National Primary Health

Care Strategic Framework:

2024-2030

December 2024
Addis Ababa, Ethiopia
National Primary Health
Care Strategic Framework:
2024-2030

December 2024
Addis Ababa, Ethiopia
Contents
I. Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V

II. Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI

III. Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII

IV. Key Message. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VIII

List of major contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IX

Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1. Country Context. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2. Evolution of PHC in Ethiopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.3. Burden of diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.4 Ethiopia’s Health Service Delivery Structural Arrangement . . . . . . . . . . . . . . . . . 5

2. Situation Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.1. Political, economic, and social environment analysis. . . . . . . . . . . . . . . . . . . . 6

2.2. Health System Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.2.1. Leadership, Governance and Multisectoral collaboration: . . . . . . . . . . . . . . . 8

2.2.2. PHC Financing: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2.2.3. Adjustment to Population Health need: . . . . . . . . . . . . . . . . . . . . . . 11

2.3. Health System Inputs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2.3.1. Medicines and other health products . . . . . . . . . . . . . . . . . . . . . . . 11

2.3.2. Health Infrastructure: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2.3.3. Human Resource for Health (HRH): . . . . . . . . . . . . . . . . . . . . . . . . 13

2.3.4. Health Information System: . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

2.3.5. Digital Health Technology: . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

2.4. Service delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

2.5. Community engagement and empowerment: . . . . . . . . . . . . . . . . . . . . . . 18

2.6. Public health emergency preparedness and response. . . . . . . . . . . . . . . . . . . 19

3. Rationale for the development of the National PHC Strategic Framework . . . . . . . . . . . 21

4. PHC Strategic Framework Development Processes and Methods. . . . . . . . . . . . . . . 21

5. Definition of Primary Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

6. Scope of the PHC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

7. Vision, Mission, and Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . 23

8. Theory of change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

9. Goal of the PHC Strategic Framework . . . . . . . . . . . . . . . . . . . . . . . . . . 25

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 III

 10. Strategic Objectives and major Interventions . . . . . . . . . . . . . . . . . . . . . . . 25

10.1. Strategic Objective 1: Enhance the functionality of leadership, governance and multisectoral action

for PHC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

10.2 Strategic Objective 2: Optimize Sustainable PHC financing . . . . . . . . . . . . . . . . 27

10.3 Strategic Objective 3: Improve infrastructure of health facilities . . . . . . . . . . . . . . 28

10.4. Strategic objectives 4: Improve Health Workforce development and management for PHC. . 29

10.5. Strategic objective 5: Improve availability of Medicine and medical technologies . . . . . . 30

10.6. Strategic objective 6. Enhance digital health use. . . . . . . . . . . . . . . . . . . . . 31

10.7. Strategic objective 7: Optimize Health Information Systems . . . . . . . . . . . . . . . . 32

10.8. Strategic objective 8. Improve access, quality, and equity of PHC services at all levels. . . . 33

10.9. Strategic Objective 9. Improve PHEM system . . . . . . . . . . . . . . . . . . . . . 34

10.10. Strategic Objective 10: Enhance community engagement and empowerment . . . . . . . . 35

11. Implementation arrangement of the Framework . . . . . . . . . . . . . . . . . . . . . . 37

11.1. PHC Governance:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

11.2. Integrated implementation: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

11.3 Multi-sectoral policy and actions: . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

11.4. Private health sector engagement: . . . . . . . . . . . . . . . . . . . . . . . . . . 37

12. Monitoring, Evaluation and Learning. . . . . . . . . . . . . . . . . . . . . . . . . . . 38

12.1. Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

12.2. Data Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

12.3. Routine Monitoring of PHC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

12.4. Health Facility Assessments: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

12.5. PHC Dashboard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

12.6. Primary Health Care Review Meeting. . . . . . . . . . . . . . . . . . . . . . . . . 40

13. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

14. Annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

IV NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

I. Acronyms
ANC Antenatal Care JSI John Snow Inc

AYH Adolescent and youth health KII Key Informant Interview

BHS Basic Health Service LEO Lead Executive Officer

BHP Basic Health post LIP Leadership incubation Program

CBHI Community Based Health Insurance LMG Leadership, Management and Governance

CBRHA Community based Reproductive Health Agent LMICS Low Middle-income countries

CHA Community Health Agent LNOB Leave no one behind

CHIS Community health Information System MDG Millennium development Goal

CHP Comprehensive Health Post MFR Master Facility register

CHW Community Health Worker MOE Ministry of Education

CMNN Communicable, Maternal, Newborn and Nutrition MOH Ministry of Health

COVID-19 Corona Virus Infection Disease-2019 NBE National Bank of Ethiopia

CPD Continuous Professional Development NCD Non-communicable Diseases

CSA Central Statistics Authority NGO Non-Government Organization

DALY Disability Adjusted Life Year NHA National Health account

DHIS District Health Information System OOP Out of Pocket

DHS Demographic and Health Survey PEST Politics, Economy, Social and technology

eCHIS electronic Community health Information System PHC Primary Health care

eLMIS electronic Logistics Management Information System PHCSF Primary Health care strategic Framework

eHRIS electronic Human Resources Information System PHCU Primary Health care unit

EHIA Ethiopian Health Insurance Agency RDQA Random Data Quality Assurance

EHSP Essential Health Service package RHB Regional health Bureau

EPI Expanded Program on Immunization RMNCH Reproductive, Maternal, New-born and Child Health

EPHI Ethiopian Public Health Institute SARA Service Availability and readiness Assessment

EPHA Ethiopian Public Health Association SDG Sustainable Development Goal

FDRE Federal Democratic Republic of Ethiopia STI Sexually Transmitted infection

FP Family Planning SSA South Saharan Africa

GDP Gross Domestic Product TGE Transitional Government of Ethiopia

HC Health Center THE Total Health Expenditure

HEP Health Extension Program TOC Theory of Change

HEW Health Extension Worker TTBA Trained Traditional Birth attendant

HIS Health Information System TWG Technical Working Group

HMIS Health Management Information System UHC Universal Health Coverage

HP Health Post UN United Nations

HSDP Health Sector Development Plan UNICEF United Nations Children’s Fund

HSTP Health Sector transformation Plan USAID United States Aids for International Development

ICT Information Communication Technology USD United States Dollar

IDP Internally Displaced People WASH Water, Sanitation and Hygiene

IPHC-E International Primary Health care- Ethiopia WDA Women development Army

IRT Integrated refresher Training WHO World Health organization

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 V

 II. Foreword
The third health policy hailed as a Primary Health Care focused,
issued in 1993 and still in effect, was developed, considering the
scope, nature, and magnitude of existing health problems. The
focus of the policy is to address the major communicable diseases,
nutritional problems, maternal and child health issues. The policy
has contributed towards the improvement of health status of the
population, particularly, maternal and child health and reduction
of morbidity and mortality due to communicable diseases by
building a comprehensive primary health care system that focuses
on disease prevention, including the introduction and rollout of
the national flagship program, the Health Extension Program. As
a result, Ethiopia has registered remarkable achievements in the
health sector in the last three decades, including elimination of
neonatal tetanus; a decline in Under 5 mortalities from 166 per
1000 to 67 per 1000 in 2016 and 55 per 1000 in 2019.

Moreover, institutional delivery and acceptance of antenatal care (ANC) has gone up from 5% and 28% in
2005 to 48% and 74% in 2019, respectively. Stunting has also gone down from 51per cent in 2005 to 39per
cent in 2022 in children under five years of age (EPHI, 2023). According to the latest UN (United Nations)
estimates, the MMR has reached a record low (267/ 100,000 Live Births. The country has also registered
notable success in reversing the public health impact of major communicable diseases by reducing deaths
from malaria and HIV by 92% and 90%, respectively.

As a signatory to the Alma Ata Declaration and UN political declaration on universal health coverage
(UHC), Ethiopia is committed to achieving UHC through primary health care (PHC). This has led to growing
investment to expand health services, infrastructure, and the workforce. Improved availability of essential
health commodities and medical equipment, and increased health literacy through community engagement
platforms. Specially, the introduction of HEP has significantly improved access to PHC services.

However, the UHC index remains at 43.7% (2019). Besides, the emergence of new public health emergencies
like COVID-19 has been a signal to invest more in our health systems to create a resilient PHC system
which ensures the strength and sustainability of essential health care services. The epidemiological shifts,
demographic changes and fast-moving technological advancement will also call for mobilizing all our efforts
towards realizing a resilient PHC that accelerates the attainment of health-related Sustainable Development
Goals (SDGs). As a result, it is an opportune time to develop a national PHC strategic framework that serves as
an overarching document to strengthen PHC in Ethiopia. This strategic framework has various directions and
expected outcomes to address the major challenges of the PHC. It is purposefully aligned with the national
health policy, Visioning Ethiopia’s path towards UHC through PHC, Ethiopia’s ten-year development plan and
other relevant international milestones including the sustainable development goals (SDG).

The Ministry of Health wants to extend its compliments to those individuals and organizations that have used
their precious time and resources to realize this critical document. Moving forward, I would like to ask all
partners, governmental and non-governmental organizations, funding agencies and others who have roles in
the PHC, to use this framework as the exclusive source for strategic planning and collaboration.

Mekdes Daba, (MD, MPH)

Minister, Ministry of Health-Ethiopia

VI NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

III. Acknowledgement
Ethiopia has been implementing a pro-primary health care
health policy for the last three decades. By making PHC
central to the agenda of all stakeholders, the country has
scored an encouraging achievement in improving the health
of its citizens. The achievements are attributed to the access
created through expansion of PHC services, introduction of
the health extension program, the efforts exerted to mobilize
communities through different community engagement
platforms, resource mobilization from non-state actors
and engagement of development partners. Despite these
achievements, we are applying the lessons from the recent
COVID-19 pandemic to reimagine our PHC system and to
create a resilient system that overcomes shocks and maintains
the essential health services. We are working towards the
attainment of health-related SDGs through a strong PHC system.

Cognizant of this, the Ministry of Health in collaboration with various stakeholders has developed
the National PHC Strategic Framework. This comprehensive framework will serve as a guiding
document for the formulation and execution of other program-specific strategic plans. The
strategy was developed through a meticulous process that involved reviewing pertinent local and
international documents, as well as collecting and analyzing primary data.

The Ministry of Health would like to express its heartfelt appreciation to the Community Engagement
and Primary Health Care Lead Executive Office for leading the preparation of the strategic
framework. Our appreciation goes to the members of the steering committee; Bill & Melinda Gates
Foundation, United States Agency for International Development (USAID), JSI IPHCSD, PATH The
Institute for Primary Health Care Ethiopia (IPHC-E), WHO, UNICEF, FCDO, AMREF Health Africa,
Project HOPE, Clinton Health Access Initiative (CHAI), professional Associations, Private Health
sectors Associations, CSOs, Line ministers, academia and MERQ Consultancy for financially and
technically supporting the development of the strategic framework.

Dereje Duguma (MD, MIH)

State Minister, Ministry of Health-Ethiopia

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 VII

 IV. Key Message
Addressing PHC challenges is essential for attaining
national health goals and advancing towards universal
health coverage (UHC). This strategic framework,
thus, was developed to pave the way for addressing
the prevailing PHC challenges and ensuring the
existence of resilient PHC systems. The Framework
outlines the past development, present situation, and
desired future course for Ethiopian PHC.

The document was developed with the active

involvement of internal and external partners to secure
technical inputs and guarantee the development
process’s inclusiveness.

this document concentrates on high-level PHC issues alongside the health policy. I anticipate
that there will be several supplemental documents such as an implementation manual,
guidelines, standards and Monitoring and Evaluation Framework in alignment with ministry of
health strategic documents.

It takes time and a team approach to put the Framework into practice. Therefore, I convey
this message to anyone: it may affect managers, coordinators, implementers, collaborators,
advocates, and communities that we all need to work together to make this historical document
a reality.

Israel Ataro (BSc, MPH)

Lead Executive Officer, Community Engagement and Primary Health Care (CE-PHC), Ministry of Health-Ethiopia

VIII NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

List of major contributors
Name designation Organization
1 Israel Ataro CE-PHC- Lead Executive Officer MOH
2 Dr Kebede Worku Senior Advisor to the Minster of Health MOH
3 Woldemariam Hirpa Senior Public Health Consultant MOH
4 Kasahun Sime Senior PHC Advisor MOH
5 Wondesen Nigatu CE-HEP Desk Lead MOH
6 Dr Firehiwot Nigatu Executive Director IPHC-E
7 Girma Ashenafi PHC Senior Consultant WHO
8 Chala Tesfaye PHC and Field Programs Director JSI/L10k
9 Dr Kassu Ketema Senior health system officer WHO
10 Dr Fitsum Girma USAID/ PHC Team lead USAID
11 Biruhtesfa Bekele (PhD) Field programs Director JSI/ L10k
12 Eskinder Wolka (PhD) National PHC program lead IPHC-E
13 Dr Zelalem Tadesse Technical Advisor MOH
14 Firew Solomon Senior CE& PHC Technical Adviser MOH
15 Aklog Getnet Health Center Desk lead MOH
16 Temesgen Ayehu PHC Director AMREF
17 Yibeltal Kifle (PhD) Executive Director MERQ Plc
18 Fasil Walelign (PhD) Director, Monitoring, Evaluation and Learning MERQ PLc
19 Dr Tamiru Wondie Deputy CoP USAID- ECA
20 Dr Abreham Endashew Deputy Country representative CHAI
21 Dr Anteneh Zewede Director of programs IPHC-E
22 Addis Girma PHC Coordinator MOH

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 IX

Executive Summary
Introduction

Primary Health Care (PHC) is a holistic approach to health, combining multi-sectoral policy,
empowered people, and primary care as the core of integrated health services. It aims for universal
health coverage and sustainable development goals. The Ethiopian government has welcomed
and implemented both the Alma-Ata and Astana declarations for the maximum benefit of all citizens.
PHC is both a strategy and an approach to providing comprehensive, equitable, and accessible
quality care at an affordable cost.

Ethiopia as a country has a long history of medical practices, with modern medical services first
introduced in 1897. Key milestones include the establishment of the Ministry of Health in 1948, the
inception and expansion of Basic Health Services in the 1950s and 1960s, and the declaration of
PHC in 1978. Historically, notable progress has been made during the last two decades with the
expansion of Public and private PHC infrastructure; accelerated training and deployment of mid-
level health professionals and commencement of a flagship Health extension Program (HEP). As
a result, the country has made an impressive progress towards reducing mortality and morbidity
related to common communicable diseases and motherhood cases which in turn, resulted in an
improved child survival and life expectancy at birth.

Despite remarkable progress in PHC, Ethiopia still faces a high rate of morbidity and mortality
due to a triple burden consisting of communicable diseases, non-communicable diseases, and
injuries. Non-communicable diseases and injuries represent 46% of the total disease burden in
Ethiopia, which is expected to rise rapidly in the coming decades due to economic development,
urbanization, and lifestyle changes. On the other hand, The WHO Rehabilitation Needs Estimator of
2019 shows that approximately 1 in 5 Ethiopians (24 million people) had health conditions that need
rehabilitation

The country’s current health sector development and investment plan also emphasizes maintaining
maternal and newborn care, child health, reversing the spread of major communicable diseases
(HIV/AIDS, Tuberculosis, malaria) and combating NCDs.

Situation Analysis

The current situation of PHC was assessed using WHO`s result chain framework and health system
dynamics framework1. Externally, the macro environment and internally the health system the sector
critically analyzed. The key findings are summarized as follows.

Major strengths and opportunities:

It is clear that there are several strengths across the components of the health system. Creation
of enabling policy, strategies and plans coupled with strong leadership commitment; expansion of
accessible and equitable health services to all Ethiopian citizens regardless of their age, gender,
socioeconomic status, and area of settlements. Currently, potential health service coverage is said
to be more than 95%.

1 Van olmen et al, 2012

X NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

On the other hand, PESTL analysis shows that there has been a favorable external macro-
environment (political, economic, social, technology and legal framework) which are collectively
seen as a good opportunity for health development endeavors (see annex 1).

In spite of notable gains in the strengthening of the wider health system, there are still the remaining
challenges in the areas of PHC which are thought to be addressed by this strategic framework.

