita current health expenditure of US$33. Because Ethiopia seems to be efficient for the given resources, spending more would certainly have a direct beneficial effect on health outcomes. The program aims to support the Government’s revised Health Financing Strategy (2020 -– 2024), in particular the roll out of CBHI and launch of Social Health Insurance which addresses a key concern in how health is financed. Overall, the program is deemed to be financially sustainable given the smaller percentage of the government’s overall program that it finances. Overtime, government’s expenditure on health is projected to increase as per its commitments under the HSTP II. 44 112. Government is giving priority to lower levels of primary health care (PHC) facilities (health centers and health posts) than hospital care, a sign of allocative efficiency. In 2016/17, the government allocated 49 percent of the public expenditure to health centers, health posts, and preventive health care facilities and 29 percent to public hospitals. While Ethiopia is facing a double burden of disease, the resource allocation is skewed toward communicable, maternal, neonatal, and nutritional diseases (CMNNDs). The disease burden (measured through DALY) associated with noncommunicable diseases and injuries has increased over time, from 26 percent in 2000 to 40 percent in 2017 while disease burden associated with CMNNDs has decreased from 74 percent in 2000 to 60 percent in 2017. 70 percent of total health expenditure goes to CMNNDs in 2016/17, which may be justified because CMNNDs are still the main cause of DALYs in 2017. However only 15 percent of expenditure is allocated to noncommunicable diseases and injuries, while disease burden associated to noncommunicable diseases and injuries increased to 40 percent in 2017, indicating that Ethiopia may need to spend more on prevention of noncommunicable diseases. 113. Although budget execution rates for government health spending (channel 1) have been high, there is room to improve the budget execution of both capital and recurrent non-salary expenditures. On average, between 2011/12 and 2015/16 budget execution of capital expenses were 89 percent at federal level, 64 percent at regional level, and 66 percent at woreda levels. These differences may be explained by weaknesses in the procurement process at regional level. Although budget execution of the salary budget line is close to 100 percent at all levels, non-salary recurrent expenditures are below 85 percent at the regional level but high at the federal level, perhaps because at the federal level the focus is more on capital than on recurrent expenditures. VII. Program Economic Evaluation Rationale for public sector intervention 114. The proposed operation is strongly justified in the case of Ethiopia on the grounds of equity. Public provision of activities directly supported by this PforR operation are justified on the grounds of equity, public good, externality, public sector reliance and efficiency, because the SDG PF targets financing gaps in priority areas including maternal health, child health, capacity building and health systems strengthening. Furthermore, DLIs are linked to public investment in key areas such as those dedicated to addressing inequity (Skilled Birth Attendance; CBHI, rural CPR, etc), with targets designed to make sure there will be concerted efforts to enhance coverage among the poor. 115. The use of public resources to address the project objectives is justified for the following reasons: i) The public sector is the main provider of health services in Ethiopia, but these facilities are severely underfunded and often understaffed. Wide socioeconomic and geographic inequities in access to services exist between and within regions, which cannot be addressed through the private sector. Investing in RMNCAH through strengthening the primary healthcare is not only a sound economic decision, but a moral issue that cannot be left to the private sector. ii) Some of the interventions proposed under the project such as vaccination have positive externalities. Providing these services through the free market may lead to under-supply, undermine herd immunity, and pose public health risks. 45 Health Sector Expenditure 116. Government health expenditure as a percent of total government expenditure has increased over the last years shifting from 4.5% in 2015/2016 to 7.2% in 2018/2019. Government health expenditures as share of total government expenditures has increased at regional level (8% to 12% from 2015/2016 to 2018/2019) while it has stagnated at 9% between 2015/2016 and 2017/18 according to the MoF expenditure report data. Despite variations between regions in terms of proportion of government spending on health, government health expenditures remain low (around $4 per capita) and the latest health PER has showed that those regions with lowest health service coverage (Somali, Oromia, SNNRPR, Amhara) may need to allocate a larger increase of government resources for health. The observed differences in per-capita government spending on health could stem from multiple factors, including the regional differences in prioritizing health, compliance with the national health priorities, the capacity of the respective health bureaus to make a case for more budgetary funds, differences in budget absorptive capacity, and the availability and magnitude of other external resources from channels 2 and 3. It is not surprising that the regions with the highest health service coverage indicators (Addis Ababa, Dire Dawa, Harari, Gambela, and BG) allocate more per-capita government funding to health than the four regions with lower health service coverage (Amhara, SNNPR, Oromia, Afar, and Somali). 