concept note for cross-cutting health systems …

Health System Strengthening Concept Note 15 October 2014│ 1

Investing in Health Systems Strengthening

CONCEPT NOTE

FOR CROSS-CUTTING HEALTH

SYSTEMS STRENGTHENING

IMPORTANT NOTE: Applicants should refer to the Instructions for the Health Systems Strengthening concept note and to the HSS Guidance Note.

The concept note details the applicant’s request for Global Fund support to cross-cutting health systems strengthening (HSS). The concept note should present an ambitious, strategically focused and technically sound investment, informed by the national health strategy and the national disease strategic plans. It should represent a prioritized, full expression of demand for resources, and it should be designed so as to maximize the strategic impact of the investment.

The concept note is divided into the following sections:

Section 1: The description of the national health sector, including health system constraints and the national response.

Section 2: Information on the overall HSS funding landscape, additionality, and financial sustainability.

Section 3: The funding request to the Global Fund, including a programmatic gap analysis, rationale and description of the funding request, and the modular template.

Section 4: Implementation arrangements and risk assessment.


SUMMARY INFORMATION

Applicant Information

Country Federal Democratic Republic of Ethiopia

Funding Request

Start Date July 1, 2015

Funding Request

End Date

Dec, 2017

Principal

Recipient(s) Federal Ministry of Health

Funding Request Summary Table

Priority HSS Modules Allocation Request Above Allocation Request

Human Resource 12,037,140 10,239,400

Pharmaceutical supply

Chain Management

8,694,319 5,140,411

Health Information System 10,367,826 4,206,200

Service Delivery: Laboratory

System

8,618,145 10,634,045

Financial Management 3,063,590 0

Leadership and Governance 2,913,000 0

Total 45,694,020 30,220,056

A funding request summary table will be automatically generated in the online grant

management platform based on the information presented in the programmatic gap

table and modular templates.


SECTION 1: COUNTRY CONTEXT

This section requests information on the country’s health system, and the health system

strengthening priorities according to the national health strategy. In addition, information is

required regarding synergies between the health system and community systems, as well

as how human rights and gender are being addressed. This description is critical for

justifying the choice of appropriate interventions.

1.1 National Health Sector

With clear references to the current national health strategy and the relevant national

disease strategic plans (including the names of the documents and specific page

references), and in addition to the portfolio analysis provided by the Global Fund:

a. Provide a concise overview of the national health system in the country, covering

both the public and private sectors at the national, sub-national and community

levels.

b. Describe key problems in the health system at national, sub-national and

community levels that constrain the country from improving health outcomes for at

least two of the three diseases.

c. Highlight the community systems, human rights and gender issues that constrain

health system functioning (as related to two or more of the three diseases), by

leading to poor coverage, access and use of health services.

2-4 PAGES SUGGESTED

a) Overview of the national health system

The Ethiopia’s health policy focuses on democratization and decentralization of the health

care system and assurance of accessibility of health care for all; and encouraging private

and non-governmental organizations (NGOs) participation in the health sector1.

The health sector has a three-tier health care delivery system: level one is a

Woreda/District health system comprised of a primary hospital (cover 60,000-100,000

people), health centers (15,000-25,000 population) and their satellite Health Posts (3,000-

5,000 population) connected to each other by a referral system. The primary hospital,

health centre and health posts form a Primary Health Care Unit (PHCU) mainly in rural

1 Health Policy of the Transition Government of Ethiopia, 1993; page 4


settings. Level two is a General Hospital covering a population of 1-1.5 million people; and

level three is a specialized Hospital covering a population of 3.5-5 million people (see

figure-1 below). At the various levels, rapid expansion of the private for profit and NGO

sectors is augmenting health service coverage and utilization2.