Major Challenges/Limitations:

• Leadership and governance: PHC governance structure and functions are weak and
fragmented notably at regional and sub-regional levels with limited governance accountability
mechanism and weak PHC regulatory systems and functions at all levels; double standard
regulatory enforcement at private health facilities which resulted in limited engagement
of private sectors in PHC interventions; limited/ lack of multi-sectoral engagement in PHC
endeavors with limited gender and disability mainstreaming in PHC as well as lack of
segregation and standardization of provider, purchaser and regulatory functions. On the
other hand, volatile sustainability and ownership of community engagement with limited use
of alternative community engagement, and empowerment approach

• Finance: PHC is underfinanced to deliver the required essential health service because,
Proportion of government budget allocation to health is low as compared to Abuja`s target;
Lack of clear strategy for financing PHC which resulted in disproportionate budget allocation
for preventive and promotive care as compared to that of curative services; increased OOP
expenditure (31%) against WHO`s threshold (20%); Narrow fiscal space at regional and
woreda level as well as low financial management capacity at woreda level

• Adjustment to Population health need: A Potential for the adjustment to population health
has not been fully utilized

• Drugs and medical equipment and technology: Weak PHC supply chain management
system notably at PHCU level coupled with frequent stock out and erratic supply of PHC
essential medicines and medical equipment because of internal and external factors

• Health Infrastructure: Poor physical structure and inadequate basic amenities of all PHC
infrastructures and lack of mobile health services for the pastoralists, IDPs and hard-to-reach
populations

• HRH: Lack of adequate and motivated multidisciplinary team at PHC; Low health workforce
density in all professions as compared to WHO standard and inefficient professional
development schemes due to limited use of technology and lack of evaluations on the
health training programs; weak HRH management and regulatory system which resulted in
compromised adherence to the practices in professional scope of work

• Health Information System and Digital Health: Weak data use culture as a lack of adequate
data sources and limited data quality; limited expansion of ECHIS at community level as
well as a lack or minimal applications of EMR with in the health center; shortage of HIT
infrastructure and DH software coupled with limited motivation of the health professionals
to utilize DH solutions.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 XI

 • Service delivery: Limitations in PHC service delivery structure, process and outputs in
terms of addressing quality, equity, accessibility and resilience; demonstrated variability
of health service equity amongst the population by residential areas, gender, age, wealth
and education; ill-defined PHC-related role and scope of secondary and tertiary level care
hospitals; Lack of comprehensive service at PHC level against the evolving epidemiologic
shift and service need (mostly overlooked the rehabilitation and palliative care service
integration with PHC); lack of continuity and coordination of care within PHC setting;
unsatisfactory PHC service quality in terms of technical efficiency, client satisfaction, safety,
timeliness of care and respectfulness

• External threats of the macro environment

o Slowdown in GDP growth due to numerous shocks (war, internal displacement, outbreaks
like COVID-19 pandemic, climate change induced recurrent droughts, etc.
o Poverty has still been a concern as it affects large proportion of the population (25.6% in
rural areas and 14.8% in urban settings) to utilize the available health care services
o Due to limited local manufacturing, more than 85% of health commodities are imported
using limited foreign currencies which as a result challenge importing capacity of medical
equipment and supplies and further aggravates the stockouts
o Current Per capita spending on health (USD 36) is also far below WHO`s target for low-
income countries (USD 86) in order to ensure essential PHC services
o Limited internet/data penetration and high airtime cost can compromise application of
DH
o Rapidly increasing population size may result in an increased proportion of children
and youth population that bear economic pressure on the government to provide them
health services

Primary Health care Strategic Framework

Development Process and methods

A variety of interconnected processes and activities carried out; as well as several methods have
been used to draft, enrich, and finalize the PHCSF document. During the process, different methods
and approaches were employed to define and construct the contents. Accordingly, The CTT and
TWG have collected, synthesized and analyzed the required data/ information by reviewing the
required literature and documents, deploying KIIs and Delphi technique, and organizing several
deliberative workshops with key stakeholders such as LEOs and agencies of the MOH, Regional
Health Bureaus, WHO (headquarter and country offices), USAID, UNICEF, other international NGOs,
Universities, Professional associations, CSOs, Private Health Sectors, parliamentarians, other sector
organizations, thinktank groups. In general, since the first inception, the PHCSF has gone through
an extensive review and revision processes to be such a comprehensive and high-level document.

XII NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

Definition and scope

Ethiopian PHC has been defined as being a whole-of-society approach to health that aims to
maximize the level of production and distribution of health and well-being by bringing together the
three interrelated and synergetic components; integrated health service, multisectoral policy and
action and empowered individuals, families and communities. Regarding its scope, Ethiopian PHC
shall make use of the Ethiopian Essential Health Service Packages (EHSP) which include various
health service interventions (1019) to be implemented at different levels of care (primary, secondary
and tertiary) in all public and private health sectors. The framework will give equal attention to
agrarian, urban, and pastoralist settings, while, the urban and pastoralist areas would greatly benefit
from this framework as they currently lack clear primary healthcare (PHC) strategies and rely solely
on the agrarian PHC strategies.

Goal, Strategic Objectives and major interventions

The main goal of the PHCSF is to guide the PHC to improve health outcomes of all Ethiopians
through universal health coverage, health security, and realization of a high-performing PHC-
oriented health system.

Strategic Objectives (SOs) and major interventions are carefully identified on the basis of addressing
those challenges related to key components of PHC (integrated health services with an emphasis on
primary care and essential public health functions; multi-sectoral policy and actions; and empowered
people and community). Collectively, there are ten interlinked SOs and 48 priority interventions
which are thought to optimize PHC towards achieving the desired goal by 2030 and beyond. Those
SOs are listed as follows. They are:

1. Enhance the functionality of leadership, governance and multisectoral actions for PHC
2. Optimize sustainable PHC financing.
3. Improve infrastructure of health facilities
4. Improve Health workforce development and management for PHC.
5. Improve availability of Medicine and medical technologies
6. Enhance digital health use.
7. Optimize Health Information Systems
8. Improve access, quality, and equity of PHC services at all levels
9. Improve PHEM system.
10. Enhance community engagement and empowerment.

About this document

This document is a high-level strategy document perhaps next to the health [Link] tries to describe
what has been done in the past (evolution of PHC); what we are doing now (current situation of
PHC); and what we wish to do in the future (progressing towards achieving UHC and SDG targets).
It provides a framework for the future Ethiopian PHC. it doesn’t replace or modify other similar
documents but synergizes or overarches them. Rather it tries to avoid duplications, fragmentations
and overlapping efforts.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 XIII

 It is developed in alignment with WHO frameworks to maintain its international standards and
quality. It can be used by planners, strategists, document developers, regulatory bodies, program
managers and supervisors, evaluators, health professionals, academia, curriculum developers, and
others working in and with any public and private health entities. It also can help other sectors align
their plans with the “Health in All Policy” strategy.

It can also be used by the stakeholders as a reference to develop advocacy strategies and tools.
It can also serve as a tool for effective communication and resource mobilization. Other CBOs and
CSOs may use it to ensure that the health needs of the population and emergency situations have
been addressed properly.

Glossary2

1. Access to health services: the ability, or perceived ability, to reach health services or health
facilities in terms of location, timeliness and ease of approach.

2. Community health volunteers: Individuals who volunteer to provide key health information/
messages for a member or members of their family, friends or community. They may also be
involved in organizing care delivered by others. (Example: Woman development groups,
community health leaders, adherence supporters, home based care providers).

3. Catchment area: A geographical area defined and served by a health programme, facility
or institution, which is delineated based on national health facility standard.

4. Chronic care: Health care that addresses the needs of people with long-term health
conditions.

5. Clinical guidelines: Systematically developed, evidence-based recommendations that

support health professionals and patients to make decisions about care in specific clinical
circumstances.

6. Community: A unit of population, defined by a shared characteristic (for example,

geography, interest, belief, or social characteristic), that is the locus of basic political and
social responsibility and in which every day social interactions involving all or most of the
spectrum of life activities of the people within it takes place.

7. Comprehensiveness of care: Comprehensive care encompasses health promotion,

prevention treatment, rehabilitation and palliation care services that respond to the full
range of health needs of a given community.

8. Continuum of care: The spectrum of personal and population health care needed
throughout all stages of a condition, injury, or event throughout a lifetime, including health
promotion, disease prevention, diagnosis, treatment, rehabilitation, and palliative care.

9. Community empowerment: The process of involving and supporting individuals, families

and communities to take control of their own health needs resulting, for example, in the
uptake of healthier behaviors or an increase in the ability to self-manage illnesses.

2 Operational Framework for PHC; World Health Organization

XIV NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

 10. Community engagement: Is the process of developing relationships that enable
stakeholders to work together to address help related issues and promote wellbeing to
achieve positive health impact and outcomes

11. Equity in health: The absence of systematic or potentially remediable differences in

health status, access to health care and health-enhancing environments, and treatment
in one or more aspects of health across populations or population groups defined
socially, economically, demographically or geographically within and across countries.

12. Essential Health Service packages: A list of prioritized interventions and services
across the continuum of care that should be made available to all individuals in a defined
population. It may be endorsed by the government at national or subnational levels or
agreed by actors where care is by a non-State actor.

13. Essential medicines: Medicines that satisfy the priority health care needs of the population
and are selected based on public health relevance, evidence on efficacy and safety, and
comparative cost– effectiveness and are intended to be available and accessible to
individuals and communities at all times.

14. Essential public health functions: The spectrum of competences and actions that are
required to reach the central objective of public health improving the health of populations
through health protection, health promotion, disease prevention, surveillance and response,
and emergency preparedness.

15. Family Health Team approach: a service delivery approach implemented by a

multidisciplinary team of health professionals to underserved and vulnerable community
segments through home-based care, outreach and facility-based care.

16. Health in All Policies approach: An approach to public policies across sectors that
systematically takes into account and emphasizes the effect of public policies on health
determinants and aims to improve the accountability of policy-makers for the effects on
health of all levels of policy- making.

17. Health literacy: the achievement a level of knowledge, personal skills and confidence to
take action to improve personal and community health by changing personal life styles and
living conditions

18. Health product: Health technologies and devices used for prevention, diagnostics,
treatment, rehabilitation or palliation. It includes medicines, vaccines, medical devices,
protective equipment, assistive devices, dietary supplements and vector control tools.

19. Health service: Any service (not limited to medical or clinical services) aimed at contributing
to improved health or to the diagnosis, treatment and rehabilitation of individuals and
populations.

20. Health Extension Workers: A full-time professional community health worker with level
three and level and level four formal qualification and having regular remuneration who are
deployed to provide health service to the local community, often in partnership with other
health professionals.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 XV

 21. Integrated health services: Is meeting health needs of the community through
comprehensive promotive, protective, preventive, curative, rehabilitative and palliative
care throughout life, by prioritizing key health services through primary care and essential
public health functions as central elements of integrated health services.

22. Model of care: is an approach by which health services are delivered, including the
processes of care, organization of providers and management of services.

23. Multisectoral policy and action: systematically addressing broader determinants of health
(including social, economic and environmental factors, as well as individual characteristics
and behaviors) through evidence-informed health in all policies and actions across all
sectors;

24. Public Health Emergency Management: Public Health Emergency Management is the
process of anticipating, preventing, preparing for, detecting, responding to, controlling and
recovering from consequences of public health threats in order that health and economic
impacts are minimized.

25. Population health needs: a continuous collection and analysis of data and evidence about
population health status and needs to continually learn and adapt to changing population
health needs to allocate limited resources to improve population health.

26. Primary care: A key process in the health system that supports first-contact, accessible,
continued comprehensive and coordinated patient-focused care.

27. Primary health care: A whole-of-society approach to health that aims to maximize the
level of production and distribution of health and well-being by bringing together the three
interrelated and synergetic components; integrated health service, multisectoral policy and
action and empowered individuals, families and communities

28. Primary health care-oriented health system: A primary health care-oriented health system
is composed of a core set of structural and functional elements that support achieving
universal coverage and access to services that are acceptable to the population and
ensure equity and global health security.

29. Primary health care strategic framework: A comprehensive and overarching strategic
document having a set of organized and aligned strategic drivers or objectives and
initiatives towards attaining the overall PHC goal. It guides the implementation of these
objectives and initiatives through active participation of all stakeholders and partners.
Several sub-documents are required to put this strategic framework into practice.

30. Public health emergency management: is the process of anticipating, preventing,

preparing for, detecting, responding to, controlling and recovering from consequences of
public health threats in order that health and economic impacts are minimized.

XVI NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

 31. Quality care: Care that is safe, effective, people-centered, timely, efficient, equitable and
integrated.

32. Regulation: a framework designed to ensure safety and quality of health and health
related services through regulating the availability of professionals, products, practices and
premises against the national minimum standard.

33. Resilient health system: The capacity of a system, community or society exposed to
hazards to resist, absorb, accommodate to and recover from the effects of a hazard in a
timely, efficient and effective manner, including through the preservation and restoration of
its essential basic structures and functions.

34. Self-care: Individuals, families and communities are supported and empowered to
appropriately manage their health and well-being when not in direct contact with health
services.

35. Universal health coverage: Ensured access for all people to needed promotive, preventive,
curative, rehabilitative, and palliative health services, of sufficient quality to be effective,
while also ensuring that the use of these services does not expose any users to financial
hardship.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 XVII

1. Introduction
Primary Health Care (PHC), as defined in the 1978 Declaration of Alma-Ata and the 2018 Astana
document, is a holistic approach to health that combines multi-sectoral policy, empowered people,
and primary care as the core of integrated health services, aiming for universal health coverage and
sustainable development goals. The Declaration of Astana commits to make bold health choices,
build sustainable primary health care, empower individuals and communities, and align stakeholder
support with national policies. This builds on previous resolutions from Alma-Ata, which aimed to
strengthen primary health care (WHO and UNICEF, 2020).

The Ethiopian government welcomed and put into practice both the Alma-Ata and Astana
declarations for the maximum benefit of all Ethiopian citizens. For Ethiopia, PHC is both a strategy
and an approach to providing the population with comprehensive, equitable, and accessible quality
care at an affordable cost.

1.1. Country Context

Ethiopia covers an area of 1,104,300 km2. It shares boundaries to the north and northeast with
Eritrea, to the east with Djibouti and Somalia, to the south with Kenya, to the west with Sudan and
to the southwest with South Sudan. Ethiopia has a wide range of geographical and topographical
diversity, with a massive highland complex of mountains and plateaus, with the highest peaks with
an altitude of 4,620 m (about half the height of Mount Everest) above sea level and with the lowest
depression of 148 meters (about 485.56 ft) below sea level.

The Federal Democratic Republic of Ethiopia is composed of 12 Regional States: Tigray, Afar,
Amhara, Benishangul-Gumuz, Gambella, Harari, Oromia, Sidama, Somali, Southwest Ethiopia
Peoples’, Southern Ethiopia, Central Ethiopia, and two city administrations, Addis Ababa and Dire
Dawa. The regional states and city administrations are subdivided into Zone/Sub city, Woredas
(districts) and Kebeles.

Based on the 2007 population and housing census, the total population for 2022 is projected to
be 120 million. The average family size is 4.6. The pyramidal age structure of the population has
remained young with 44.9% under the age of 15 years, and over half (52%) of the population in
the age group of 15 and 65 years. The population in the age group of over 65 years accounts for
only 4% of the total. While the sex ratio between male and female is almost equal, women in the
reproductive age group constitute 23% of the population. The average fertility trend in recent years
has shown some significant decline from the 2000 level of 4.7 births to 4.1 births per woman (Central
Statistical Agency, 2016).

Ethiopia is among the countries that has registered rapid and high economic growth. On average,
the agricultural sector has contributed 24% to the overall GDP growth, while the industry sector has
contributed 37.9%. To sustain the rapid economic growth, the country will implement a multi-sectoral
growth approach by diversifying sources of economic growth and job creations by undertaking
necessary and substantive policy reforms across the different sectors. Key focus areas include
the agricultural sector, manufacturing sector, mineral sector, tourism sector, and the Information
and Communications Technology (ICT) sector, which are seen as crucial drivers of growth (FDRE
Planning and Development Commission, 2021).

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 1

1.2. Evolution of PHC in Ethiopia
Ethiopia has had a long history of medical practices. It is assumed that the modern medical services
were first introduced to Ethiopia in 1897 when the Russian Red Cross Hospital was established in
Addis Ababa. After that several milestones were achieved. These include the establishment of MOH
in 1948; the inception and expansion of BHSs in 1950s and 1960s; the declaration of PHC in 1978
followed by expansion of PHC services by developing enabling policies, strategies, and strategic
plans over 40 years’ time. The following figure (Figure 1) depicts key milestones of Ethiopian PHC.

1890s
10/15/2023
Modern medicine stated

Ministry of Health established

1940s
First Public Health
College established 1950s
Inception of BHS
BHS facilities (HSs and HCs) expanded
mostly in urban centers
1960s
PHC declared in Alma-Ata (USSR)
Socialist oriented new
Health Policy issued 1970s
Six tier health care
Provision of Comprehensive health
system declared
services through CHAs and TTBAs
1980s
Integration of essential health services
notably family health programs

New and inclusive health policy

and strategy developed
Three-tier health care system
devised 1990s
PHC management
system decentralized

A 20-year HSDP
developed

The Rural, Urban and Pastoral

2000s HEP launched consecutively
PHCU (mostly HCs and HPs) expanded significantly
2010s Private HCFs also expanded
A long term HSTP
developed

CBHIS launched
A new community engagement strategy
devised: WDA networks established
A 15-year HEP optimization roadmap launched: a range
PHC oriented National EHSP developed of comprehensive health care including curative
2020s services started at CHP

National PHC Strategic Framework developed

Figure 1: Key milestones of Ethiopian PHC

2 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

1.3. Burden of diseases
Ethiopia has achieved notable strides in improving child survival, reducing maternal mortality and
total fertility rates. The life-expectancy at birth has steadily increased in Ethiopia from 60.9 years in
2010 to 67.8 years in 2022. This is a 10% increase in about a decade, and was achieved through
reductions in neonatal, child and maternal mortality, prevention, and control of major communicable
diseases. In the current strategic plan period (HSTP II), the country has planned to sustain gains and
give due emphasis to maintain maternal and newborn care, and child health, and aims to halt and
reverse the spread of major communicable diseases such as HIV/AIDS, Tuberculosis (TB), Neglected
tropical diseases (NTDS), and malaria and Non communicable diseases as priority agenda of the
sectors (Misganaw, et al., 2017; GBD 2019 Diseases and Injuries Collaborators., 2020)

Despite the major progresses made to improve the health status of the population in the last three
decades, Ethiopia’s population still faces a high rate of morbidity and mortality due to triple burden
consisting of communicable diseases, non-communicable diseases, and injuries. Many of the
deaths for all ages happened due to major preventable communicable diseases followed by non-
communicable diseases like heart failure and cerebral infarction (EPHI, 2021).