117. In Ethiopia, the per capita total health expenditure has increased from US$5.6 in 1999/2000 to US$33.2 in 2016/17. However, it remains below the US$86 recommended by the WHO as needed to provide a basic package of health services. Generally, total health expenditure remains low and is largely financed by households and donors. External resources for health as a share of total health expenditure increased from 9 percent in 1995/96 to 50 percent in 2010/11 and then dropped to 35.2 percent in 2016/17. Out-of-pocket payments as a share of total health expenditure has also declined over time: from around 53 percent in 1995/96 to 30.6 percent in 2016/17. Meanwhile, the government’s contribution to total health expenditure dropped from 39 percent in 1995/96 to 32 percent in 2016/17. Other private funding as share of total health expenditure declined from 5 percent in 1999/00 to 2 percent in 2016/17 (Figure 8). 46 Figure 8: Available resource projection: HSTP II (2019/20 – 2021/22) 118. Government budget execution rate is fairly high but remain low for capital budget lines pointing to lost in efficiency resulting from limited capacity in planning, budgeting, and project management capacity at lower levels. As expected, execution rates for recurrent expenditure are high as the majority goes to salary payment (99, 97 and 98 percent at federal, regional, and woreda levels, respectively). Execution rate of capital expenditure at federal level has increased from 88 percent in 2013/14 to 94 percent in 2017/18, reflecting the heavy investment in infrastructure. Execution level for capital expenditure at the regional and woreda levels have been deteriorating between 2013/14 and 2017/18 from 75 to 41 percent at woreda level and from 78 to 71 percent at regional level. On average, over 5 years, capita budget execution was 63 percent at woreda level and 67 percent at regional level. Regional differences in budget execution for capital expenditure ranged from 27 percent in Gambela to over 90 percent in a number of regions, but execution rates for recurrent expenditure were high and more comparable across regions. Cost effectiveness of the Program 119. This operation focuses on strengthening the primary healthcare (PHC) system of the country for equitable and quality delivery of essential RMNNCHYA health services. There are powerful evidence suggests that primary health care (PHC), particularly primary care, can produce a range of economic benefits through its potential to improve health outcomes, health system efficiency and health equity. In 2019, the MOH has revised the list of essential health service package delivered at primary Healthcare Level. The revision of the interventions included under the essential health service package has centered on the cost effectiveness of those interventions. Figure 9 below shows that majority of the RMNNCHY are very cost effective, with an ACER value of less than US$200 per Healthy Life Years gained. By reducing maternal mortality and morbidity, women will be more productive in the labor force, will support their children through the critical development stages and contribute to other non-income generating activities. The effect of maternal mortality in GDP per capita has shown increment between 2005 and 2010. In 2010, it was 47 estimated that one maternal death in the African region reduced GDP by US$ 0.42 per capita per year 58 while in 2005 it was 0.32%. Figure 9: Cost effectiveness of Interventions in Ethiopia revised Essential Health Service Package. Project Development Impact 120. The World Health Organization estimates that annually 42 percent of women who give birth experience at least mild complications during pregnancy and 15 million women annually develop long-term disabilities attributable to pregnancy related complications. About 50 to 80 percent of pregnant women in developing countries develop acute health problems, and between 8 and 29 percent develop chronic health problems as a result of pregnancy. About 830 died from preventable causes related to pregnancy and childbirth every day. Approximately 99 percent of 58 Kirigia et al (2014). Indirect costs of maternal deaths in the WHO African region in 2010. BMC Pregnancy and Childbirth (14): 299 48 maternal deaths occur in developing countries and more than half occur in Sub- Saharan Africa. According to WHO, between 2000 and 2017, the MMR, number of maternal deaths per 100,000 live births) dropped by about 38% worldwide. 94% of all maternal deaths occur in low and lower middle-income countries. Young adolescents (ages 10-14) face a higher risk of complications and death as a result of pregnancy than other women. Skilled care before, during and after childbirth can save the lives of women and newborns. 