Creating Resilient PHC System:
Lessons from Covid -19 Response in
Ethiopia and Beyond
Module 1: Describing the fundamental principles of
PHC and explaining the structure and major functions
of Ethiopia’s
HEP
Overview: This section will provide a foundation of the origins and key principles of
PHC as well as an overview of the structure of Ethiopia’s health system, in particular
the HEP.
Learning Objectives: Upon completion of this section, you will:
● Describe fundamental principles of PHC
● Summarize major changes in the vision for PHC over recent decades
● Explain the structure and major functions of Ethiopia’s HEP
● Identify the successes and evolving challenges of Ethiopia’s HEP
Introduction
National responses to the corona virus disease 2019 (COVID-19) have tested the
strength of primary health care (PHC) systems throughout the world. It may be
through this PHC system that patients visit or consult trusted providers for medical
advice and presentation concerning symptoms. PHC systems may also lend a critical
framework for governments to implement large-scale testing and public health
communications efforts in the wake of COVID-19.
The Declaration of Alma-Ata, Health for All, and Universal Health
Coverage (UHC)
The Declaration of Alma-Ata, a set of principles affirmed during the International
Conference on PHC in 1978, formally adopted PHC as the means for achieving
Health for All through comprehensive, universally accessible, equitable and affordable
health care services for everyone in all countries (Hall & Taylor, 2003). The
Declaration was indeed a paradigm shift away from the Western facility-based
curative model of health care that had dominated the developing world up to that
time. The core principles of the PHC approach included (WHO, 2003):
● Universal access to basic and essential care;
● Commitment to health equity (giving priority to those in greatest
need) as part of development that promotes social justice;
● Community participation in defining and implementing health agendas;
● Intersectoral approaches to health (affirming the importance of
nutrition, clean water and sanitation, and education to good health)
The Alma-Ata PHC approach takes into account the need for a broader approach to
the improvement of health beyond simply the provision of curative medical care, as
shown in the following eight priorities of PHC defined in the Declaration of
Alma-Ata in 1978 (WHO, 2003).
1. Promotion of food supply and proper nutrition
2. An adequate supply of safe water, basic sanitation
3. Maternal and child care, including family planning
4. Immunization
5. Prevention and control of locally endemic disease
6. Health education concerning prevailing health problems, and methods
of prevention/control
7. Treatment for common diseases and injuries
8. Provision of essential drugs
While the Alma-Ata approach to health discussed in the Declaration of Alma-Ata
looks beyond solely curative care, curative care is still part of a comprehensive
approach to health that encompasses promotion, prevention, treatment (curative
care) and rehabilitation.
The Declaration of Alma-Ata calls for both selective services (immunizations and
family planning, for instance) together with comprehensive services (treatment of
common diseases and injuries) that are part of a functional referral system. (WHO,
2003)
Primary Health Care and the Health System Building Blocks
The Declaration of Astana on Primary Health Care and the accompanying Vision for
Primary Health Care in the 21st Century reinforce the commitment of countries and
international partners to make concerted efforts to orient health systems towards
primary health care (PHC) for accelerated progress on universal health coverage and
the health-related Sustainable Development Goals (SDGs).
The Vision for Primary Health Care in the 21st Century described the three
components of PHC, that is, “what” needs to be delivered, and also proposed a set
of levers to help countries to advance across the components of PHC. Expanding on
the health system building blocks, these levers address key elements of the health
system that can be used to accelerate progress on PHC. Of note, they do not repeat
the technical or programme aspects of PHC in the Vision for Primary Health Care in
the 21st Century. (WHO, 2020)
Although all levers are interdependent and interrelated, the levers are separated into
ones that primarily function at the core strategic and operational levels. Core
strategic levers can pave the way for actions around other levers, but any sustainable
improvement around the operational levers is unlikely without a strong grounding in
the strategic levers. Actions and interventions around each lever are thus not
intended to be carried out independently, but should be mutually and
comprehensively considered throughout inclusive national health planning processes.
The following Table summarizes the levers.
TABLE : OVERVIEW OF PRIMARY HEALTH CARE LEVERS (WHO, 2020)
Title Full Description
Core Strategic Levers
Political commitment and leadership Political commitment and leadership
that place PHC at the heart of efforts to
achieve universal health coverage and
recognize the broad contribution of
PHC to the SDGs
Governance and policy frameworks Governance structures, policy
frameworks and regulations in support
of PHC that build partnerships within
and across sectors, and promote
community leadership and mutual
accountability
Funding and allocation of resources Adequate financing for PHC that is
mobilized and allocated to minimize
financial hardship, promote equity and
enable high-quality care and services
Engagement of community and other Engagement of communities and other
stakeholders stakeholders from all sectors to define
problems and solutions and prioritize
actions through policy dialogue
Operational Levers
Models of care Models of care that promote
high-quality, people-centered primary
care and essential public health
functions as the core of integrated
health services throughout the course
of life
Primary health care workforce Adequate quantity, competency levels
and distribution of a committed
multidisciplinary primary healthcare
workforce that includes facility-,
outreach-, and community-based health
workers supported through effective
management supervision and
appropriate compensation
Physical infrastructure Secure and accessible primary care
facilities to provide effective services
with reliable water, sanitation and waste
disposal/recycling, telecommunications
connectivity and a power supply,
including transport systems that can
connect patients to other care
providers
Medicines and other health products Availability and affordability of
appropriate, safe, effective, quality
medicines and other health products
through transparent processes to
improve health
Engagement with private sector Sound partnership between public and
providers private sectors for the delivery of
integrated health services
Purchasing and payment systems Purchasing and payment systems that
foster a reorientation in models of care
towards prevention and promotion and
towards care delivered closer to where
people live and work. Such systems
provide incentives for the delivery of
high-quality primary care services and
facilitate integration and coordination
across the continuum of care
Digital technologies for health Use of digital technologies for health in
ways that facilitate access to care and
service delivery, improve effectiveness
and efficiency, and promote
accountability
Systems for improving the quality of Systems at the local, subnational and
care national levels to continuously assess
and improve the quality of integrated
health services
Primary health care-oriented research Research and knowledge management,
including dissemination of lessons
learned, as well as the use of knowledge
to accelerate the scale-up of successful
strategies to strengthen PHC-oriented
systems
Monitoring and evaluation Monitoring and evaluation through
well-functioning health information
systems that generate reliable data and
support the use of information for
improved decision-making and learning
by local, national and global actors
Overview of PHC in Ethiopia’s Health System
While PHC is now the foundation of Ethiopia’s health care system, this was not
always the case. In 1972, 92% of government expenditure for health care was
allocated for hospitals, with most being spent in large cities.