Figure 1: Ethiopian Health care tier system

There has been massive expansion of health facilities over the last decade. As of June

2014, there are a total of 156 public hospitals (including 26 university and referral

hospitals), 3,335 health centers and 16,251health posts providing health services. A

number of new constructions of health facilities is going on including 123 hospitals, 211

health centers and 203 health posts3. Private health facilities have also significantly been

contributing in increasing access to health services. Furthermore, there are civil society

organizations (CSOs)/faith based organizations (FBOs) backing up the care and support

through community based systems supporting continuity of care. In total, MoH documented

more than 4090 private facilities including 63 private hospitals, 280 higher clinics, 850

medium clinics and 2,899 lower clinics for its consideration of HMIS scale up at private

health institutions4.

The devolution of power to regional governments has resulted in largely shifting the

2 HSDP IV 2010/11-2014/15, and 75 3 HSDP IV Annual performance report 2014 4 Special Bulletin 16th Annual Review Meetings 2014, page 71-73


decision making for public service delivery from the centre to being under the authority of

the regions and down to the district level. Offices at different levels from the Ministry of

Health (MoH) to Regional Health Bureaus (RHBs) and Woreda Health Offices are

mandated to run their own decision making processes, duties and responsibilities. MOH

and the RHBs focus more on policy matters and technical support while Woreda Health

Offices manage and coordinate the implementation of the district health programs under

their jurisdiction.

Ethiopia`s overall strategic development framework, the Growth and Transformation Plan

(GTP 2010/11-2014/15), is geared towards achieving the Millennium Development Goals

(MDGs). The GTP is an important enabling strategic framework for the realization of the

MDG targets. Much broader in scope, the GTP is inclusive of all the MDG relevant sectors

(road, water, education, health, economic sectors) and most of the targets for these sector

programs are in line with MDG targets.

The medium of translating the health component of the GTP is the Health Sector

Development Program (HSDP 2010/11-2014/15), the main program of the health sector

that is being implemented within the framework of the Sector-Wide Approach programs

(SWAP). HSTP is a 20 years program launched in 1997 and includes incremental

investment programs and mid-term plans to reform the health service delivery system. It

serves as guiding framework for detailed planning, implementation, monitoring and

evaluation of intervention in the health sector throughout the country. The primary goal of

this program is to provide comprehensive and integrated essential health service packages

through strengthening the primary health care system. In 2009/2010, MOH developed the

fourth HSDP which was consulted and jointly assessed using the Joint Assessment of

National Health Strategies (JANS) tools. HSDP IV is now in its final year demanding for a

heightened momentum to ensure all health related targets are met. Encouraging results are

achieved so far in all the three health related MDGs, prominently on reducing child mortality

and combating HIV/AIDS, Tuberculosis and malaria (ATM).

Building on lesson learnt in the past and anticipating the potential circumstances in the

future, MoH in consultation with relevant stakeholders has drafted a 20 year envisioning

document and a five year strategic plan named Health Sector Transformation Plan (HSTP)

for the post MDG era.

b) Key problems in the health system

HSDP IV has put clear strategies how to achieve the MDGs in the defined five years before

2015. During the planning of the HSDP IV, there was a big funding gap. However, through


active resource mobilization activities, considerable amount of the funding gaps were filled

by contribution from the Government of Ethiopia (GoE), bilateral and multilateral

development partners. The GoE has committed itself to cover as much prevailing gaps as

possible so as to reach the MDGs and post-MDG targets, which are being set in the new

Health Sector Transformation Plan (HSTP 2015/16-2019/20). As per the International

Health Partnership (IHP+) compact, development partners have also committed

themselves to provide predictable additional financing and work towards aid effectiveness.

Ethiopia has made a very good progress to achieve many of health related MDGs.

However, sustaining the gains made and continuing further progress is a point of concern

to all stakeholders of the health sector. Financial constraints, gaps in human resource

development, quality of the health information, managing the supply chain and meeting the

ever increasing health needs of the community are among the challenges of the sector.