121. Between 2000 and 2020, maternal, child and infant mortality rates has shown strong improvements between 2000 and 2020. In 2016, 412 out of 100,000 women die during pregnancy and childbirth, and 47 in 1,000 babies die before their first birthday. Neonatal mortality accounts for 67 percent of mortality in children under five years of age. Cost-effective interventions to reduce maternal and childhood deaths exist but they are not always available to those who need them most. The proposed program will contribute towards addressing these challenges, economic growth and development through the following pathways: • The project will contribute to improved child survival and development by supporting a range of high impact cost-effective interventions to address the major causes of child morbidity and mortality, including increasing vaccination coverage and nutrition interventions. A study showed that 28 percent of all child mortality in Ethiopia is associated with undernutrition; 16 percent of all repetitions in primary school are associated with stunting; stunted children achieve 1.1 years less in school education; child mortality associated with undernutrition has reduced Ethiopia’s workforce by 8percent; 67 percent of the adult population in Ethiopia suffered from stunting as children, and that the annual costs associated with child undernutrition are estimated at Ethiopian birr (ETB) 55.5 billion, which is equivalent to 16.5 percent of GDP. By addressing causes of childhood mortality, more children will survive into adulthood, will be healthier, have higher cognitive development, complete education and actively participate in the labor force. • Contributing to saving health care costs related to maternal and child morbidity. For every death, there are a number of women and children who survived, with long-term disability that require constant medical care. In addition, the high level of unmet need for family planning (which the project aims to address) leads to high incidence of unintended pregnancies and abortions (estimated as 101 per 1000). The most recent available data suggests and increase in the number of induced abortions from 382,000 in 2008 to 620, 296 in 2014 About 52,600 and 103,648 women were treated for abortion related complications in 2008 and 2014 respectively. Reducing unplanned births potentially saves public spending on social services, contributing to social and economic development. • The project will contribute towards long-term economic benefit in the form of high GDP arising from increased labor force participation and productivity. Healthier communities give rise to increasing investment in human and physical capital, generating higher rates of economic growth. By reducing maternal mortality and morbidity, women will be more productive in the labor force, will support their children through the critical development stages and contribute to other non-income generating activities. It is estimated that one maternal death in the African region reduced GDP by US$ 0.42 per capita per year. In addition, indirect costs of maternal deaths in Africa amounted to US$ 4.5 billion in 2010. With the high number of maternal deaths in Ethiopia, the costs of maternal deaths to the economy can be substantial. 49 Value Added of World Bank and Partners support to the Government Program 122. The Bank and partners bring the following additional value in support of the Government’s HSTP: (i) Technical expertise and international experience in supporting health systems strengthening; reforms in health care financing, strengthening PHC approach and roll out and strengthening of CRVS; (ii) its strong track record in mobilization of resources and working in harmonized partnerships; iii) capacity in fiduciary management which in the context of a PforR helps to strengthen the overall system. Health Financing The trend and level of total health expenditure in Ethiopia have shown progress, but still remains low to achieve the UHCs and the domestic contribution is to improve. The Government’s ambitions for UHC are hindered by low levels of health financing. Although the HSTP I target of US$32.2 per capita health expenditure has been achieved (Figure 10), still it is far below the US$86 recommended by WHO to provide a basic package of health services in low-and-middle income countries. Between 1999/00 and 2016/17, government spending reached only 33 percent of Total Health Expenditure, whereas external source and households’ out-of-pocket expenditure accounted for 35 and 31 percent, respectively. The share of other sources, mainly CBHI, has reached 2% in 2016/17. In 2019, 20% of the population is covered by CBHI which is a marked increase from a baseline of 1.2% in 2015. One should note that this increase did not contribute much to the reduction of the existing high household out of pocket payments. Indeed, the main uptake in CBHI enrolment happened between 2017 and 2019 which was not covered by the 2016/17 National Health Account (NHA) assessment. 123. In 2016/17, the share of out-of-pocket payment in the total health expenditure is less than the Sub-Saharan Africa countries. These are above the average for sub-Saharan Africa and, present a major barrier to access for the poor and millions of people are at risk of health-related financial impoverishment. Cost of drug accounted for 45 percent of total outpatient health spending and 43 percent of inpatient health spending. Among the poorest households, cost is the main impediment to health service utilization, and purchase of drug as the main drivers of out-of-pocket (OOP) expenses. 