According to 2016 estimates, non-communicable diseases and injuries represented 46% of the
total disease burden in Ethiopia, which is expected to rise rapidly in the coming decades owing to
economic development, urbanization, and lifestyle changes. Similarly, WHO NCD country profile
2018 indicates that there were a total of 700,000 deaths in Ethiopia in 2016. Among these deaths 39%
were attributed to non-communicable diseases (NCDs), 12% to Injuries and 49% to Communicable,
maternal, neonatal, and nutritional (CMNN) conditions. Among the NCDs, the overall cardiovascular
diseases accounted for 16%, cancers for 7% and respiratory disease for 2% of all causes of death.

A recent report revealed that Ethiopia has made remarkable improvement in lessening the gross
mortality over the last three decades. Since early 2000, many regions in the country have achieved
substantial improvement from the loss of premature life. The increasing burden of NCDs and injuries
in the country further exacerbates premature mortality and challenges socio-economic status and
the health system. Likewise, the top five leading causes of premature loss of life in 2015 were
lower respiratory infections, tuberculosis, diarrheal disease, ischemic heart disease, and HIV/AIDS.
According to an estimation of the top twenty specific leading causes of death regardless of age and
sex in 2019, diarrheal diseases, Lower respiratory infections, and Neonatal encephalopathy due to
birth asphyxia and trauma were the top three causes of death (Misganaw et al., 2017).

There are risk factors that drive mortality and disability in all age groups. Diarrheal diseases,
Neonatal encephalopathy due to birth asphyxia and trauma, and Lower respiratory infections were
the top three drivers of DALYs (disability adjusted life years) (Figure 2). In 2019, 58% of disability
adjusted life years (DALYs) were due to maternal and neonatal conditions, communicable diseases,
and malnutrition. Over the past two decades, the share of NCDs has increased from 17% to 35%.
On the other side, morbidity, and mortality from common communicable diseases such as HIV,
drug susceptible TB and vaccine preventable diseases like measles has decreased in the last two
decades (Figure 3). Contrary to this, according to data from the Global Burden of Disease (2019)
there was an increasing trend in the proportion of deaths attributable to NCDs. Injuries, accidents,
and mental health problems are also becoming a growing concern (MOH 2021 h). Ethiopia is among
the countries with greater than 2% annual reductions in age-standardized DALY rates over the last

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 3

decade (2009 and 2019). This achievement is due to the improvement in health service coverage
in the country over the last few decades (GBD 2019 Diseases and Injuries Collaborators., 2020).

Figure 2: Leading causes of DALYs in Ethiopia

The WHO Rehabilitation Needs Estimator shows that in 2019 approximately 1 in 5 Ethiopians
(24million people) had health conditions that could benefit from rehabilitation. Of these individuals,
the most common health condition category was musculoskeletal disorders (approximately 57%),
followed by sensory impairments (approximately 30%) including vision and hearing loss. These
and other conditions requiring rehabilitation constitute approximately 2.7 million years lived with
disability (YLDs) in 2019 alone. The prevalence of such conditions has nearly doubled since 1990,
indicating an increasing need for rehabilitation in Ethiopia.

The number of Persons with Disabilities (PWDs) in Ethiopia is debatable due to the loose definition
of disability and lack of utilization of international data collection tools such as the Washington
Group Questions (WGQs), leading to probable under-reporting of disability. According to the
Central Statistical Authority (CSA), in 2007 PWDs comprised 1.7% of the total population. In contrast,
in 2015/16, the United Nations International Children’s Emergency Fund (UNICEF) estimated that
approximately 9.3% of Ethiopians (7.8 million people) have some form of disability. Of these, up to
2.4% had very profound difficulties. Another estimate from the World Report on Disability issued by
the World Bank and WHO indicated that Ethiopia is home to 15 million PWDs, representing 17.6% of
the population (Institute for Health Metrics and Evaluation (IHME and WHO, 2021)

In fact, the country is experiencing a huge burden of diseases as explained by DALY, which
necessitated the revision of the EHSP in 2019 for all levels of care to combat such burden of disease.
Therefore, the scope of this framework is to guide the effective implementation of the EHSP but with
periodical revisions (see section xx Scope of Ethiopian PHC).

4 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

1.4 Ethiopia’s Health Service Delivery Structural Arrangement
With the intent of decentralizing the decision-making power and ensuring continuum of care,
Ethiopia has introduced a three-tier health care delivery system (Figure 3). The Primary level of care
consists of a primary hospital (PH) per 60,000-100,000 people; a health center (HC) per 15,000-
25,000 population in rural settings and 40,000 population in urban areas and health post serving
3000-5000 population. The primary hospital, health center and health posts are linked to form a
Primary Health Care Unit (PHCU). Secondary level of care is a General Hospital serving a population
of 1-1.5 million people and tertiary level of care is a specialized and teaching hospital serving a
population of 3.5-5 million people (MOH, 2021).

The private health sector is present across all levels of care in Ethiopia, ranging from primary level
facilities such as private pharmacies and drug stores, non-government health facilities and civil
society organizations, and primary clinics/medium clinics; to secondary level facilities including
private for-profit specialty clinics; to tertiary level facilities like non-government and private for profit
hospitals and specialty centers. (Ethiopia Health Private Sector Assessment, 2019)

Figure 3: Ethiopian Health Service Delivery Structural Arrangements

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 5

2. Situation Analysis
2.1. Political, economic, and social environment analysis
It is critical to understand the big picture determinants of change in the macro environment
including political, economic, social, cultural, and technological environments (PEST). These forces
operate outside the health system but have considerable influence on the health system. Thus, a
thorough analysis is conducted to identify the underlying opportunities and threats that may impede
implementation of the framework.

Political Environment: The emergence of the Transitional Government of Ethiopia in 1991 brought
the elements of democratization, decentralization, and promotion of the participation of the
private sector and non-government organizations (NGOs) in health care (TGE, 1993). As part of
decentralization the Regional State Health Bureaus and sub-regional structures (Zonal Health
Departments and Woreda Health Offices) were given more autonomy to plan and implement health
programs in line with the national priorities and targets (Kloos, 1998). National Health Policy and
Strategy also developed in support of decentralizing the health care system to reach the majority
rural population with comprehensive health services (TGE 1993). Similarly, the revised Ethiopian
health policy has explicitly stipulated that decentralized equitable and accessible health services
shall be availed for all citizens at all levels of care using PHC as a main service delivery strategy
(FDRE 2024).

The current political system (recent reforms since 2018) supports the previous political scheme
regarding expanding PHC in the country. According to the Ten-Year Development Plan of the Federal
Democratic Republic of Ethiopia, the development of an all-round human resource capacity will be
achieved through the provision of equitable access to health by building an effective health system
for the prevention and control of diseases, mitigate maternal and child mortalities, and protecting
citizens from injuries (FDRE Planning and Development Commission, 2021).

Economic Environment: Like other health care markets, the demand and supply of PHC services are
shaped by broader contexts outside the health system (World Bank, 2007; Pakdaman, et al., 2019).
There are various channels through which macroeconomic factors can affect the effectiveness of
the public and private health sector in the healthcare market.

Gross Domestic Product: The real GDP and per capita have declined in the last 6 years with a notable
shrink since 2019 partly due to several reasons (war, conflict, civil unrest, internal displacement,
COVID-19 pandemic, and drought (National Bank of Ethiopia, 2021). Evidence shows that poverty
rate in Ethiopia has steadily declined from 45.5% in 1995/96 to 23.5% in 2015/16 (National Planning
Commission, 2017) Nonetheless, poverty is still a significant development concern and is more
pervasive in rural (25.6%) than urban areas (14.8%). This situation compromises the capacity of rural
citizens to utilize available health services.

Exports and imports: The growing gap between the value of exports and imports implies that it
has become harder for the Ethiopian government to finance the costs of importing essential goods,
including medical and pharmaceutical items (National Bank of Ethiopia, 2021)

6 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

Foreign Exchange: Financing the health sector is strongly associated with access to foreign
exchange. However, the declining value of ETB together with shortage of foreign currency (USD)
put the sector in a demanding situation to import essential medical equipment, medicines, and
supplies (NBE, 2009).

Mega infrastructure expansion (road, Telecom, electric energy, and water supply): the road
infrastructure has expanded for the past two decades or so with the road density increasing from
about 45 km (about 27.96 mi)/1000 km2 in 2004–05 to 131 km (about 81.4 mi)/1000 km2 in 2019.
The time taken to reach the nearest all-season road decreased from 3.7 hours to 1.3 hours over the
same period. This has contributed to better accessing available social services, including education
and health care, (Nakamura et al).

On the other hand, based on official data (NPC, 2015), the percentage of rural kebeles with access
to telecom services within a five-kilometer radius increased to 97% in 2014/15 from 62.1% in 2009/10.
Additionally, electric power generation rose from 2,048 MW in 2009/10 to 4,478 MW in 2019/20. The
Ministry of Water and Energy has announced plans to ensure 100% access to reliable and sufficient
electricity services for hospitals by 2021, and for health centers and 75% of health posts by 2025
(MOWIE, 2019). Similarly, substantial investments have been made to provide the population with
safe and sufficient water. The percentage of the population with access to safe water supply has
increased from approximately 46% in 2004/05 to 59% in 2020/21 (National Bank of Ethiopia, 2021).

Socio-demographic Environment: As a result of aggressive expansion of education infrastructures,

primary and secondary school enrollment has improved with net enrollment rate of 100% for (grades
1-8) between 2015 and 2018 and secondary gross enrollment rate (9-12) 42% during the same period
(Ministry of Education, 2021). On the other hand, there has been encouraging progress in improving
literacy rate. Global statistics depicted that Ethiopia’s literacy rate increased from 39% in 2007 to
51.77% in 2017-an increase of 12.78%. However, about half of the adult people are still illiterate. This
implies that there can be a challenge to use digital health such as mHealth, self-care applications,
etc.

Demographic changes and urbanization: UN projection shows that about 69% of Ethiopia’s
population is children and youth less than 30 years old which may put economic pressure on the
government to provide the needed education and health care services. Concerning urbanization,
35% of Ethiopia’s total population is projected to be living in urban areas by 2030 (FDRE Planning and
Development Commission, 2021). The population shift toward urban areas changes the structure of
economic activities and increases demand for urban social services including PHC services.

Macro environment in the context of private sectors: On the basis of favorable political and legal
conditions, over the last two decades, the private health sector in Ethiopia has been expanded
in terms of health facilities and human resources, from an extremely low base. I.e., the lower, the
middle and higher clinics (as certified by FMOH) increased from 862 in 1996 to 4088 in 2010/2011
comprising 40% of all health facilities in the country (Kitew, 2017). The Ethiopia health private
assessment showed that 27% of the total health facilities are owned by private sectors (MOH, GFF
and World Bank, 2019). This has made considerable support to raise access to and coverage of
health care services in the country particularly, in urban settings. However, their contribution to the
coverage of PHC services is not clearly known because of the weak reporting system between the
private and public sectors.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 7

2.2. Health System Analysis
2.2.1. Leadership, Governance and Multisectoral collaboration:
In “Buenos Aires Declaration,” the Ministers of Health (MOH) demonstrated their commitment
towards strengthening inter sectoral collaboration including assisting other sectors in developing
health related policies. Such collaborations are needed for joint planning, implementation, review,
and evaluation of sectoral programs; effective and efficient use of resources at all levels (World
Health Organization, 1997).

To coordinate multisectoral action for health, the MOH has developed directives and manuals for
various initiatives, such as Woreda Transformation, public health emergency management, health
regulation, nutrition, Seqota Declaration, One WaSH (Water, Sanitation and Hygiene) National
program, and health in all policy (Rasanathan et al. 2017). Additionally, multisectoral efforts have
been seen in emergency response, immunization campaigns, COVID-management. (EPHI, 2022).
The Health Sector Transformation Plan (HSTP) promotes the involvement of all stakeholders in the
planning, implementation, review, and M&E process. Joint coordination platforms, such as Joint
Steering Committee, Joint Consultative Forum, and Joint Core Coordinating Committee, have been
used for planning, monitoring, and evaluation.

Though multi-sectoral collaboration for health is guided by policy it is not well implemented across
levels and regions. Frequent restructuring, lack of political commitment, shared goals, resources,
accountability, communication, and information sharing, competition for resources and conflict of
interest are barrier (Mesele, et al., 2020)

Furthermore, during its Health Sector Transformation Plan II (HSTP II), the MOH aimed to transform
leadership by redesigning and restructuring the health system, institutionalizing accountability
mechanisms, ensuring regulatory system autonomy, building leadership capacity at all levels, and
incorporating the Health in All Policies approach throughout the government (MOH, 2023a).

Accordingly, progress has been made in these areas, including restructuring the back offices in 2023;
the development and approval of the alignment action plan, and the expansion of the Leadership
Incubation Program (LIP) for MOH staff. To ensure accountability and community ownership, the
Community Score Card (CSC) is being implemented in 800 woredas and 2250 HCs (Health
Centers). The Good Governance Index is also being implemented in 64 hospitals. On the other
hand, the MOH leadership has effectively managed the COVID-19 response, mobilized resources,
and created platforms to engage development partners, NGOs, civil society, and the private sector.
Post-conflict recovery efforts have been successful, with the twinning of some hospitals with those
affected by the conflict (MOH, 2023a)

Grievance handling and monitoring mechanisms have been standardized and institutionalized at
all levels of the health sector, with institutions having grievance committees accountable to the
institution head.

Partnership and coordination mechanisms exist among public sectors, private for profit, CSOs, and
NGOs, with the COVID-19 response proving successful. The Health Service Delivery, Administration,
and Regulation Proclamation and the Health Professional Council Proclamation have been
developed but stalled without Parliament endorsement.

8 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

Despite the efforts made to promote leadership and governance, the effort is still fragmented and
of limited coverage. Similarly, coverage of merit -based assignment of leaders is still low. Regardless
of all efforts to improve alignment, there is suboptimal alignment and an increased number of in
program activities that hinder the implementation of the alignment agenda. Effective planning and
monitoring systems for leadership action plans are also lacking (MOH, 2023a).

2.2.2. PHC Financing:

Although PHC is the most efficient route to UHC, the overall funding available for PHC is insufficient
in many countries, leading to budgeting and financial challenges on their road towards UHC (WHO,
2022a). This is compounded by fragmented financing systems, reliance on donor funding and out-
of-pocket payments by consumers, and inefficient and inequitable distribution of limited healthcare
resources. In 2016, only five out of 16 low-income countries spent more than US$30 per capita on
PHC (WHO, 2022a). A recent modeling study suggested that most low-middle-income countries
(LMICs) including Ethiopia would need to at least double current spending on PHC to provide
universal access to essential PHC services (Sternberg, et al., 2019).

Since the introduction of formal health services in Ethiopia; responsibility of providing health services
rests entirely on the government sector. Several health financing modalities were applied during the
past regimes. With the provision of TGE health policy in 1993 and the subsequent health financing
strategy in 1998, there have been several reforms. Examples of these are the creation of revenue
retention and use at the health facility level, strengthening of protection packages for the poor,
standardization of exempted services, outsourcing of non-clinical services, and promotion of health
facility autonomy through establishment of a governance system.

In 2008, the Ministry of Health ratified the health insurance strategy and since 2010 endorsed
the legal framework (proclamation and regulation) to implement Social Health Insurance (SHI) and
establish the Ethiopian Health Insurance Agency (EHIA). The establishment of the EHIA at the center
and branch offices is envisaged to streamline the systems like provider payment mechanisms, and
financial sustainability (MOH, 2015b).

Regardless of various challenges in the last couple of years the CBHI program has made promising
progress. High political commitment, community knowledge, and ownership at all levels of the system
are the major forces behind success. However, the CBHI program has been successful because
it provides a legal basis for the roles, responsibilities, and accountability in CBHI implementation,
including the introduction of mandatory membership. As a result, in 2022/2023, CBHI woreda
coverage reached 980, 84.7% of all woredas, excluding Tigray. Nearly 12.2 million households
enrolled, surpassing the 80% enrollment target set for 2025. 18% of CBHI members are indigent
(MOH, 2015b).

Recently, a national Resilience and Equity Health Fund (REHF) is being developed to transform health
financing including PHC financing. The REHF, which currently is under approval process, aims to
mobilize sufficient and sustainable health finance from domestic resources (sin tax) for emergency
responses, exempted health services, and equity-promoting activities for socioeconomically
disadvantaged groups. The approval of the REHF is expected to result in increased resources,
bridging existing resource gaps, and reducing reliance on external funding sources.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 9

 In addition, the Treasury has increased its co-financing for programs from Birr 1.23 billion in the 2014
EFY (Ethiopian Fiscal Year) to Birr 2 billion in the 2015 EFY, which has allowed some of the priority
programs to be included in program-based budgeting. The Seqota Declaration’s implementation,
immunization, and HIV/AIDS initiatives are among those that receive the most co-financing from the
Treasury (MOH, 2015b).