The need to strengthen the health system has become prominent more than ever to

address the existing and new constraints. It is believed that addressing the prioritized

health system components in this concept note alleviate a considerable size of the health

system constraints:

c) Highlight the community systems, human rights and gender issues that

constrain health system functioning

Community ownership is among the major objectives of the current HSDP and remains so

in the future. Without the community ownership of the health system, sustainable

development in the health and related sectors is unthinkable. Cognizant of this fact, the

government of Ethiopia has put the Health Extension Program (HEP) in place with a key

philosophy of transferring the right knowledge and skill to households can make people

take responsibility for producing and maintaining their own health at household and

community level. The HEP is the flagship health sector program mainly focusing on

community based activities with a strong linkage with the rest of the health system

components.

The PHCU mentioned above make use of HEP as main pillar of the community health

system with the context of PHC approach. This approach insures health is a human right

agenda by making essential health service packages readily available and closer to the

community with minimal barriers to access the services. The 16 health extension services

under maternal and child health (MCH), disease prevention and control (DPC), hygiene

and environmental packages are provided in more than 16,000 kebeles (the lowest

administrative units) for free by deploying more than 38,000 salaried HEWs and millions of

health development army (HDAs) networks. The HEP focuses on women’s and children’s

health carried out by HEWs who are predominantly women that make health


communication relatively easy to women. The women health development army promotes

women empowerment and improve access to health care by mothers and children in the

spirit of solidarity. With this approach, equity to essential health services is better

addressed including gender disparities.

Table 1: Packages of the HEP

Hygiene and

Environmental Sanitation

Diseases

Prevention and

Control

Family Health

Services

Health

Education

1. Proper & safe excreta

disposal system

1. Prevention &

control HIV/AIDS

1.Maternal & child

health

1. Health

Education &

communication

2. Proper & safe solid &

liquid waste management

2. Prevention &

control TB

2. Family planning

3. Water supply safety

measures

3. Prevention &

control Malaria

3. Immunization

4. Food hygiene & safety

measures

4. Adolescent

Reproductive

Health

5. Healthy home

environment

5. Nutrition

6. Arthropod & rodents

control

7. Personal hygiene

GoE has a strong focus on gender mainstreaming and human right to be addressed in all

political, economic and societal spheres so that women and men participate and benefit

equally from development. This focus is evident by gender sensitive policies and legal

frameworks such as Developmental Social Welfare Policy, National Reproductive Health

Strategy, Civil Servant Proclamation with Women’s Right to Affirmative Action, Family Law

Addressing Harmful Traditional Practices and the Health Sector Gender mainstreaming

manual to guide equity at all levels of the health sector.

Special attention is given to people of developing regional state to address the existing


inequalities in accessing health services mainly due to their lifestyle (e.g. pastoralist areas).

Civil society organization particularly the local CSOs are taking part in the health sector

making sure that members of their constituencies are reached with essential health

services. Associations of people affected by diseases are taking part in the health sector

mainly through awareness creation, being voice of the needy and improve access to health

care. Hence, the Ethiopia’s health system is highly considerate of strengthening the

community system to ensure rights of every citizen for health and insure equity to essential

health services.

1.2 National Health Strategy

With clear references to the current national health strategy and the relevant national

disease strategic plans (including the names of the documents and specific page

references), briefly describe:

a. The priority health goals in the national health strategy, as relevant to this specific

request, and how well the disease specific plans are aligned to these goals.

b. The performance of priority health system components, as relevant to this request.

Highlight the strengths, weaknesses and measures needed to strengthen health

system performance in a way that addresses the constraints described in 1.1.

c. The processes for reviewing and revising the national health strategy, including

how the government and partners have addressed or are responding to health

system weaknesses based on lessons learned. If the current strategy has less than

18 months to run, explain the process and timeline for the development of a new

strategy and how key populations will be meaningfully engaged. Also briefly

describe how the health sector review is linked to the disease specific reviews, and

any efforts to align.