124. According to the 2015/16 Ethiopia Health Accounts Household Health Service Utilization and Expenditure Survey (FoMH 2017a), lack of money is the primary reason households do not seek care when sick. Regression analysis confirms that socioeconomic status is a key determinant of health-seeking behavior. Individuals in the richest households are almost twice more likely than those in the poorest households to consult a health care provider when sick. In Ethiopia, the rate of catastrophic health expenditures has slightly increased over time, from 2 percent in 2011 to 2.2 percent in 2015 and according to econometrics analysis, the main drivers of catastrophic health expenditure are being poor (households in the poorest quintiles are almost 60 percent more likely than those in the richer quintiles to incur them), having an elderly household member, and living in an urban area. Figure 10: Total health expenditure by funding source, 1995/96–2016/17 50 125. A recent CBHI impact assessment indicated that CBHI membership decreased the incidence of catastrophic health spending and narrowed socio-economic disparities in health service utilization. PSM estimates showed that CBHI membership results in a 28–43% reduction in annual OOP payments as compared to non-member households and CBHI member households were significantly less likely to incur catastrophic health expenditures. In general, health service utilization is higher among households with better socio-economic status. CBHI seems to have reduced this socio-economic disparity in health service utilization. The health service utilization concentration index was 0.02 in CBHI woredas, as compared to 0.09 in non-CBHI woredas (p < 0.001). in contrast to the general population, financial barriers were less a reason (35%) for not seeking care for CBHI member households who failed to seek care after an illness, compared to non-member households (64%). 126. Economic growth remains the main driver of the domestic general government health expenditure. Health expenditures increased annually at a rate of 4 percent between 2000 and 2015, even after adjusting for population growth and inflation. The increase in public spending on health was driven mainly by economic growth—5.2 percent a year on average. By contrast, the average change in the domestic general government health expenditure as a share of the general government expenditure has remained flat between 2000 and 2015 indicating that health is less prioritized in the general government budget. The level of public revenues has also not been conducive to a higher public health expenditure because of the low tax revenue-to-GDP ratio. Thus, the change in aggregate public spending contributed very minimally (1.6 percent) to the annual growth of the domestic health expenditure between 2000 and 2015. This demonstrates that, on average, major contributor to higher budgetary health expenditure was economic growth. 51 Figure 11: Public Health Expenditure as share of total public expenditure by region (2010/11 – 2016/17) 127. Despite a low level of health expenditure relative to regional figures, Ethiopia is achieving better health outcomes than many Sub-Saharan African (SSA) countries. Ethiopia has a much higher level of health-adjusted life years (59 years) than many other countries that spend more or less the same amount as Ethiopia (such as Malawi and Benin) and even much higher than countries that spend more (Uganda, Tanzania, Burkina-Faso, and Togo). Likewise, Ethiopia has achieved a low Infant Morality Rate (MMR) and MMR in view of its per capita current health expenditure of US$33. Because Ethiopia seems to be efficient for the given resources, spending more would certainly have a direct beneficial effect on health outcomes. 128. Additionally, the government is giving priority to lower levels of primary health care (PHC) facilities (health centers and health posts) than hospital care, a sign of allocative efficiency. In 2016/17, the government allocated 49 percent of the public expenditure to health centers, health posts, and preventive health care facilities and 29 percent to public hospitals. While Ethiopia is facing a double burden of disease, the resource allocation is skewed toward communicable, maternal, neonatal, and nutritional diseases (CMNNDs). The disease burden (measured through DALY) associated with noncommunicable diseases and injuries has increased over time, from 26 percent in 2000 to 40 percent in 2017 while disease burden associated with CMNNDs has decreased from 74 percent in 2000 to 60 percent in 2017. 70 percent of total health expenditure goes to CMNNDs in 2016/17, which may be justified because CMNNDs are still the main cause of DALYs in 2017. However only 15 percent of expenditure is allocated to noncommunicable diseases and injuries, while disease burden associated to noncommunicable diseases and injuries increased to 52 40 percent in 2017, indicating that Ethiopia may need to spend more on prevention of noncommunicable diseases. 