On the other hand, a user fee regulation No. 477/2021 was approved for universities and tertiary
hospitals, and a revision of the user fee was conducted, to allow facilities to recover some of their
costs. To date, over 3020 health centers and 120 hospitals retain and use the fees to improve
service quality.

The fee waiver system introduced the reimbursement of costs to health facilities for the services
they rendered for patients with fee waiver benefits. Currently 1.4 million people are covered under
the waiver system (MOH, 2015b).

However, health including PHC financing is still inadequate. The share of general government
expenditure on health as a share of general total government expenditure is not progressing well. It
is 8.3 % and quite low compared to the target set. According to the recent National Health Account
(NHA), Ethiopia’s Total Health Expenditure (THE) from all sources was estimated at ETB 127.47 billion
(USD 3.63 billion) in 2019/20 (Donors 33.9%, government 32.2%, Out of Pocket payment 30.5%,
CBHI 0.9% and private employers and others constitute 2.5%). Spending at the primary health care
unit (primary hospitals, health centers, and health posts) accounted for 44% of the Total Health
Expenditure (THE), of which health centers and health posts accounted for about one-third (30%) of
the THE (MOH, 2019b).

More than half of THE (56%) is spent on curative care. The share of preventive care from THE
decreased significantly from 30% in 2016/17 to 19% in 2019/2020. About 35% of curative care
spending was made at the primary-health-care level (i.e., district hospitals, health centers, and
health posts). The 6th NHA estimated the contribution of community volunteers through Women
Development Army (WDA) and malaria control programs to be US$ 99 million in 2016/17 in monetary
value.

In addition, according to the HSTP II MTR, the implementation of Domestic Resource Mobilization
(DRM), one of the health financing transformation initiatives, did not make major progress, particularly
in relation to the high-level political advocacy and cascading it to regional level). (MOH, 2019b)

On the other hand, despite the commendable progress, there are major gaps and challenges in
the design and implementation of the CBHI program. There is slow progress in narrowing inequality
to access the CBHI scheme. The current flat CBHI contribution rates (which do not account for the
difference in ability-to-pay) are regressive, can potentially be a barrier to enrolment for people with
low income, and reduce the revenue generation capacity of the CBHI schemes. The schemes have
also created challenges for health workers and facilities due to increased demand and limited
supply (Bayked et al., 2023).

The startling problem with health financing is that, according to certain research, it is not just the
lack; there have also been a lot of restrictions in connection to financial management at the Woreda
level. There is a lack of understanding of the Health Care Financing Reform (56.4%), followed by a
lack of funding (55%) and a lack of technical expertise (43%). In addition, the implementation of the

10 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

fee waiver system has been shown to be prone to significant leakage and under coverage. Though
the Woreda administration is expected to allocate a budget to reimburse the health facilities based
on their report of clients with fee waiver, health facility managers often complain that they are not
being reimbursed in a timely manner (MOH, 2015b)

2.2.3. Adjustment to Population Health need:

Population health needs are dynamic and often change during life events due to demographic,
socio-cultural and economic alterations of the given populations. Despite this, there have been
limited or fragmented PHC systems to make timely adjustments to the ever-changing need of the
population through a regular collection of local data/ evidence and participatory analysis of trends
and determinants of health.

According to WHO’s SCORE assessment for Ethiopia, the country has the highest capacity for
review of progress and performance at the country level and high capacity for enabling data use
for policy and action. This includes capacities to conduct reviews of past performance (trends) in
the form of annual performance reviews, midterm reviews and end term reviews at country-level
and at the regional-level. Annual performance review reports indicate that despite good capacity
at the national level to perform reviews, disaggregated data to highlight gender responsiveness,
populations experiencing vulnerabilities and spatial inequities is inadequate. Furthermore, the
capacity to perform reviews and data analysis of performance at the subnational level is almost
non-existent or limited. Overall National level adjustment to population needs at 67% score remains
a challenge (MOH, 2023) (WHO, 2021)

2.3. Health System Inputs

2.3.1. Medicines and other health products
Vital and essential drugs were 85% and 83% available nationally in 2020. No HFs had all essential
medicines and equipment. Medicine availability varied by region and care level. HPs had more
stock-out (MOH 2021 b).

As far as blood and blood products are concerned, currently, a number of hospitals (about 420) in
the country access safe blood supplies through a network of blood banks (EPHI 2018)(SARA, 2018).
Ethiopia is making efforts to research and produce quality-assured traditional medicine, which is an
investment area recommended by WHO for medicine availability and accessibility (FMOH Health
indicator, 2021). Only 19% of health centers and 4.6% health posts met more than 80% of storage
conditions (MOH, 2021a)while hospitals had better storage conditions (SARA, 2018)

Some factors affecting medicine and health product availability and accessibility are: foreign
currency shortage, limited local production, few private importers and wholesalers, low attention
to traditional medicine, and poor supply chain management. (ETHIOPIA HEALTH PRIVATE SECTOR
ASSESSMENT October 2019, 2019)

2.3.2. Health Infrastructure:

Based on the revised health tier system the number of public health care facilities, HPs (Health
Posts) and HCs increased from 76 and 241 in 1997 to 18,428 and 3,917 in 2023 respectively with

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 11

 significant changes to the HPs and HC. According to HSTP-II, MTR report, the number of health
facilities, 308 PHs (Primary Hospitals), 3,917 HCs and 18,428 HPs including those under construction,
which makes health facility to population ratio of; HP= 1:5,760; HC= 1: 26,276 (MOH, 2023a). Similarly,
the number of private health sectors (PHS) rapidly expanded in the last two decades. Increased
from 862 in 1996 to 7,638 in 2016/17 comprising 27% of all health facilities in the country (Kitew, 2017,
Ethiopia Health Private Sector Assessment, 2019), most of them located in urban areas.

Health Posts are widely available in all kebeles in Ethiopia (97%). However, most of them are sub-
standard and lack basic amenities including water, electricity, road access, and communication
technology. According to SARA, only 5% of the HPs have access to power sources, 15% improved
water supply and 51% have sanitation facilities. None of the HPs fulfilled all the basic amenities.
In addition, HPs were not available for urban population and the majority of them are not suitable
for the mobile communities in pastoralist and semi-pastoralist areas (Yitbarek , et al., 2023; EPHI,
2018). Besides, the newly established Comprehensive HP were not adequate in number and most
of them were lacking the required workforce, health products (drugs and medical supplies) and
basic utilities; so that they were not able to provide a comprehensive and quality services to their
communities (MOH, 2023a; MOH, 2019a; MOH, 2023b)

According to HSTP-II MRT, a total of 3,917 Health Centers are available, out of which 410 have OR
blocks to provide basic emergency surgery service. However, about 11.4 % of the population do not
have access to HCs. Despite their wide availability, some HCs still lack the required basic amenities.
Only 28% of the HCs have power sources, 69% have improved water sources. Surprisingly, 7% of
the HCs lack consultation rooms. Only 1% of them have all seven basic amenities (MOH, 2020a;
EPHI, 2018).

Based on the Hospital to population ratio, there should be a minimum of 1030 PHs by the year 2020
nationally. However, currently, only 308 (29.9%) Primary Hospitals are available, of which 40% of them
are without power supplies; 54% did not have a computer and internet connection. Moreover, only
24% of the PHs fulfill all the recommended basic amenities (EPHI MOH and ICF (Inner City Fund).,
2023) On the other hand, the presence of primary Hospitals in the same major cities and towns in
line with the HCs and the General hospital is also questionable. In addition, the accountability of
primary hospitals is not clear across the county and needs attention.

However, General Hospitals and Comprehensive specialized hospitals are expected to deliver the
Primary care services and complex medical care. However, most of them are in urban settings and
serve as a referral for Primary hospitals by undermining the primary care services. Furthermore,
there has been a lack of or fragmented PHC structure and management functions in such hospitals
which were further compromised by lack of basic amenities. According to SARA (EPHI, 2018) about
29% and 48% of Comprehensive specialized hospitals and General Hospitals did not have all basic
amenities, respectively.

In general, except for the Primary hospital, HPs and HCs are accessible to the community in rural,
urban, and pastoral areas. The remaining challenges include lack of basic amenities in all facilities,
unregulated facility standards; and shortage of other critical infrastructure such as power grid, water
supply, roads, and telecommunication.

12 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

2.3.3. Human Resource for Health (HRH):
The health workforce is an essential part of the healthcare system. It is impossible to provide and
enhance access to and the quality of healthcare without such a workforce. Therefore, improving
the population’s access to and satisfaction with health care depends heavily on the availability,
acceptability, quality, and accessibility of the health staff.

Accordingly, the government has been committed to own a motivated, competent, and
compassionate (MCC) health workforce by developing a robust HRH strategic framework. Besides,
the MOH has developed a series of strategic and investment plans and implemented the national
health workforce account (2030) to progressively measure and report the improvements in the
health workforce availability and quality.

As a result, a significant number of health professionals notably all categories of mid- level and
low- level cadres have been produced over the last two decades. A recent study on labor market
analysis showed that there was a cumulative of 273,054 health workforces by the end of 2019. Out
of which 30,238 (11%) were deployed in the private and other sectors. Regarding the composition
of the workers in the public sector, the share of clinical and para-clinical staff was 68%, while
administrative and support staff accounted for 32%. In terms of Professional mix among Clinical
staff, 21% were nurses, 17% HEWs (Health Extension Workers), 6% Health Officers, 2% GPs (General
Practitioner) (General Practitioner) and 1% medical specialist (WHO, 2022b). The 2022 data showed
a total health workforce of 342,899, with 64% being health professionals and 36% administrative/
supportive staff (WHO, 2022b). Nonetheless, the health workforce density for core professional
categories (physicians, health officers, nurses and midwives) in 2023/24 was only 17.85 per 10,000
populations, which is low compared to the required standard (xxx). Additionally, according to WHO’s
Health Workforce Support and Safeguards List 2030, a number of countries, including Ethiopia
were identified as having a density of doctors, nurses, and midwives below the global threshold and
universal health service coverage index (below 55)

As seen from the perspective of implementing Essential Health Services Package (EHSP) 2019, the
current stock of health workers in Ethiopia covers only 49% of the required workforce to deliver the
defined health service interventions (MOH, 2019c). This implies that it is difficult to avail all essential
health services for the population with the current number of the workforce. Despite such critical
needs, out of 20,936 graduated health professionals in 2019, 20% (5026) remained unemployed or
underemployed without adjusting this for the Private Health sector. Unemployment was significant
for nurses (63%) followed by pharmacists and midwives (43% each). Even 29% of the general
practitioner medical graduates (GPs) were unemployed (WHO, 2022b).

In terms of distribution, there is also geographic difference in health workforce density across the
regions which was the highest in Harari (4.03 per 1000 population) and the lowest in Somali region
(0.9% per 1000 population) in 2016 (EPHI, 2018).

On the other hand, in spite of some improvements in continuous professional development (CPD)
endeavors, there are still the remaining gaps in terms of maintaining a continuous capacity-building
process and conducting regular assessments of provider competency. The mass training approach
used in pre-service training facilities was found to compromise the quality of education for health
professionals. Furthermore, concerns persist regarding inadequate mechanisms for motivating,
retaining, and managing the performance of the health workforce in Ethiopia (WHO, 2022b). In

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 13

 addition, because of inadequate safe working conditions and limited emergency preparedness,
the unforeseen occurrences such as COVID-19 and conflicts negatively impacted human resource
development and management, leading to health workers’ deaths, displacement, and increased
workload, psychological trauma particularly in northern regions (WHO, 2022b).

2.3.4. Health Information System:

Health information was one of the four transformation agendas of the last two Health sector
transformation plans. The DHIS2 software was customized and fully scaled up with user-friendly data
use features. Other service recording systems for logistics, regulatory systems, and other functions
were also introduced. An electronic Community Health Information System (eCHIS) application
was developed and implemented in close to 7800 health posts among rural health posts; and
several other applications are in development including a Master Facility Registry, a web-based
HRIS (Human Resource Information System), and a National Health Data Dictionary (MOH, 2023a;
MOH, 2021b) & Full digitization of regulatory core functions (such as licensing, product registration,
and quality assurance) has been achieved, enhancing the traceability of data, and improving cost-
effectiveness. However, a study found that resource availability including the ICT infrastructure,
guideline compliance, and information utilization was below standard (Bogale, 2021).

Other study done in Oromia, West Shoa Zone region has shown overall, the three dimensions:
availability of resources, compliance to guideline, and utilization of information were below the
standards (Biru, et al., 2022). Maturity assessment of the Ethiopian HIS using Stages Of Continuous
Improvement (SOCI) tool in five domains namely HIS leadership and governance, HIS management
and workforce, HIS ICT infrastructure, HIS standards and interoperability, and Data quality and use
has concluded that the maturity level to be 2.68/5 and enforcement of policies and legislation, data
exchange among systems, and ICT infrastructure business continuity plans are the main challenges
of Ethiopian HIS requiring further investment (Biru, et al., 2022).

Regarding the public health surveillance information system, 23 reportable diseases, including
maternal and perinatal death surveillance and response, are reported through the disease
surveillance system. Vital events and civil registration systems were implemented, the notification
rate of births and deaths were 75% and 4%, respectively, at the end of 2015 EFY (2015 ARM Report).
Regarding data quality, reporting completeness was 85% and the timeliness was incredibly low with
only 41% of institutions reporting timely in 2015 EFY. However, notification and registration of births
and deaths are still low especially at PHCU levels (MOH, 2023a).

Most findings from technical reports and research are indicating weaknesses in research coordination
and knowledge management, limited human resources, poor documentation, inadequate
implementation of data quality assurance and limited ICT infrastructure continue to challenge the
implementation of the health information system (MOH, 2023a).

2.3.5. Digital Health Technology:

Digital Health Technology (DHT) is a recent phenomenon in Ethiopia, their potential harnessing
clinical and public health practices are highly visible. The MOH has developed a digital health
blueprint to align its eHealth and digital health initiatives with the digital Ethiopia strategy. (MOH,
digital health blue print,2021). The MOH has been working to support the growing digital health
infrastructure and ensure the availability, reliability and security of health data and digital systems

14 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

(MOH, 2023a). Studies on use of EHR showed that a substantial number of health professionals
either are not ready or not willing to use technology (Manyazewal, et al., 2021). Another research
also has shown that only 46% of study participants who own smartphones were willing to use mobile
e-Partograph. Similarly, the use of advanced DHT like AI (Artificial Intelligence) is limited as indicated
by one study that has evaluated use of AI in eye care (Brant AR, et al., 2021).

Limited usability of digital interventions, digital skills of the workforce, poor infrastructure including
shortage of gadgets, electricity and connectivity, weak support system, huge implementation cost,
ownership of the systems, coordination of efforts, and governance have been major challenges to
advance digital health interventions. In general, the implementation of digital health interventions is
characterized by being slow in progress, poorly institutionalized to the sector, and limited in scope
of operation to certain programs and levels of the health system in particular areas (Teklu, 2021;
MOH, 2021c).

In addition to limited utilization of digital intervention and infrastructure, there is also weak device
management and tracking systems, including maintenance capacity. The major reason for the entire
shortfall has been availability of limited financial resources to scale up digital systems as per the
plan (MOH, 2023a). Digital health technology holds much promise tackling major clinical and public
health backlogs and strengthening the healthcare system in Ethiopia (Manyazewal, et al., 2021).

2.4. Service delivery

Service delivery platform:

Ethiopia’s health service delivery is structured into a three-tier platform system: primary, secondary,
and tertiary levels of care. Services are provided through these platforms, other approaches (e.g.,
household, schools, community centers, mobile services) and outreach services, campaigns, or
digital platforms. The service delivery platform is designed to ensure continuity and continuum
of care at all levels of care including private health facilities. The HEP is positioned, implemented,
and managed under the umbrella of the primary health care unit (PHCU). The HEP was recently
reformed to address the implementation challenges, community needs, epidemiological and
demographic shifts and optimize the program to sustain its contribution towards the attainment of
UHC. Implementation of the optimization roadmap has been initiated since 2021 (MOH, 2021; WHO
and UNICEF, 2020).

Service packages:

Selection of services: the development of the EHS package followed a transparent, consultative,
and evidence-based process. (Getachew , et al., 2020). The essential package of services was
revised in 2019. The service package was designed around the nine components (RMNCAH, MCD,
NCD, surgical and Injury care, Emergency and Critical care, NTD, Hygiene and Environmental Health
Services, Health education and behavior change communication services, Multi-sectoral nutrition
interventions) to be delivered across the spectrum of PHCU (Primary Hospital, Health Center,
Health Post and Community) and secondary and tertiary level of care and includes around 1,019
interventions (MOH, 2019). The essential health services (EHS) package for UHC is available but is
not guaranteed. Currently only 70 interventions are guaranteed through service exemptions. The
package does not include ageing-related services and does not identify routine services to be
maintained during emergency (MOH, 2019).

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 15

 Service design:

Empanelment systems. Community-based health insurance initiatives have supported

empowerment at primary care facilities. Nationally around 66% of the households are empaneled
under the CBHI. The empanelment does not offer choice to register with a specific provider /facility,
and it is annually renewed (MOH and WHO, 2023).