For example, Addis Ababa and Asmara spent an estimated 22 and 12 times more,
respectively, per capita than the rest of the country (Kloos, 1998). This changed in
1993, with PHC taking a central role in Ethiopia’s health system as a result of it being
integrated into health policy, a change since health policies were highly influenced by
physicians who were focused on highly specialized, curative care.
Launch of Ethiopia’s Health Extension Program (HEP)
The Health Extension Program (HEP) is one of the strategies aimed at expanding the
reach of PHC services to the community and household levels. The HEP focuses on
disease prevention and health promotion through a package of services executed by
full-time, salaried and trained community health extension workers (HEWs). Since its
launch in 2003, the HEP has become the hallmark of the Ethiopian PHC system,
delivered by 40,000 HEWs deployed in 16,440 health posts (FMOH, 2015).
The Essential Health Service Package
Launched in 2005, the Essential Health Service Package (EHSP) comprises preventive,
promotive, curative, and rehabilitative services, with a major focus on PHC. This
package of services is intended to be available to everyone in the population through
the government’s various service delivery strategies and facilities.
The EHSP is organized into five major components that are somewhat different from
HEP, giving slightly more emphasis to curative care: family health services,
communicable disease prevention, and control services, hygiene and environmental
health services, health education and communication services, basic curative care,
and treatment of major chronic conditions (FMOH, 2005). The EHSP is currently
under revision in response to the changing epidemiological landscape in Ethiopia and
ongoing changes in the health system.
The MOH has recently added two more packages - mental health and
non-communicable diseases - to keep up with the growing importance of these
health problems in the Ethiopian population.
Reorganization of the Tier System
A reorganization of the health system from six-tiers to three-tiers began in 2010,
giving special attention to PHC and the delivery of a balanced mix of promotive,
preventative, curative, and rehabilitative services (Figure 1).
Figure 2: Ethiopia’s three-tier health system along with the population size it sees.
Tertiary level
Specialized hospital (3.5 – 5 million people)
care
Secondary level
General hospital (1.0 – 1.5 million people)
care
Urban Rural
Health center (each serving 40,000 Primary hospital Primary level
people) 60,000 – 100,000 care
people
Health post (each serving 3,000 – 5,000
people) Health center
15,000 – 25,000
people
Health post
3,000 – 5,000 people
Source: Federal Ministry of Health, 2012
In rural areas, each woreda should ideally have one primary hospital, 4-5 health
centers, 20-25 health posts, 40 - 50 HEWs, and around 4,000 Health Development
Army (HDA) volunteers, serving a population of approximately 100,000 people. PHC
is delivered at the home and through these health posts, health centers, and primary
hospitals, with HDA volunteers providing health promotion and referrals.
Health Development Army (HDA)
Working under the guidance of HEWs, the HDA volunteers offer services related to
community mobilization and health promotion (Exemplars in Global Health, 2020).
They provide an effective mechanism for linking every household in every community
with PHC services and for providing peer support to mothers in each household for
the uptake of household behaviors to improve maternal and child health services and
to improve household hygiene and sanitation.
Successes, Challenges and Lessons Learned from Ethiopia’s PHC System
Ethiopia’s investment in PHC in the past years has paid dividends. Significant
improvements have been made in maternal and child health indicators.
Mainly driven by making readily available to rural households and communities the
delivery of a package of basic and essential promotive, preventive, and curative health
services. The HEP is central to these improvements through its implementation of
high-impact and cost-effective interventions, such as improving sanitation and
personal hygiene, immunizations, family planning, prevention and treatment of
malaria, and treatment of diarrhea and pneumonia in children younger than five years
of age.
Ethiopia’s effort to expand PHC services has not been devoid of challenges. Most
notable has been the inability to fulfill human, material and infrastructure needs at
the pace with which the rapid expansion of PHC facilities was occurring. Other
challenges include: limited coverage of improved water and sanitation services, a high
burden of neglected tropical diseases such as trachoma and soil-transmitted
helminths (STH), a growing burden of non-communicable diseases, limitations in the
quality of health care services, the lack of water and electricity for many PHC
facilities, supply chain bottlenecks, inadequate data quality, and use, and gaps in
leadership and management.
To address these challenges, the government has made substantial investments in the
production and deployment of mid-level health professionals and community-based
HEWs. Also, a revolving drug fund was established and a parastatal entity—the
Ethiopian Pharmaceuticals Supply Agency (EPSA) has been set up to improve
efficiency in the procurement and delivery of health commodities, with encouraging
results.
Important lessons can be drawn from Ethiopia’s experience with PHC. Among the
key ingredients for Ethiopia’s success have been strong political will and commitment,
substantial investment in health care infrastructure and midlevel and community
health care workers, community mobilization and engagement, leveraging vertical
programs for building stronger health systems, and building capacity at the
decentralized woreda level.
Quizzes
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