129. Although budget execution rates for government health spending (channel 1) have been high, there is room to improve the budget execution of both capital and recurrent non-salary expenditures. On average, between 2011/12 and 2015/16 budget execution of capital expenses were 89 percent at federal level, 64 percent at regional level, and 66 percent at woreda levels. These differences may be explained by weaknesses in the procurement process at regional level. External funding as a share of total health expenditure has dropped significantly between 2010/11 (50 percent) and 2013/14 (34 percent). Health expenditure remains dependent on external sources,59 and while progress has been made in harmonizing donor support through the SDG PF, a large proportion of channel 3 funds is for specific diseases (Malaria, HIV/AIDs/ Tuberculosis) remains off-budget. 130. Recurrent health expenditure has almost doubled over the last four years. Although expenditures on capital investment have increased at a much slower rate than recurrent expenditures, they have also declined since 2016. Recurrent expenditures increased by 12 times, in nominal terms, between 2000 and 2017 whereas capital expenditures increased by 24 times between 200during the same period. This trend can be explained by the development of the Ethiopian health sector which passed through several phases, infrastructure development followed by deployment human resource and functionality of health facilities. 131. Whereas expenditures on capital investment have increased at a much slower rate than recurrent expenditure, it has also started to decline from 2013/14 to 2016/2017. This could be an indication that there is a shift from expansion of infrastructure to service provision and operations. This will require a further disaggregation and analysis to assess trends in the non-salary portion of the recurrent expenditure. In line with the decentralized service provision arrangements, a substantial portion of the health expenditure is incurred by subnational governments, i.e. regional states and woreda councils. For the years 2011/12 to 2013/14, on average, 95 percent of the recurrent and 75 percent of the capital health expenditure is regional (this includes Woreda) and between 2014/15 and 2016/17, the share of the capital expenditure started to drop at the regional level. Budget execution rate is fairly high with over 93 percent for recurrent and over 75 percent for capital budget. Execution rate at the federal level is slightly higher compared to the regional levels. 59 Ethiopia’s Fifth National Health Accounts, 2013/2014. Forthcoming. 53 Figure 12: Trends in Recurrent and Capital Expenditure 132. External funding through channel 2 (managed by MOH) and channel 3 (managed by other implementing partners) is substantial part of the health financing. Expenditure through channel 2 has been close to US$500 million annually since 2011/12 of which over US$120 million is the SDG PF, which is targeted to financing reproductive, maternal and child health programs. Expenditure through channel 3, implemented by various implementing partners, has continued to be substantial at annual average of over US$250 million. A Changing Health Financing Architecture 133. The Sector Strategy describes the country’s ambitions to achieve Universal Health Coverage using a combination of health systems strengthening and financial protection measures to cover the majority of households. The Government has developed a Health Financing Strategy (2020-2030), which proposes a major shift in the health financing architecture. The overall objective of the HCFS is to accelerate Ethiopia’s progress toward UHC by defining a ‘framework for strategic actions’ to enable Ethiopians to achieve the best health outcomes, financial protection against catastrophic illness, and satisfaction in the health system that is comparable to LMICs by 2025, and upper middle-income countries by 2035. The HCF strategy has included five strategic objectives: i) mobilize adequate resources, through traditional and innovative approaches, from domestic and external sources; ii) reduce OOP spending at the point of use; iii) enhance efficiency and effectiveness; iv) strengthen public-private partnership; and v) develop capacity for improved HCF. 54 134. The Strategy proposes a major shift in the health financing architecture, away from out-of- pocket payments to health insurance for all Ethiopians and a reliance on domestic resource for health. Through support from the WB, the Ethiopia health insurance agency, has conducted the assessment of possible CBHI design for the pastoralist community and political economy and financial feasibility of social health insurance (SHI) in Ethiopia. Based on these evidences, preparation is underway to launch CBHI design for the pastoralist communities and SHI for the formal sector is part of the coming five-year plan of the agency. 135. The Government’s UHC agenda aims to ensure that sector financing transitions from the one based on donor financing to a domestic financed and sustainable sector. This requires a shift in various aspects, including: developing an annual plan for the Health Care Financing strategy, rolling out of CBHI and Social Health Insurance; building institutions and capacity in health insurance functions such as purchasing, targeting, resource mobilization, economic analysis, health care management, financing, at all levels; and engaging the private sector and civil society organizations in support of the efforts of mobilizing domestic financing and improving access to quality health services. The Government is already implementing select areas of the draft Health Care Financing Strategy while refining remaining areas to be rolled out later. 