First contact accessibility: Basic Emergency care is provided at the first level of the health facility
i.e., health center. Improvement in access to critical emergency surgical services is being worked
upon by MOH to operate around 410 health centers with OR facilities. Access to critical services is
ensured without requirement for referral. Currently the family health practitioner is being trained in
emergency and person-centered care. Expanding the network of health posts and health centers
has improved geographic access as described in section 5.1. Existing policies, strategies such as
HSTP II, PHC HEP Optimization roadmap implementing strategies such as empanelment systems
through HEW and CBHI schemes are clearly promoting first contact accessibility to primary care.
Despite improved accessibility, there has been no commensurate improvement in the utilization
rates and demand for services. In addition, no incentives exist that promote primary care as first
point of contact for most care (e.g., removal of out-of-pocket payments and fee structures whereas
conditional access to specialist care, is partially coordinated through a longitudinal primary care
relationship

Referral system: The country has a national referral guideline, along with an ambulance directive and
standard operating procedures (SOPs). However, the referral guidelines are not fully comprehensive,
as they exclude health posts and health centers. The referral checklist and referral algorithm are
part of Ethiopian primary health care clinical guidelines (E-PHCG). However, explicit agreement may
be lacking between referring and receiving institutions, particularly the private health facilities.

Regarding the availability of Ambulance services, seemingly, the country has an ambulance-to-
population ratio of 1:40,760. However, currently, only 2944 (74%) ambulances are functional; while
1030 (26%) ambulances have been out of service due to different defects or total damages to
the vehicles but with repairability potential of 842 (82%) non-functional ambulances. Additionally,
there has been weak enforcement of the directives and a lack of digitalization which resulted in
ambulance misuse. Ref. HSDIP 2024.

Service availability: Availability of maternal and child health services including nutrition varies by
level of care, but vaccination, family planning, antenatal care, PMTCT, HIV, STI, and TB services
are widely available. Diagnosis and management services for diabetes, chronic respiratory and
cardiovascular diseases are provided in 36%, 53%, and 49% of facilities. Emergency services are
available at all primary hospitals and health centers (EPHI, 2018). According to a recent study, only
one-fifth (20%) of facilities were found rendering all basic health services. Curative child health
(89%), basic child care services like outpatient curative and growth monitoring (61%), modern family
planning (84%), antenatal care (75%) and child vaccination (75%) services are provided in most of
the facilities. Less than two-thirds of referral hospitals offer all basic client services. Availability of
components of basic client services ranged from 63% for all basic client services, to 69% for child
vaccination services, and to 100% for STI services (EPHI MOH and ICF, 2023).

16 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

Quality of services: Improving the quality of primary health care services remains a challenge
despite increased availability. Quality improvement initiatives have been implemented, but there
are still issues in all dimensions. Over 50% of patients in Ethiopia experience disrespect and abuse
while seeking healthcare, and patient satisfaction scores are low at 46% (Kruk, et al., 2018). Data
also show that recommended interventions are not being met in ANC, FP, and sick childcare. The
national healthcare quality score is at 53%, with safety and timeliness being challenging for users.
Surgical site infections and blood transfusion reactions are prevalent, and waiting times for elective
surgeries can be up to 55 days (Mann, et al., 2016; Gelaw, et al., 2020).

Ethiopia has been implementing different initiatives and reforms that aim at improving the quality
and accessibility of health service by means of maintaining continuum of care though the entire
level. One of the initiatives was improving the referral system at levels of care. Though there are
encouraging improvements, challenges remain there. Poor referral documentation, weak feedback
mechanism, no operational guideline for referral catchment, limited provider communication skill,
very weak communication among health care facilities, shortage of human resource which is affecting
referring and receiving site, lack of properly equipped ambulance, lack of basic amenities and
uneven distribution of number of patients’ between health facilities are among the key challenges
(MOH, 2023a; MOH, 2020b).

Though there are improvements in the service delivery among all platforms, lack of technical
and administrative linkages among levels of care, weak accountability, and disruption of
essential health services during emergencies, low staffing and client satisfaction are among the
major challenges. In addition, HEP service packages were redefined, and service delivery platforms
were restructured, but actual implementation of the new packages has been suboptimal. (MOH,
2023a).

Service utilization: OPD Utilization rate: The outpatient attendance rate has increased from 0.27 in
2000 to 1.5 per capita per year in 2023. There exists a notable regional disparity in performance, with
regions like Harari (2.7), Addis Ababa (2.7), Dire Dawa (2.0), Amhara (1.9), and SNNP (1.7) surpassing
the national average. Conversely, the remaining regions exhibited performance levels either below
or on par with the national average, with Somali (0.2) and Afar (0.5) being the least performing
regions (MOH, 2023). About 80% of OPD attendees receive care in primary health care units (health
centers and health posts), which serve as the primary point of contact for healthcare (MOH, 2023).

Equity in primary health care: Urban women receive more ANC and give birth in health facilities
more often than rural women. Child mortality rates are higher in rural areas, but the gap between
rural and urban areas has decreased over time (EPHI, 2018). Many women have limited access to
health services due to financial or geographic barriers, leading to low utilization and higher maternal
mortality rates. In 2016, 61% faced cost barriers, while 58% had to travel far for medical care. Wealthier
households had a 36% advantage. The gap between the lowest and highest wealth quintiles was
35.4%. (EPHI, 2018; Kruk, et al., 2018). Higher maternal education levels led to increased use of
RMNCH services. The gap in demand for modern family planning services between educated and
uneducated individuals was 22%, with Addis Ababa having the highest satisfaction rate (75.40%).
The coverage gap for four or more ANC services between uneducated and educated individuals
was 42.3% (MOH, 2021c)

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 17

 Resilience in Essential Health Services provision: The coronavirus disease of 2019 (COVID-19)
pandemic highlighted the wide-ranging impacts of emerging disease threats and the fragility of
health systems. Many health facilities faced critical challenges in maintaining normal operations and
even essential health services while responding to the pandemic. This highlights the need to invest
in strengthening the essential public health functions towards realization of a resilient health system
(Squires, et al., 2023). The readiness of the health system to deliver essential health services is
hampered due to COVID-19 and the conflicts that caused interruption of essential health services
and damage to health infrastructure, medical equipment and medicines, and displacement of
households & 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 (EPHI,
2022).

2.5. Community engagement and empowerment:

Ethiopia has implemented various community engagement approaches to increase participation of
communities in health systems for decades. The engagement of communities in health has been
more pronounced since the launching of the Health Extension Program (HEP) in 2003. To sustain the
gains, enhance the efforts of the HEP, improve its geographic penetration and further participation
of individuals, families, and communities in PHC, the government of Ethiopia introduced the Women
Development Army (WDA) strategy in 2011. This strategy has consolidated the gains of the HEP in
terms of improving RMNCH and hygiene practices (MOH, 2015a), (Maes, et al., 2015). A meaningful
community involving decision-making processes built on mutual trust and understanding have
resulted in influencing policies, service deliveries, priorities, processes, guidelines, and other PHC
related initiatives. Additionally, the community focused interventions approaches are resulted in
significantly higher coverage of PHC services at a low cost (Erku D, Khatri R, Endalamaw A, Wolka E,
Nigatu F, Zewdie A, et al. (2023)

Service uptakes and health development have improved with different communities’ participation
and ownership (Mesele , et al., 2020; Damtew , et al., 2018). Communities have contributed to health
facilities and ambulances. But community engagement approaches have faced challenges such
as sustainability and the ability to institutionalize social accountability approaches, limited capacity,
and coordination, support, and motivation systems. Model family training and the WDA extend basic
health services. But these strategies have problems such as low training quality and coverage,
political changes, and lack of sustainability. The strategies implemented so far were not suitable for
pastoral and urban settings (Teklu, 2021). Currently, the MOH, RHBs, and partners are implementing
the community engagement and empowerment strategies for agrarian setting by adding new
elements such as Village Health Leaders, men and youth engagement, informal structures, and
motivation schemes. Customization was also done for pastoralist settings (MOH, 2020c)

On the other hand, during HSTP I, the government introduced the Community Score Card (CSC)
social accountability tool to empower the community to regularly measure the responsiveness of
the health system, satisfaction of the community and identify priority areas of the health sector. The
CSC has been implemented in 67% of the PHCUs (Primary Health Care Units) in 2021/22 (MOH,
2015a). The average community scorecard measurements on health workforce behavior toward
patients, availability of services, patient waiting time, facility infrastructure, ambulance service,
and cleanliness and safety of the health facility significantly improved at primary health care units
(Mesele, et al., 2020).

18 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

However, there have been notable challenges in the implementation of community score cards which
include; poor implementation, lack of feedback systems, limited sustainability, and the challenge
of addressing illiterate populations. These challenges resulted in irregularity of joint community-
health facility meetings, the lack of adaptability and flexibility, poor responsiveness of government
institutions and actors, low health and health system literacy of the community, and low functionality
of facilitators (client councils) (MOH, 2017).

2.6. Public health emergency preparedness and response

Ethiopia’s public health system faces challenges from domestic and imported disease outbreaks.
Global factors such as urbanization, travel, and environmental changes also contribute to emergency
response challenges (EPHI, 2019)

Ethiopia faces numerous public health emergencies, including diseases like COVID-19, accidents,
rapid urbanization, conflicts, and environmental hazards. These challenges result in increased
morbidity and mortality rates across the population. The delay in detecting and responding to major
public health emergencies causes considerable damage. Median times for detection, notification,
and response are 13, 12, and 10 days, respectively (EPHI, 2019). Many African countries including
Ethiopia lack the necessary health systems to detect and respond to potential outbreaks or health
threats (Jung, et al., 2021).

1. SWOT Analysis

The SWOT analysis is done to identify ‘gains’ and `pains` of PHC using the readily available data.
Accordingly, strength and weakness are derived from the analysis of the health system (internal),
while opportunity and threat are synthesized from the analysis of macro environments (Politics,
Economy, Social Technology, legal frameworks (see Annex 1: the SWOT analysis matrix).

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 19

The Primary Health Care
Strategic Framework
3. Rationale for the development of the National PHC Strategic
Framework
The rationale of this PHC strategic framework is to:
• Define the concept and scope of PHC in the Ethiopian context.
• Provide guidance to realize coordinated and functionally integrated primary health care
• Create integrated, resilient, responsive, and accountable PHC oriented health systems in
all settings.
• Improve primary health care service delivery model
• Strengthen monitoring of primary health care performance

4. PHC Strategic Framework Development Processes and

Methods
This strategic framework emerged from a collaborative and participatory process involving multiple
stakeholders. It was initiated by the Ministry of Health (MoH) at the ministerial level, led by the
Minister herself, along with the Lead Executive office of Community Engagement and Primary Health
Care within the MoH, and the International Institute of Public Health (IIPHC). Discussions have been
held on the importance of the Primary HealthCare Strategic Framework for Ethiopia (PHCSF), and
consensus has been reached to develop it under the steering committee’s guidance and the
Minister’s leadership.

The process began with developing a preliminary concept paper and terms of reference (TOR) to
validate the framework’s importance and scope. This document outlined the rationale, objectives,
expected outputs, methodology, timeline, and budget for development. The TOR underwent critical
review by a Technical Working Group (TWG) before being approved by the steering committee led
by the service and program wing state minister for further action.

To engage various stakeholders, the subsequent workshops were held. Participants included
representatives from MoH departments and agencies, regional health bureaus (RHBs), academia,
health professional associations, the private health sector, the Prime minister’s office, relevant line
ministries, civil society organizations (CSOs), media organizations, National think tank group of
Primary Health Care and development partners. The workshops provided a platform to deliberate
on the concept paper, TOR, and PHCSF.

To facilitate stakeholder engagement, various governance structures were established with distinct
roles and responsibilities for guiding and supporting framework development. These included a
steering committee, a technical working group (TWG), and a core technical team (CTT).

The steering committee, composed of senior officials from the Ministry of Health (MoH) and
alongside key development partner representatives, provided strategic direction, oversight, and
approval for framework development. The TWG, comprising the Lead executive officer of Community
Engagement, experts from MoH departments, agencies, regional health bureaus (RHBs), academia,
and development partners, provided technical guidance, inputs, reviews, and validation of the
[Link] CTT, selected from the TWG based on extensive PHC experience and expertise,
drafted, revised, and progressive writeup of the framework document.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 21

 Throughout the process, a series of consultation platforms engaged internal and external
stakeholders and governance structures. These included regular meetings, workshops, online
surveys, and feedback sessions. Through these platforms, consensus was reached on the PHCSF
outline, defining the document’s structure and content. Adapting the WHO PHC definitions and
conceptual framework for the Ethiopian context guided our vision, mission, scope, theory of change
(TOC), and strategic objectives for PHC. The governance structure then reviewed, enriched, finalized
and validated the document’s content based on various evidence sources and perspectives.

Multiple evidence sources informed the framework through diverse methods. A scoping review of
relevant Ethiopian and international PHC literature and government documents was conducted,
utilizing checklists developed through consultation to ensure inclusivity. Facilitated discussions with
PHC policy, planning, implementation, monitoring, and evaluation experts in Ethiopia and elsewhere
used tailored questions and guides. Brainstorming sessions with the core team and TWG generated
ideas and insights, while stakeholder sessions gathered further input on challenges, opportunities,
strengths, weaknesses, priorities, and recommendations for Ethiopian PHC.

5. Definition of Primary Health Care

To align with the Ethiopian context, WHO primary health care definition is adapted. Accordingly;
PHC is a whole-of-society approach to health that aims to maximize the level of production and
distribution of health and well-being by bringing together the three interrelated and synergetic
components; integrated health service, multisectoral policy and action and empowered individuals,
families and communities.

6. Scope of the PHC

The Ethiopian Essential Health Service Packages (EHSP) blueprint, which was developed in 2019,
serves as the main guide for Primary Healthcare (PHC) service packages (EHSP, 2019). These
packages include various interventions outlined in the EHSP for Primary hospitals, health centers,
health posts, and communities. It is important to note that these service packages should be available
and provided at all levels of care in both public and private health sectors. These service packages
will be reviewed and updated to meet the needs of Universal Health Coverage (UHC) and health
security, ensuring that people of all ages receive appropriate care. Additionally, this framework will
give equal attention to agrarian, urban, and pastoralist settings. The urban and pastoralist areas
would greatly benefit from this framework as they currently lack clear primary healthcare (PHC)
strategies and rely solely on the agrarian PHC strategies.

As clearly described in the PHC definition above, PHC Primary health care encompasses primary
care and essential public health functions as the core of integrated health services; multisectoral
policy and action; and empowered people and communities to maximize the level and distribution
of health and well-being of a given population. This implies that PHC is not limited to the health
sector only. It requires the engagement and action of multiple sectors and the community to address
several determinants of health.

Primary Health Care allows a full package of health services (health promotion, disease prevention
interventions, treatment, rehabilitative and palliative cares) to a given population across the
continuum of care.

22 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

7. Vision, Mission, and Guiding Principles
Vision: To see a healthy, productive, and prosperous society

Mission: To promote the health wellbeing of the societies through providing and regulating a
comprehensive package of health services of the highest possible quality in an equitable manner

The Guiding Principles: Quality, Equity; Community empowerment; whole-person-centered, whole-

of-society approach, multisectoral coordination; public private partnership, social accountability,
appropriate technology; self- reliance, Integrated and comprehensive services, resilience, all hazard
approach, and timely action.

8. Theory of change
After studying numerous literature sources related to Primary Health Care (PHC), the WHO Primary
Health Care performance measurement and indicators (WHO and UNICEF, 2020) has been tailored
to suit the national scenario (see Figure 4). This TOC illustrates how addressing challenges related
to integrated health services, empowering individuals, and communities, and implementing multi
sectoral policies and actions through strategic measures can result in enhanced access, utilization,
equity, and quality of healthcare. It can also lead to improved participation, health literacy, and
healthcare seeking, and better health determinants, which help the country achieve its goal of
Universal Health Coverage (UHC) and improved health status.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 23

 Key Challenges Strategic Objectives Outputs Outcomes Impact

• Lack of multisectoral collaboration legal • Ensure the functionality of

framework leadership, governance and
Universal Health
• Limited regulatory functions in public multisectoral actions for PHC Improved access, Coverage
health sectors • Optimize Sustainable PHC and availability
financing Improved
• Limited engagement of private sector in
PHC • Improve infrastructure of Improved health
• Inadequate funding and fragmented health facilities availability and Improved status
• Improve health workforce readiness
financing system for PHC determinants of
• Below standard availability of tracer development and
Improved health
essential medicines and basic medical management for PHC quality and Equity
equipment at all levels of care • Ensure availability of Medicine utilization
• Substandard health infrastructure and medical technologies
• • Enhance digital health and
• Low health workforce density, skill mix,
competence and motivation innovation
• Limited data use culture, innovation, and • Optimize Health Information Improved health
knowledge management system Systems literacy and care
• Improve access, quality, and seeking
• Fragmentation and suboptimal program
alignment equity of PHC services at all
• Lack of contextualized service delivery levels
models • Enhance community
• Weak technical and administrative linkage engagement and
among levels of care empowerment.
• Limited sustainability and • Improve capacity of PHEM
contextualization of community system
engagement platforms
• Limited integration of PHEM to PHC
systems

Figure 4: Theory of Change of Ethiopian PHC

24 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

9. Goal of the PHC Strategic Framework
GOAL: The goal of this strategic framework is to guide the PHC to improve health outcomes of all
Ethiopians through universal health coverage, health security, and realization of a high-performing
PHC-oriented health system.

10. Strategic Objectives and major Interventions

Ethiopia’s health system has its own strength, as do outside opportunities or facilitators (refer to the
macro-environment analysis: section 2.1). While using the Primary Health Care Strategic Framework,
these must be optimized. Conversely, there are several obstacles and constraints facing the health
system (see health system situations analysis: section 3.2) which must be addressed appropriately.
Annex xx (SWOT Analysis) also details internal and external factors affecting the health system. In
order to maximize use of the available opportunities, to minimize any potential external threat, and to
overcome the health system challenges, the following strategic objectives and major interventions
are proposed. Collectively, it is assumed that these interlinked strategic objectives and the
corresponding interventions can result in achieving the intended goal of the strategic framework.

1. Enhance the functionality of leadership,

2. Optimize sustainable PHC financing.
governance and multisectoral actions for PHC

4. Improve Health workforce development and

3. Improve infrastructure of health facilities
management for PHC.

5. Improve availability of Medicine and medical

6. Enhance digital health use.
technologies

8. Improve access, quality, and equity of PHC

7. Optimize Health Information Systems
services at all levels

10. Enhance community engagement and

9. Improve PHEM system.
empowerment.

Table 1: list of strategic objectives

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 25

 10.1. Strategic Objective 1: Enhance the functionality of leadership,
governance and multisectoral action for PHC
In order to create transparent, responsive, and accountable health systems, it is essential to
establish robust leadership and governance mechanisms that adhere to both local and global best
practices. To achieve this goal, capacity building for governance will be prioritized to ensure that
primary healthcare service packages are effectively coordinated and delivered with engrained
accountability at all levels . Furthermore, there will be a strong emphasis on strengthening multi-
sectoral coordination and engagement by implementing the Health in All Policies (HiAP) approach
and actively involving the private health sector, civil society organizations and professional
associations in PHC.

Major Interventions

• Enforce the implementation of Essential Public Health Functions in the context of

Ethiopian PHC
• Enforce adherence to and proper implementation of regulations and standards
• Design mechanisms that ensure the health systems are transparent, responsive,
and accountable to the public.
• Ensure meaningful participation & engagement of communities, professional
associations and civil society organizations in decision-making processes related
to PHC.
• Increase resource allocation and proper utilization for PHC at all levels
• Enhance the PHC leadership and governance capacity to effectively coordinate
and deliver PHC interventions in all contexts.
• Design and implement mechanisms that improve women’s leadership in PHC.
• Restructure health regulation, purchasing, and provider function of the health
system.
• Restructure the PHC leadership and governance systems which include Woreda
health office capacity and the role of primary hospital in PHC governance.
• Establish a mechanism for regular assessment and PHC- related research to
generate evidence on population health need
• Enhance the engagement of private health sector in PHC
• Redesign and implement multi sectoral coordination, collaboration, and
accountability legal framework for PHC
• Implement and design a mechanism to monitor health in all policies and strategies
• Establish a system for the implementation of continuous PHC advocacy

26 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

10.2 Strategic Objective 2: Optimize Sustainable PHC financing
To ensure effective financing of primary health care (PHC), it is crucial to prioritize quality services
that align with the country’s defined PHC packages, while also minimizing financial strain on families
and preventing catastrophic expenses. This can be accomplished by establishing or strengthening
a system that ensures the equitable allocation of resources.

Major Interventions

• Enhance domestic resource mobilization including innovative financing for PHC

• Establish and implement Health funding mechanism
• Improve PHC financing monitoring systems
• Establish strategic health purchasing and define payment mechanisms for PHC.
• Diversify and strengthen health insurance schemes
• Monitor the reimbursement of fee weaver and exempted services
• Identify inefficiencies in PHC spending to improve effectiveness and efficiency in
PHC financing.
• Enhance financial management capacity at all levels.
• Increase proportion of PHC spending from total health expenditure (THE)
• Implement performance-based financing mechanisms to improve the quality and
efficiency of PHC services.
• Strengthen Public-Private Partnerships to leverage additional resources and
expertise for PHC financing

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 27

 10.3 Strategic Objective 3: Improve infrastructure of health facilities
Infrastructure development plays a vital role in establishing a robust and efficient healthcare system.
It encompasses a wide range of elements, including physical facilities, basic amenities, and medical
equipment. This entails activities such as constructing new infrastructure, expanding existing
facilities, and conducting regular preventive maintenance to ensure optimal functioning.

Major Interventions

• Improve equitable access to quality health infrastructure

• Regularly assess the health facilities following standards and timelines set in the
infrastructure roadmap
• Updating and applying national health facility standards
• Ensure the availability and functionality of basic amenities in all types of health
facilities
• Undertake regular health infrastructure and capacity assessment
• Develop mechanisms that respond to community input around basic improvements
in health facilities
• Work towards making healthcare facilities climate resilient and align with MOH
climate and health action plans
• Accelerate the restoration of damaged health infrastructure

28 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

10.4. Strategic objectives 4: Improve Health Workforce development and
management for PHC
The focus of this strategic objective is to ensure that the primary healthcare workforce meets
the required ratio of health professionals with the appropriate gender and skill mix. This will be
achieved by implementing effective HR management systems, providing adequate supervision,
offering appropriate compensation, and providing continuous professional development packages
that will enable them to be competent, motivated, and passionate about their work. In addition, it
is important to consider primary healthcare qualifications when recruiting and producing health
professionals based on the international standard classification of occupations (ISCO).

Major Interventions

• Conduct robust workforce planning and forecasting exercises to determine the

current and future needs of the PHC workforce.
• Implement regulatory frameworks for PHC workforce in the public and private
health facilities.
• Develop and implement comprehensive PHC related continuous professional
development and integrate with re-licensing
• Improve quality of Pre-Service Education
• Ensure an equitable distribution of health professionals in PHC settings to address
geographical and population disparities.
• Implement regular supportive supervision and mentoring programs to provide
guidance, feedback, and support to PHC providers.
• Encourage task shifting and task sharing to different cadres of health workers to
optimize their skills and address workforce shortages
• Explore and implement packages to improve the productivity and performance of
the PHC health workforce.
• Develop a comprehensive and binding motivational package for PHC workforce
• Design and implement tailored and evidence-based HR deployment systems
• Develop and implement clear career path to HEWs and revisit/update training as
relates to PHC

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 29

 10.5. Strategic objective 5: Improve availability of Medicine and medical
technologies
Medicines and medical technologies are essential in providing health services at all levels of care.
This strategic objective emphasizes the sustained availability of quality, safe and affordable essential
medicines, and medical technologies. Additionally, the strategic objective addresses regulatory
issues that ensure drug safety, quality and efficacy of essential drugs, promotion of local production
of essential medicines and medical equipment.

Major Interventions

• Explore and implement innovative supply chain management systems including

digital technologies, and private sector engagement.
• Ensure end to end visibility of medical supplies at all levels of the Supply Chain
System
• Expand community pharmacy and diagnostic laboratories.
• Promote rational use of medicines and medical products
• Design and implement efficient uses of supplies like reverse logistics
• Strengthen access to affordable and quality-assured essential medicines,
diagnostics and medical equipment.
• Promote local production capacity of medicines and medical products
• Strengthen regulatory systems for medicines and medical products
• Expanding last-mile delivery from hub to health facilities

30 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

10.6. Strategic objective 6. Enhance digital health use
Digital health involves the use of digital technologies and innovations to enhance the health
and well-being of individuals and communities. Ethiopia has adopted digital health tools such
as telemedicine, health information system, supply chain and others to enhance the quality and
accessibility of healthcare services. More efforts are needed on enhancing the emerging DHTs
including artificial intelligence, cyber security, and others to materialize the country’s strategy on
Digital Health. Therefore, this strategic objective focuses on enhancing the digital health platforms
and implementation and use to improve effectiveness, quality, and efficiency of health systems.

Major Interventions

• Build the Capacity of leadership and health workers on digital health

• Explore and implement innovative approaches to create paperless healthcare
facilities and woredas
• Expand ICT infrastructure and governance
• Accelerate the implementation of digital health blueprint and strategic plan

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 31

 10.7. Strategic objective 7: Optimize Health Information Systems
Timely, adequate, and reliable health information is often needed to take prompt actions and make
appropriate and effective decisions on the inputs and processes of PHC service delivery. Having
managed population and facility-based health data is also important to make the system responsive
to growing population health needs, outbreaks, and other health conditions. This strategic objective
ensures the optimization of PHC- related HIS (Health Information System) and digitalization of health
information, data quality and utilization and national digital health blueprint.

Major Interventions

• Strengthen data generation, use, access and sharing to improve visibility and
accountability
• Strengthen routine HIS, IHRIS, LMIS, MEMIS, IFMIS at community and facility levels
• Strengthen data quality assurance (LQAS, RDQA,) system
• Strengthen governance of the health information system
• Enhance the capacity of program managers and implementers to generate and
use information.
• Expand Electronic Medical Record (EMR) implementation
• Expand e-CHIS implementation
• Expand vital events and civil registration system
• Establish a mechanism which ensures the undertakings of PHC- oriented research
on regular basis

32 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

10.8. Strategic objective 8. Improve access, quality, and equity of PHC
services at all levels
This strategic objective aims for ensuring access to quality, affordable and equitable essential
healthcare through enforcing functional linkage of healthcare facilities, integration of service,
designing and implementing different models of care specially for underserved and populations
with special needs and optimum utilization of digital technologies. This strategic objective would
also ensure the private health facilities’ engagement in PHC.

Major Interventions

• Design and implement quality improvement initiatives at all levels of care

• Implement national health care quality and safety strategy
• Promote Public health innovations
• Ensure accessibility of first contact at all levels of care
• Strengthen impalement system
• Improve household, community and institutional WASH and Environmental Health
initiatives
• Strengthen functional linkages and smooth referral system at all levels of care
• Revise and implement essential health service packages
• Standardize and contextualize service delivery models with special focus for
gender, people with special needs, mobile and displaced communities
• Accelerate implementation of Health Extension Program optimization
• Strengthen family health team approach at urban settings
• Establish mechanisms to ensure resilient health facility and services
• Promote and implement service delivery standards and regulatory framework
• Ensure the provision of integrated and comprehensive care at levels of care
• Harness the use of digital health technologies to improve access to health care
• Establish a system that promotes traditional medicine
• Explore and utilize the potential of private health sector in PHC implementation
• Promote life-style modification

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 33

 10.9. Strategic Objective 9. Improve PHEM system
This strategic objective aims to build a resilient primary health care-oriented health system that
can cope with public health emergencies (PHEs) by strengthening and integrating emergency
preparedness and response within the core functions of primary healthcare facilities.

Major Interventions

• Devise a strategy/ guideline to ensure the operationalization of essential public

health functions
• Strengthen surveillance and early warning system
• Strengthen emergency preparedness and response mechanism at all levels
• Implement PHEM legal framework to realize coordinated management of PHEs
• Optimize PHE management system at community and facility levels
• Strengthen the implementation of national health security action plan
• Devise mechanism to create climate resilient health system
• Conduct regular exercises, surge planning, and community engagement to ensure
readiness and response of health care facilities
• Strengthen and Integrate emergency preparedness and response within routine
health system function

34 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

10.10. Strategic Objective 10: Enhance community engagement and
empowerment
This strategic objective aims to empower individuals, families and communities through the
development and implementation of a comprehensive, context-specific community engagement
strategy. It will focus on strengthening social accountability and promoting meaningful engagement
of individuals, families, and communities.

Major Interventions

• Ensue and enhance the implementation of tailored and comprehensive

community engagement strategies (Mobilization and awareness raising,
Participation in planning and decision-making, Community action and ownership,
Monitoring and evaluation) for different contexts (urban, agrarian, pastoral, and
semi-pastoral).
• Enhance social accountability systems through assessing past interventions
and seeking out ways to incorporate into existing systems
• Develop a strong social accountability legal framework and authority by
integration into government annual planning and budgeting cycle
• Explore and implement strategies to improve health and health system literacy
for individual, family, and community
• Strengthen community representations at health facility governance systems

Prioritization and key Milestones

The Primary Health Care Strategic Framework (PHCSF) provides a 10-year vision for organizing and
improving Primary Health Care and the overall health system, aimed at achieving Universal Health
Coverage (UHC) and health security. It outlines a phased approach (three milestones) aligned with
the Health Sector Development and Investment Plan (HSDIP) and HEP Optimization Roadmap
starting from 2024-2026 and stretching to 2030 and beyond, featuring 10 interrelated strategic
objectives. The framework emphasizes a dual-faceted prioritization strategy that addresses both
strategic goals and geographic needs, ensuring targeted and impactful interventions. It includes
an implementation plan that sets priorities for thematic and geographic areas, with initial critical
interventions during the first three years (first milestone/Phase) and with adjustments for the
subsequent milestones based on performances of the first phase. This approach links the strategic
framework to practical investments and improvements.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 35

 Methods of Prioritization

1. Geographic prioritization

Geographic prioritization was carried out by prioritizing Woredas of all regions using composite
index (service delivery coverage (42%) and health system capacity to deliver services (58%). Service
packages were selected based on BOD while health system capacity has been determined by
several resource inputs (HR, physical infrastructure and basic amenities, budget, geo-locations,
damage to HCFs due to conflicts, type of settlements and others). Please refer to the PHC investment
and implementation Plan.

2. Thematic Prioritization

Thematic prioritization focuses on phased interventions categorized into Milestone 1, milestone 2,

and Milestone 3 areas. It is better to note that the third Milestone goes beyond PHCSF life span
(2030). This phased approach allows for immediate and critical needs to be addressed, aligning
with the current HSDIP and the intervention areas identified in the HEP Optimization roadmap. It also
lays the groundwork for sustainable improvements over the rest of the implementation Milestones.

Accordingly, Milestone 1 priority interventions focus on:

• Delivery of Essential Health Services by implementing a comprehensive and basic health

post model through the Health Extension Program (HEP) to deliver essential health service
packages and public health functions; as well as by strengthening the HCs to complement
health post service deliveries.
• Ensuring community- based strategies and interventions related to HEP to promote
multisectoral actions and community empowerment.
While Milestone 2 Interventions are designed to strengthen systems and processes to ensure
the continuity and improvement of services such as geographical scaling of phase-one actions,
enhancement of service deliveries (shifting towards strengthening higher PHCUs, i.e. Primary
Hospitals. This phase also includes implementing the designated Milestone 2 Interventions.

Milestone 3 Interventions are meant for further geographical scaling and sustainability of the
preceding phases actions: continuing infrastructure improvements and health information system
enhancements and supporting long-term health sector goals through policy development and
advocacy platforms. Annex 2 summarizes PHCSF`s ten strategic objectives and the corresponding
major interventions which are going to be implemented in the three milestones. The major
interventions also will be further decomposed to detailed activities.

36 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

11. Implementation arrangement of the Framework
It is crucial to design and utilize an implementation arrangement to operationalize the strategic
objectives of this strategic framework. This arrangement aims to facilitate its implementation at all
levels of the health system and by relevant stakeholders. The following implementation arrangements
are designed to address systemic challenges of Primary Health Care (PHC) in Ethiopia and ensure
smooth implementation of the strategic framework.

11.1. PHC Governance:

One of the key drivers for successful implementation of any program is the strength of governance
structure. In this regard, the success of effective governance is measured by leading and creating
a responsive, inclusive, accountable, transparent, and engaging PHC oriented health care delivery
system. As part of the PHC governance system, the current health governance system will be
reviewed and revised as deemed necessary. At national, regional, and sub-regional level, PHC
governance platforms will be strengthened /established.

11.2. Integrated implementation:

To address fragmentation of service delivery and ensure continuum of care, key program initiatives
will be implemented in an integrated manner at all levels of care. The integration will ensure whether
cross-cutting issues such as gender, equity, and quality are well addressed in the implementation
process. To realize this system will be designed to ensure functional linkage between health facilities.

11.3 Multi-sectoral policy and actions:

Multi-sectoral policy and action from the PHC perspective is aimed at systematically addressing
broader determinants of health (including social, economic, and environmental factors, as well
as individual characteristics and behaviors) through evidence-informed policies and actions
across all sectors. Multi-sectoral collaboration will be strengthened through implementation and
institutionalization of the Health in All Policies (HiAP) framework in Ethiopia. As part of this different
mechanism will be designed and implemented to ensure engagement and collaboration of
stakeholders.

11.4. Private health sector engagement:

The role of private health care is evolving from time to time in Ethiopia. Considering their capacity
in terms of human resources and health care technologies, strategies will be designed and
implemented to engage them in the health system strengthening activities.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 37

 12. Monitoring, Evaluation and Learning
Monitoring, evaluation, and learning on PHC are integral to the overall MEL system of the health
sector. It focuses on a collaborative process involving continuous tracking of standard/tailored
indicators measuring the extent to which PHC is adopted as an approach to health service delivery,
financing, and regulation and the PHC system delivers the results it is supposed to deliver to society.
A separate system will not be introduced for monitoring PHC in Ethiopia; rather, MEL plans for PHC
will be integrated in the overall national processes for health sector planning, monitoring, review,
and accountability mechanisms. The performance of PHC will be monitored and evaluated regularly.
Periodic evaluation of the performance of PHC will be supported by evidence generated through a
routine information system at all levels. A national PHC performance evaluation will be conducted
every five years using standard evaluation tools. To augment performance, cross-learning will be
facilitated within and between public and private health facilities.