136. The HSTP-II is the next five-year national health sector strategic plan, which covers the period between 2013–2017 Ethiopian fiscal years (July 2020–June 2025). During this strategic period, the sector envisions building on the successes and consolidating the gains of HSTP-I to build a resilient, sustainable, high-quality, equity-based health system. Thus, the preparation of HSTP-II was informed by in-depth situational analysis of the performance of the health sector during HSTP- I. The plan also took into account the nation’s long-term socioeconomic strategic directions and priorities, the global situation and country’s commitments to sustainable development goals, and the dynamics of social determinants of health. 137. The Government has shown continued commitment to improve the health of its population as a core pillar of the overall country development process. The contribution of the sector towards national socioeconomic development is critical, as equitable human development well-being relies on the health status and well-being of individuals and communities. In line with the lesson from the implementation of HSTP I, HSTP II identifies key challenges facing the sector and strategies to address systemic bottlenecks and sets out ambitious targets on key health outcomes. The HSTP II has defined a results chain linking the inputs to the outcomes envisaged and how these outcomes contribute to the Sustainable Development Goals and government wide socio-economic growth and transformation. A cornerstone of HSTP II is the focus on quality and equity- planned as an iterative process requiring careful supportive supervision and tracking of performance. 138. The HSTP II establishes goals in terms of improving equity, coverage and utilization of essential health services, quality of health care, financial sustainability, and enhancing implementation capacity of the health sector at all levels of the system. The HSTP II renews the strong priority given to Reproductive, Maternal, and Child Health and Nutrition. It sets ambitious targets for nutrition, maternal and child health outcomes to be achieved by 2025, which would ensure it is on track to achieve its commitments under the SDG agenda. High impact interventions of Reproductive Maternal and Child Health, nutrition, prevention and control of communicable and non-communicable diseases were identified and prioritized to help achieve the set outcomes. The 55 overall objective of HSTP-II is to improve the health status of the population–by accelerating progress towards universal health coverage, protecting populations during health emergencies, transforming woredas, and improving the health system’s responsiveness. Costing of the Government Program 139. The costing of the Program was prepared under two scenarios: i) The base case scenario costing assumes achievement of comparatively more modest but realistic targets set in Government Program for the coming five years; and ii) The high-case scenario which has more ambitious targets and requires much higher human resources capacity and infrastructure requiring higher investment.60 140. The HSTP is the Government’s costed program with well-defined set targets to be achieved between 2019/20-2024/25. The financing needed to reach targets was calculated under two scenarios: i) The base case scenario costing assumes achievement of comparatively more modest but realistic targets set in Government Program for the coming five years; and ii) The high case scenario which has more ambitious targets and requires much higher human resources capacity and infrastructure requiring higher investment. MMR expected to decline from 401 to 279 and 220 per 100,000 live births in 2024, in base case and high case scenario, respectively. Achieving MMR SDG target of 140 per 100,000 live births requires to follow the high case which require increasing the coverage of high-impact interventions and mobilization of more resources. Similarly, under 5- mortality rate needs to decline from 59 in 2019 to 44 and 36 per 1,000 live births in 2024 in base case and high case scenarios, respectively. 141. Under the base case scenario, the total cost of implementing the Government Program between 2019/20 and 2024/25 is an estimated US$22 billion; while under the high case scenario the cost is US$27.5 billion. The difference between the two estimates is due to the higher costs of infrastructure; human resources and medicines supply under the high case scenario. In both scenarios, more than 45% of the total cost is to cover medicines, supplies and other pharmaceutical products. Projected Government allocation to its program is US$7.5 billion, Development Assistance is US$5.3 billion, Household out of pocket contribution US$5.61 billion and Health Insurance US$ 280 million and there is an estimated gap of US$3.2 billion under the base cost scenario. 142. The Government has identified various mechanisms to address the financing gap under its Program. This includes the roll out of social health insurance schemes and expansion of the CBHI to pastoralist areas. As part of its Health Financing Strategy, the Government is also exploring innovating financing mechanisms; enhancing efficiency especially on procurement, supply management and human resources productivity, evidence-based planning, performance-based financing and strengthening multi-sectorial approach to address the existing financing gap. 56