12.1. Measures
The PHCSF implementation monitoring framework is adapted from the PHC measurement
framework3. it provides a logical -based framework for monitoring performance and progress
in PHC implementation based on the TOC by linking the 10 Strategic objectives (health system
components) into a results chain (structures, inputs, processes, outputs, outcomes and impact) (see
Figure 3 below) in order to monitor PHC capacity performance, and impact

The framework illustrates the logical relationship between the domains, showing a causal pathway
or direction of influence that links PHC structures, inputs, and processes (presented in the TOC as
10 strategic Objectives) to desired results (outputs, outcomes and impact).

The framework shows how investments in PHC-oriented health system capacities (structure
and inputs such as governance, financing and health workforce) can result in improved PHC
performances (service delivery processes and outputs which include improved model of care;
accessibility, utilization, and quality of health services). Better outcomes (such service coverage
and financial protection) and an overall impact on health status can result from those enhanced
processes and outputs. These outcome and impact indicators are completely in line with the current
Ethiopian HSDIP and global health-related SDG indicators. The full list of indicators is presented in
Annex 3.

3 PHC performance and Impact. Primary health care measurement framework and indicators: monitoring health systems, WHO and UNICEF, 2022

38 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

 Health System determinants

Structure Inputs process Outputs

Impacts
Access and availability
Health Infrastructure
Governace Models of care (Selection (accessibility, afordability,
Health workforce (EHSP), design, facility acceptability; service
availability and readiness; UHC (service
management, linkage
service utilization) coverage;
with community)
financial Improved
Financing Medicines and other
protection) health status
health products
Systems for quality Quality of care (first
Adjustment to improvement contact accessibility,
population Health Information continuity,
health needs comprehensiveness,
people centeredness, Health security
Digital technology for Resilient health facilities
and services safety)
health

Monitoring capacity of PHC Monitoring Performace of PHC Monitoring impact

Figure 3: PHCSF monitoring conceptual framework

12.2. Data Sources

Data for measuring the extent to which PHC is used as an approach in the health system and its
performance in ensuring access to quality assured essential health services will be obtained from
multiple sources, including routine service delivery data reported through DHIS2, health facility
assessments, financial information systems and national health accounts, regular household surveys,
supply chain assessments, and other relevant studies. As an approach to the overall functions of
the health system, PHC will be prioritized in all health system assessments. Routine information
systems, including DHIS2, IPLS (Integrated Pharmaceutical Logistic Management System), LMIS,
and iHRIS will provide data on service delivery, health system inputs, and outputs on a monthly and
quarterly basis with disaggregation by level of service delivery.

Data on community engagement and empowerment and multi-sectoral collaboration will be

obtained through a horizontal data sharing mechanism aligned with platforms for multi-sectoral
coordination, collaboration, and accountability for PHC at all levels of the health system. The health
sector will provide and receive routine data with other relevant sectors. A regular review of “Health
in All Policies” will supplement routine data from the multi-sectoral data sharing system.

12.3. Routine Monitoring of PHC

Data from all routine sources will be synthesized and reviewed quarterly at all health system levels.
Service delivery facilities and administrative structures of the health sector will review the three
components of PHC as a major part of their regular performance monitoring activities. The focus
of this review is to track the progress of implementation of PHC-related action plans and adopt
performance improvement measures at all levels.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 39

 12.4. Health Facility Assessments:
Health facility assessments will be conducted regularly with an integrated approach that allows data
collection on health readiness of health facilities, service availability, and quality of care. The primary
focus of these regular assessments will be on primary care. The assessments will standardize
fragmented efforts that gather health facility data sporadically into a harmonized and integrated
system conducted regularly.

12.5. PHC Dashboard

A dashboard that pulls data on all PHC indicators in one simple visualization platform will be in place.
This provides PHC stakeholders an open access to close to real-time status of PHC in Ethiopia.
The dashboard will pull data from all routine health information systems and regular health facility
assessments.

12.6. Primary Health Care Review Meeting

All relevant stakeholders of PHC will convene once a year to review the overall situation of PHC in
the country, including the extent to which PHC is prioritized and is being used as an overarching
approach in the health system, and its performance at all levels of the health system. The health
sector annual review meeting will be used as a core platform to discuss on “the State of PHC in
Ethiopia.”

40 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

13. References
1. Bayked, E. et al., 2023. The impact of community-based health insurance on universal health coverage in Ethiopia:
a systematic review and meta-analysis.. Glob Health Action, 16(1):2189764(doi: 10.1080/16549716.2023.2189764.
PMID: 36947450;PMCID: PMC10035959.).

2. Biru, A. et al., 2022. Pathways to improve health information systems in Ethiopia: current maturity status and
implications.. Health Research Policy and Systems, 20([Link] p. Article
number: 78 (2022).

3. Bogale, A., 2021. Implementation status of health management information system in hospitals of southwest
Shoa zone, Oromia, central Ethiopia.. ClinicoEconomics and Outcomes Research, 13 ([Link]
CEOR.S288998), pp. 1-8.

4. Brant AR, et al., 2021. Artificial intelligence in global ophthalmology: using machine learning to improve cataract
surgery outcomes at Ethiopian outreaches. Cataract Refract Surg., Issue doi: 10.1097/[Link].0000000000000407.
PMID: 32932371., pp. 47(1):6-10.

5. Central Statistical Agency, 2016. Ethiopia Demographic Health survey., Addis Ababa: CSA.

6. Damtew , Z. et al., 2018. Correlates of the Women’s Development Army strategy implementation strength with
household reproductive, maternal, newborn and child healthcare practices: A cross-sectional study in four
regions of Ethiopia.. BMC Pregnancy Childbirth , Issue doi: 10.1186/s12884-018-1975-y. PMID: 30255789;
PMCID: PMC6157249., p. 18(Suppl 1):373..

7. EPHI MOH and ICF (Internal Control Framework)., 2023. Ethiopia Service Provision Assessment 2021–22 Final
Report., Addis Ababa, Ethiopia, and Rockville, Maryland, USA (United States of America: s.n.

8. EPHI, 2018. Service Availability and Readiness assessment, Addis Ababa: MOH.

9. EPHI, 2019. Public Health Emergency Management, Addis Ababa: EPHI.

10. EPHI, 2021. Ethiopia Health Atlas, 2021, Addis Ababa: Burden of Disease Unit ( BoD ), National Data Management
Center (NDMC) for health, Ethiopia Public Health Institute.

11. EPHI, 2022. ETHIOPIA CONFLICT IMPACT Assessment and Recovery and Rehabilitation Planning (CIARP),
Addis Ababa: MOH.

12. Erku D, Khatri R, Endalamaw A, Wolka E, Nigatu F, Zewdie A, et al. (2023) Community engagement initiatives in
primary health care to achieve universal health coverage: A realist synthesis of scoping review. PLoS ONE 18(5):
e0285222.)

13. FDRE Planning and Development Commission, 2021. Ethiopia 2030: The Pathway to Prosperity., Addis Ababa:
FDRE (Federal Democratic Republic of Ethiopia).

14. GBD 2019 Diseases and Injuries Collaborators., 2020. Global burden of 369 diseases and injuries in 204
countries and territories, 1990 – 2019: a systematic analysis for the Global Burden of Disease Study. Lancet, pp.
396(10258):1204-1222. doi: 10.1016/S0140-6736(20)30925-9. Erratum in: Lancet. 2020 Nov 14;396(10262):1562.
PMID: 33069326; PMCID: PMC7567026..

15. Gelaw, Y., Woldu, B. & Melku, M., 2020. Proportion of Acute Transfusion Reaction and Associated Factors Among
Adult Transfused Patients at Felege Hiwot Compressive Referral Hospital Bahir Dar, Northwest Ethiopia: A Cross-
Sectional Study. J Blood Med., Issue doi: 10.2147/JBM.S250653. PMID: 32636689; PMCID: PMC7335267., pp.
11:227-236.

16. IHME and WHO, 2021. Rehabilitation Need Estimator. Washington: University of Washington Available from
[Link] Accessed February 2, 2023.

17. Jung, A. et al., 2021. National responses to covid-19: drivers, complexities, and uncertainties in the first year
of the pandemic.. BMJ, Issue doi: 10.1136/bmj-2021-068954. PMID: 34840138; PMCID: PMC8624066., p.
28;375:e068954..

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 41

 18. Kitew, Y., 2017. Ethiopia Health Care 2050. 27, 1- 9. [Online] Available at: [Link]
uploads/2020/02/Dr_YayehYirad_Kitaw_Eth-Health_Care2050.pdf [Accessed October 2023].

19. Kloos , H., 1998. Primary Health Care in Ethiopia: From Haile Sellassie to Meles Zenawi.. JSTOR, pp. 5(1), 83–113..

20. Kruk, M. et al., 2018. High-quality health systems in the Sustainable Development Goals era: time for a revolution..
The Lancet Global Health Commission, Issue [Link] p. 1196–1252. .

21. Maes, K., Closser, S., Vorel, E. & Tesfaye, Y., 2015. A Women’s Development Army: Narratives of community
health worker investment and empowerment in rural Ethiopia*, s.l.: JSPH.

22. Mann, C., Dessie, E., Adugna, M. & Berman, P., 2016. Measuring Efficiency of Public Health Centers in Ethiopia,
Boston, Massachusetts and Addis Ababa, Ethiopia: Harvard T.H. Chan School of Public Health and Federal
Democratic Republic of Ethiopia Ministry of Health.

23. Manyazewal, T. et al., 2021. The potential use of digital health technologies in the African context : a systematic
review of evidence from Ethiopia.. Npj Digital Medicine, Issue doi: 10.1038/s41746-021-00487-4. PMID: 34404895;
PMCID: PMC8371011., p. 17;4(1):125..

24. Mesele , D. A. et al., 2020. Enhancing Leadership, Management and Governance Competencies for Performance
Improvements at Primary Health Care Entities in Ethiopia: A Quasi-Experimental Study Design. Issue [Link]
org/10.21203/[Link]-18051/v1.

25. Ministry of Education , 2021. Annual Report 2021/22, Addis Ababa, Ethiopia: MOE.

26. Misganaw, A. et al., 2017. National Mortality burden due to communicable, non communicable and other diseases
in Ethiopia 1990-2015, s.l.: s.n.

27. MOH, GFF and World Bank, 2019. Ethiopia Private Health Sector Assessment Report. [Online] Available at: https://
[Link]/sites/gff_new/files/documents/[Link]
[Accessed 30 October 2023].

28. MOH, 2015a. Health Sector Transformation Plan I 2015/16-201920, Addis Ababa: MOH.

29. MOH, 2015b. National health care financing strategy 2015-2035, Addis Ababa, Ethiopia: MOH.

30. MOH, 2017. Creating Accountability through implementing Community Score Card, Addis Ababa: MOh.

31. MOH, 2019a. HEP National assessment: Abridged report, Addis Ababa: MOH.

32. MOH, 2019b. National Health Accounts 2019, Addis Ababa: MOH.

33. MOH, 2019c. Essential Health Services Package of Ethiopia, Addis Ababa: MOH.

34. MOH, 2020a. Realizing Universal Health Coverage through Primary Health Care: A Roadmap for Optimizing the
Ethiopian Health Extension Program 2020 – 2035., Addis Ababa,: Ministry of Health.

35. MOH, 2020b. National Referral Guideline, Addis Ababa: Ethiopian Ministry of Health.

36. MOH, 2020c. Revised Community Engagement Approaches, Addis Ababa: MOH.

37. MOH, 2021b. Health and health related indicators, Addis Ababa: MOH.

38. MOH, 2021c. Annual performance of health sector report of Ethiopia, Addis Ababa: MOH.

39. MOH, 2021. Health Sector Transformation Plan II, Addis Ababa: MOH.

40. MOH, 2022. Ethiopia Conflict , s.l. s.n

41. MOH, 2023a. Mid Term Review, Ethiopia Health Sector transformation plan, Addis Ababa: MOH.

42. MOH, 2023b. HEP Optimization implementation rapid assessment, Addis Ababa: MOH.

43. MOWIE, 2019. National Electrification Program 2.0: Integrated Planning for Universal Access, Addis Ababa.
Ethiopia: Ministry of Water, Irrigation, and Electricity,.

44. MOH 2021h. National Strategic Plan for the Prevention and Control of Major Non-Communicable Diseases,
2020/21-2024/25, Addis Ababa, Ethiopia

42 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

 45. National Bank of Ethiopia, 2021. Annual Report 2021/22, Addis Ababa: NBE.

46. National Planning Commission, 2017. Ethiopia’s Progress towards Eradicating Poverty: An Interim Report on
2015/16 Poverty Analysis Study. , Addis Ababa: National Planning Commission.

47. NBE, 2009. NBE’s Monetary Policy Framework , Addis Ababa: NBE.

48. NPC, 2015. Performance under the first growth and transformation plan (GTPI) (2010\11-2014\15), Addis Ababa:
NPC.

49. Nakamura, S., Bundervoet, T. and Nuru, M. 2019. Rural Roads, Poverty, and Resilience Evidence from Ethiopia.
World Bank Policy Research Working Paper 8800.

50. Pakdaman, . M., Askari,, R., Askarisha & Geravandi, S., 2019. The Effects of Macroeconomic Indicators on Health
Care Expenditure in Iran.. Journal of Education and Health Promotion,, pp. 8, 123.

51. Rasanathan K. et al 2017. Governing multisectoral action for health in low- and middle-income countries; PLoS
Med 14(4): e1002285 available at [Link]

52. Squires , N. et al., 2023. Essential public health functions: the key to resilient health systems.. BMJ Glob Health,
Issue doi: 10.1136/bmjgh-2023-013136. PMID: 37438050; PMCID: PMC10347478., p. 8(7):e013136..

53. Sternberg, K. et al., 2019. Guide posts for investment in primary health care and projected resource needs in 67
low-income and middle-income countries: a modeling study. The Lancet Global Health , 7(11 DOI:[Link]
org/10.1016/S2214-109X(19)30416-4), pp. E15000-E1510.

54. Teklu, A. M., 2021. The Primary Health Care (PHC) capacity in Ethiopia using a PHC regression model: final
report,, Addis Ababa, Ethiopia: MERQ Consultancy PLC..

55. Transitional Government of Ethiopia, 1993. Health Policy of the Transitional Government of Ethiopia, Addis
Ababa, Ethiopia: Transitional Government of Ethiopia.

56. WHO and UNICEF, 2020. Operational framework for primary health care: transforming vision into action,
Geneva License: CC BY-NC-SA 3.0 IGO.: WHO and UNICEF.

57. WHO, 2017. Global strategy on human resources for health: Workforce 2030, Geneva [Link]
resources/global strategy workforce 2030: WHO.

58. WHO, 2022a. Data from the Global Health expenditure database, 2022, Geneva, Switzerland: WHO.

59. WHO, 2022b. Health Labour Market Analysis (HLMA) for Ethiopia; 2022, Addis Ababa, Ethiopia: WHO.

60. World Bank, 2007. Ethiopia: Capturing the Demographic Bonus in Ethiopia. Gender Development and
Demographic Actions., s.l.: World Bank.

61. World Health Organization, 1997. Intersectoral action for health: a cornerstone for health-for-all in the twenty-first
century,” in Proceedings of International Conference on Intersectoral Action for Health, Halifax, Canada: WHO.

62. Yitbarek , K. et al., 2023. Capacity of the Ethiopian primary health care system to achieve universal health
coverage: a primary health care progression approach.. Health Policy Plan, Issue 38(4) doi: 10.1093/heapol/
czad013. PMID: 36760182., pp. 474-485.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 43

 14. Annexes
Annex 1: SWOT Analysis

The following SWOT analysis is based on the” strength” and “weakness “which are derived from
situational analysis of the health system, while the opportunity and threat are synthesized from the
analysis of macro environments (Politics, Economy, Social and Technology).

Health System
Strength Weakness
(internal factors)

Leadership and • Availability of enabling environment • PHC governance structure and functions are
governance for PHC (I.e. national health policy, weak and fragmented notably at regional and
national EHSP blue print, health sub-regional levels
facility standards; several PHC-
• governance accountability mechanism is not well
related strategies and guidelines
established
• PHC lacks explicit definition
• Weak PHC regulatory system at all levels
• Double standard regulatory enforcement at
private health facilities
• Limited engagement of private sectors in PHC
interventions
• Limited/ lack of multi-sectoral engagement in
PHC endeavors
• Limited Gender and disability mainstreaming in
PHC
• Minimal budget allocation to PHC
• lack of segregation and standardization of
provider, purchaser and regulatory functions.

PHC financing • Availability of exempted services • PHC is underfinanced to deliver the required
and waiver systems for who can’t essential health service because, Proportion of
pay for services government budget allocation to health is low as
compared to Abuja`s target
• Creation of resource mobilization
mechanisms to fill gaps of health • There is no clear strategy for financing PHC
care financing
• Narrow fiscal space at regional and district level
• The availability of domestic health
• Budget allocation for preventive and promotive
financing system such as HCF, CBHI,
care is low as compared to that of curative
private wing service in public health
services
facilities and revolving fund the
presence NHA • Delayed implementation of social health
insurance
• OOP expenditure is still high and (31%) against
WHO`s threshold (20%)
• Low financial management capacity at woreda
level

44 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

 Medicines and • Availability of essential drug and • Weak PHC supply chain management system
other health medical list notably at PHCU level
products
• Standardization of the pharmacy • Frequent stock out and erratic supply of PHC
services essential medicines and medical equipment as a
result of internal and external factors
• The implementation of APTS at
health facility
• Presence of Integrated
Pharmaceutical Logistic
management system (IPLS)
• Introduction of community pharmacy
• Engagement of private sector in
local production of pharmaceutical
supplies

Human resource • Availability of national HRH strategy • Lack of adequate and motivated multidisciplinary
for health and health workforce accounts team at PHC
• Increased and sustained HRH • Low health workforce density in all professions as
production of mid-level professionals compared to WHO standard
• Availability of In-service training, • The current professional development system
and upgrading training to improve is inefficient and ineffective due to limited use
competence of the health of technology and lack of training program
professionals evaluation
• The availability of COC system • weak HRH management and regulatory system
for newly graduated as well as
• Lack of adherence to the health professional
upgrading health professionals
scope of work practice
• The introduction of CPD to renew
professional licence during practice.

Health • Rapid expansion of PHC facilities • Poor physical structure and inadequate basic
Infrastructure notably HCs and HP with potential amenities of all PHC infrastructures
health service coverage of more
• Weak mobile health services for hard-to-reach
than 100%
populations

Health Information • Establishment of routine HIS • Weak data use culture

System
• Initiation of community health • Limited data quality
information system
• Limited expansion of ECHIS at community level
• Limited expansion of EMR within the health
centre

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 45

 Service delivery • Availability of national EHSP blue • Limitations in PHC service delivery structure,
print, standards and guidelines process and outputs in terms of addressing
quality, equity, accessibility and resilience
• Institutionalized community health
services (health extension program • Demonstrated variability of health service equity
(HEP)) amongst the population by residential areas,
gender, age, wealth and education
• Availability of PHC services at all tire
systems of the country • PHC-related role and scope of secondary and
tertiary level care hospitals are not well defined
• Low client satisfaction on the service being
provided at PHC facilities
• Lack of comprehensive service at PHC
level against the evolving epidemiologic
shift and service need (mostly overlooked
the rehabilitation and palliative care service
integration with PHC)
• Lack of continuity and coordination of care within
PHC setting
• Poor PHC service quality in terms of technical
efficiency, client satisfaction, safety, timeliness of
care and respectfulness

Community • Establishment of strong community • limited sustainability and ownership of community

engagement health program (HEP) engagement
• The presence of community score • Limited use of alternative community
card engagement, and empowerment approach
• Introduction and redesign
community engagement approach
• introduction of contextualized
community engagement approaches
for pastoralist, agrarian and urban

Macro Opportunity Threat

environment
(External factors)

46 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

 Politic, Economy, • Decentralization of health • Slowdown in GDP growth due to numerous
social and governance in line with the shocks (war, internal displacement, outbreaks
technology (PEST) restructuring of political like COVID-19 pandemic, climate change induced
administration (creation of regional recurrent droughts, etc.
states)
• Poverty has still been a concern as it affects
• The current political environment large proportion of the population (25.6% in rural
is explicitly in support of PHC as areas and 14.8% in urban settings) to utilize the
clearly reflected in the Ten Year available health care services
Development Plan of the country
• Due to limited local manufacturing, more than
• National GDP growth has been 85% of health commodities are imported
improved for the last two decades
• the high cost of medical equipment and supplies
• As part of expanding macro coupled with a critical shortage of foreign
infrastructure, proximity of all- currency
weather road has been improving
• Current Per capita spending on health (USD 36)
to the rural community helping them
is also far below WHO`s target for low income
easily access the nearby health
countries (USD 86) in order to ensure essential
services
PHC services
• Improved access to
• Limited internet/data penetration and high airtime
telecommunication services
cost
• Promising potential of improved
• Rapidly increasing population size. Majority of
electrical power supply for all health
the Ethiopian population is children and youth
care facilities (100% coverage)
that bear economic pressure on the government
• Rapid urbanization to provide them health services
• Conducive investment climate
promoting private sector
engagement
• Expansion of private health care
facilities over the last 2 decades
(more than a third of total HCF in the
country)

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 47

 Annex 2: PHC implementation milestones

Milestones for the implementation of Primary Health care Strategic interventions

Implementation
Milestones
S.N Strategic Objectives and major Interventions
2025- 2028- Beyond
2027 2030 2030
Strategic Objective 1: Ensure the functionality of leadership, governance and multi sectorial action for
1.0 PHC
Ensure meaningful participation & engagement of communities, professional
associations and civil society organizations in decision-making processes related
1.1 to PHC
Enhance the PHC leadership and governance capacity to effectively coordinate
1.2 and deliver PHC interventions in all contexts.
Restructure the PHC leadership and governance systems which include Woreda
1.3 health office capacity and the role of primary hospital in PHC governance.
Establish a mechanism for regular assessment and PHC- related research to
1.4 generate evidence on population health need
Redesign and implement multi sectorial coordination, collaboration, and
1.5 accountability legal framework for PHC
1.6 Design and implement mechanisms that improve women’s leadership in PHC.
1.7 Enforce adherence to and proper implementation of regulations and standards
Design mechanisms that ensure the health systems are transparent, responsive,
1.8 and accountable to the public.
1.9 Implement and design a mechanism to monitor health in all policies and strategies
1.10 Enhance the engagement of private health sector in PHC
2.0 Strategic Objectives 2: Optimize PHC financing
2.1 Enhance domestic resource mobilization including innovative financing for PHC
2.2 Establish strategic health purchasing and define payment mechanisms for PHC.
2.3 Diversify and strengthen health insurance schemes
2.4 Enhance financial management capacity at all levels.
2.5 Increase proportion of PHC spending from total health expenditure (THE)
Implement performance-based financing mechanisms to improve the quality and
2.6 efficiency of PHC services.
2.7 Establish and implement equity and resilience funding mechanism
2.8 Improve PHC financing monitoring systems
2.9 Monitor the reimbursement of fee weaver and exempted services
Identify inefficiencies in PHC spending to improve effectiveness and efficiency in
2.10 PHC financing.
Strengthen Public-Private Partnerships to leverage additional resources and
2.11 expertise for PHC financing
3.0 Strategic Objective 3: Improve infrastructure of health facilities
3.1 Improve equitable access to quality health infrastructure
Regularly assess the health facilities following standards and timelines set in the
3.2 infrastructure roadmap
3.3 Updating and applying national health facility standards
Ensure the availability and functionality of basic amenities in all types of health
3.4 facilities
3.5 Undertake regular health infrastructure and capacity assessment
Develop mechanisms that respond to community input around basic
3.6 improvements in health facilities

48 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

 Work towards making healthcare facilities climate resilient and align with MOH
3.7 climate and health action plans
Accelerate the restoration of damaged health infrastructure focusing on conflict-
3.8 affected regions
4.0 Strategic objectives 4: Improve Health Workforce development and management for PHC
Conduct robust workforce planning and forecasting exercises to determine the
4.1 current and future needs of the PHC workforce.
Implement regulatory frameworks for PHC workforce in the public and private
4.2 health facilities.
4.3 Develop and implement comprehensive PHC related CPD curriculums
4.4 Improve quality of Pre-Service Education
Ensure an equitable distribution of health professionals in PHC settings to address
4.5 geographical and population disparities.
Implement supportive supervision and mentoring programs to provide guidance,
4.6 feedback, and support to PHC providers.
Encourage task shifting and task sharing to different cadres of health workers to
4.7 optimize their skills and address workforce shortages
4.8 Develop a comprehensive and binding motivational package for PHC workforce
4.9 Design and implement tailored and evidence-based HR deployment systems
Develop and implement clear career path to HEWs and revisit/update training as
4.10 relates to PHC
Explore and implement packages to improve the productivity and performance of
4.11 the PHC health workforce
5.0 Strategic objective 5: Ensure availability of Medicine and medical technologies
Explore and implement innovative supply chain management systems including
5.1 digital technologies, and private sector engagement.
Ensure end to end visibility of medical supplies at all levels of the Supply Chain
5.2 System
5.3 Expand community pharmacy and diagnostic laboratories.
5.4 Promote rational use of medicines and medical products
5.5 Design and implement efficient uses of supplies like reverse logistics
Strengthen access to affordable and quality-assured essential medicines,
5.6 diagnostics and medical equipment.
5.7 Promote local production capacity of medicines and medical products
5.8 Strengthen regulatory systems for medicines and medical products
5.9 Devise resource mobilization strategy for diversifying the PHC medicine financing
6.0 Strategic Objective 6: Enhance Digital Health Use
6.1 Build the Capacity of leadership and health workers on digital health
Explore and implement innovative approaches to create paperless healthcare
6.2 facilities and woredas
6.3 Expand ICT infrastructure and governance
6.4 Accelerate the implementation of digital health blueprint and strategic plan
7.0 Strategic Objective 7: Optimize Health Information Systems
Strengthen data generation, use, access and sharing including vital events and
7.1 civil registration data to improve visibility and accountability
7.2 Strengthen routine HIS, IHRIS, LMIS, IFMIS at community and facility levels
7.3 Strengthen data quality assurance (LQAS, RDQA) system
7.4 Strengthen governance of the health information system
Enhance the capacity of program managers and implementers to generate and
7.5 use information.

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 49

 7.6 Expand Electronic Medical Record (EMR) implementation
7.7 Expand e-CHIS implementation
7.8 Expand vital events and civil registration system
Establish a mechanism which ensures the undertakings of PHC- oriented research
7.9 on regular basis
8.0 Strategic objective 8 Improve access, quality, and equity of PHC services at all levels
8.1 Design and implement quality improvement initiatives at all levels of care
Strengthen functional linkages and smooth referral system among distinct levels
8.2 of care
8.3 Revise and implement essential health service packages
Standardize and contextualize service delivery models with special focus for
8.4 gender, people with special needs, mobile and displaced communities
8.5 Accelerate implementation of HEP optimization
8.6 Strengthen family health team approach at urban settings
8.7 Establish mechanisms to ensure resilient health facility and services
8.8 Promote and implement service delivery standards and regulatory framework
8.9 Ensure the provision of integrated and comprehensive care at levels of care
8.10 Harness the use of digital health technologies to improve access to health care
8.11 Establish a system that promotes traditional medicine
8.12 Explore and utilize the potential of private health sector in PHC implementation
8.13 Promote life-style modification
9.0 Strategic Objective 9. Improve PHEM system
9.1 Strengthen emergency preparedness and response mechanism at all levels ü
9.2 Implement PHEM legal framework to realize coordinated management of PHEs
9.3 Optimize PHE management system at community and facility levels
9.4 Strengthen the implementation of national health security action plan
9.5 Devise mechanism to create climate resilient health system
Initiate and implement one health approach at PHC level Conduct regular
exercises, surge planning, and community engagement to ensure readiness and
9.6 response of health care facilities
Integrate emergency preparedness and response within routine health system
9.7 function
10.0 Strategic Objective [Link] community engagement and empowerment
Design and enhance the implementation of tailored and comprehensive
community engagement strategies for different contexts (urban, agrarian, pastoral,
10.1 and semi-pastoral).
Enhance social accountability systems through assessing past interventions and
10.2 seeking out ways to incorporate into existing systems
Develop a strong social accountability legal framework and authority by
10.3 integration into government annual planning and budgeting cycle
Explore and implement strategies to improve health and health system literacy for
10.4 individual, family, and community
10.5 Strengthen community representations at health facility governance systems

50 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

Annex 3. List of indicators for PHC monitoring by the Strategic Objectives

Strategic Objectives Indicators Preferred data sources

Governance and • Health in All Policies with multisectoral coordination Qualitative assessment
policy frameworks
• Existence of national health policy oriented to PHC and
Qualitative assessment
UHC
• Existence of policy, strategy or plan for improvement of
Qualitative assessment
quality and safety
• Existence of health emergency and disaster risk
Qualitative assessment
management strategies
• Institutional capacity to meet essential public health
Qualitative assessment
functions and operations
• Coordination mechanisms with multistakeholder
Qualitative assessment
participation and community engagement
• Existence of national, subnational and local strategies for
Qualitative assessment
community participation
• Evidence of effective stewardship of mixed health systems Qualitative assessment
• Existence of an M&E framework for national health plan
• Total net official development assistance to medical
Global database
research and basic health sector
• Percentage of public research funding devoted to primary
Qualitative assessment
care research
Financing • Current expenditure on health (total and PHC specific) as a
National health accounts
percentage of gross domestic product (GDP)

• Per capita total health expenditure (and PHC specific) National health accounts

• Government PHC spending as percentage of government

National health accounts
health expenditure

• Sources of expenditure on health (and PHC specific) National health accounts

• Contingency funds available for emergencies Qualitative assessment

• Services included in health benefits package (including

Qualitative assessment
primary care)
• Purchasing and provider payment methods are in place
Qualitative assessment
(including primary care)
• Health financing follows established guidelines Qualitative assessment
Health infrastucture • Health facility density/distribution (including primary care) Facility census

• Availability of basic water, sanitation and hygiene (WASH)

Facility survey
amenities

• Availability of power Facility survey

• Availability of communications Facility survey

• Access to emergency transport for interfacility transfer Facility survey

Health Workforce National Health Workforce

Health worker density and distribution [SDG 3.c.1]
Accounts
National Health Workforce
Accreditation mechanisms for education and training institutions
Accounts
National Health Workforce
National systems for continuing professional development
Accounts

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 51

 Medicine and Regulatory mechanisms for medicines Qualitative assessment
Medical technologies
Availability of essential medicines [SDG 3.b.3] Facility survey
Availability of essential in vitro diagnostics Facility survey
HIS • Completeness of reporting by facilities RHIS
• Percentage of facilities using comprehensive patient
Facility survey
records
• Regular system of facility and patient surveys Qualitative assessment
• Functional national human resources information system
NHRIS NHWA
and national health workforce accounts
CRVS Population-based
• Completeness of birth registration
survey
• Completeness of death registration CRVS
• Regular system of population-based health surveys Qualitative assessment
• Existence of effective surveillance system SPAR
DH • National e-health strategy Qualitative assessment
• Telemedicine access Population- based
• Percentage of facilities using electronic health records Facility survey
Service delivery: • Existence of an empanelment system Qualitative assessment
Process
• System to promote first contact accessibility Qualitative assessment
• Protocols for patient referral, counter- referral and
Qualitative assessment
emergency transfer
• Existence of care pathways for tracer conditions Qualitative assessment
• Management capability and leadership Facility survey
• Multidisciplinary team-based service delivery Facility survey
• Existence of facility budgets and expenditures meeting
Qualitative assessment
criteria
• Collaboration between facility-based and community-based
Facility survey
service providers
• Community engagement in service planning and
Qualitative assessment
organization
• Services for self-care and health literacy in primary care Facility survey
• Percentage of facilities with systems to support quality
Facility survey
improvement

• Percentage of facilities meeting criteria for resilient health

Facility survey
facilities and services

52 NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030

 Service delivery Geographical access to services Facility database GIS
Outputs:
Population- based survey
Perceived barriers to access (geographical, financial,
Access; availability Facility survey (exist
sociocultural)
and readiness; interviews)
utilization and quality
Access to emergency surgery RHIS GIS
Existence of a system of post-crash care Qualitative assessment
Percentage of facilities offering services according to national
Facility survey RHIS
defined service package
Provider availability (absence rate) Facility survey
Percentage of facilities meeting minimum standards to deliver
Facility survey
tracer services
Percentage of facilities compliant with infection prevention and
Facility survey
control (IPC) measures
RHIS Population- based
Outpatient visits
surveys
Emergency unit visits RHIS
Hospital discharges** RHIS
Leading diagnoses (primary care/outpatient visits, inpatient
RHIS
diagnoses at discharge**)
People’s perception of health system and services Population-based survey
Facility survey (patient-
Diagnostic accuracy (provider knowledge) provider observations or
record review)
Facility survey (patient-
Adherence to clinical standards for tracer conditions provider observations or
record review)
RHIS
30-day hospital case fatality rate (for acute myocardial infarction
or stroke)** Facility survey (record
review)
RHIS
Avoidable complications (lower limb amputation in diabetes) Facility survey (record
review)
RHIS
Hospital readmission rate for tracer conditions** Facility survey (record
review)
Admissions for ambulatory care sensitive conditions RHIS
Prescribing practices for antibiotics Prescription database
Proportion of people 65 years and over prescribed
Prescription database
antipsychotics
Provider caseload Facility survey
Bed occupancy** RHIS
Cancer stage at diagnosis (by cancer) Cancer registry
RHIS (Waiting time
Waiting time to elective surgery **
management systems)

NATIONAL PRIMARY HEALTH CARE STRATEGIC FRAMEWORK: 2024-2030 53

National Primary Health Care Strategic
Framework: 2024-2030