4-5PAGES SUGGESTED

a) Priority health goals

The current National Health Strategy, HSDP IV, runs till mid-2015. This strategy was set

based on the countries need and well aligned with the MDGs. Encouraging results have

been witnessed in reducing under-five mortality, improving maternal health and reducing

incidence and death due to HIV/AIDS, tuberculosis and malaria. Even though Ethiopia

registered encouraging results on MDGs, the prevalence and mortality rates of HIV/AIDS,


Tuberculosis, and Malaria are considerably high, above the global averages. Many children

and mothers are still dying due to avoidable causes. Hence, reducing child mortality,

improving maternal health and combating major communicable diseases remain the priority

goals of the coming strategies with the addition of focus to non-communicable diseases.

The draft HSTP has set the following goals based on projection using OneHealth tool:

Reduce maternal mortality below 200/100,000 live births by 2020

Reduce under-five mortality below 35/1000 live births by 2020

Reduce neonatal mortality below 15/1000 live births by 2020

Reduce malaria cases by 75% by 2020 from 2013 baseline

Reduce TB mortality by 45% by 2020 from 2013 baseline

To prevent at least 70,000 new HIV infections between 2015 - 2020

b) Performance of priority health system components

Ethiopia has achieved MDG 4 three years ahead of schedule by reducing under-five

mortality rate by two-third from the 1990 estimate. Two and half decades ago, 204 children

out of 1000 live births were dying before celebrating their 5th birth day. Through the

concerted effort of the Ethiopian people, the government and our partners, it has been

possible to reduce the under-five mortality rate to 68 per 1000 live births; helping 136 more

children per 1000 live births celebrate their 5th year (WHO’s World Health Statistics report-

2014).

According to the recent UN estimate for the year 2013, Ethiopia has made a considerable

progress in reducing 69% of the maternal mortality from the 1990 estimate (Ref). With the

current rate of reduction, it is possible to exceed the MDG target by the end of 2015. Array

of maternal health programs are in place to improve the maternal health.


Figure 2: Trend of Under-five Mortality Rate and Maternal Mortality Ratio in Ethiopia5

Mortality and morbidity due to HIV/AIDS, Tuberculosis and malaria (MDG 6) has reduced

markedly. HIV new infection has dropped by 90% and mortality cut by more than 50%

(Ref). Mortality and incidence due to Tuberculosis has declined by more than 63% and

32%, respectively from the 1990 baseline.6 Death due to malaria has declined significantly.

Malaria outbreak has not been witnessed for the last 6 years (Malaria NSP).

The roles of the following health system components are immense in achieving the above

mentioned positive trend of health outcomes.

1) Human Resource Development (HRD)

The health workforce is the major component of the health system. Cognizant of this fact,

Ethiopia has given due emphasis for human resource development evidenced by

production of more than 38,000 HEWs, thousands of mid-level health professionals,

medical doctors, midwives, massive expansion of health science colleges in the last

decade.

The ever-growing need of the community in accessing quality health information and

services urges the MOH and RHBs to produce and maintain qualified and committed health

workforce. Production and maintaining of qualified human resource for health in adequate

5 http://www.countdown2015mnch.org/documents/2014Report/Ethiopia_Country_Profile_2014.pdf 6 Global TB report, 2013


quantity and skill mix remain among key challenges of the health sector (Annex_1). A case

in point in Ethiopian context is HEP. The main focus of HEP was initially on health

promotion and diseases prevention activities of selected priority conditions and diseases

with limited basic curative services. Currently, the community is demanding health

information and services in a much better quality for existing and emerging health

problems. Hence, upgrading HEWs is a pressing need of the sector while keeping on

providing Integrated refresher training (IRT). Similarly, the need to avail Health Information

Technicians (HIT) is increasing as the number of health facilities are increasing as

generating information timely with manual system becomes a daunting task. In order to

transform the current paper based reporting system to electronic based reporting system,

pre-service training of HITs is crucial.

2) Supply Chain Management System

GoE, mainly through Pharmaceutical Fund and Supply Agency (PFSA) and Food, Medicine

and Healthcare Administration and Control Authority (FMHACA) is exerting a tremendous

effort to improve the supply chain of the sector with their role of availing pharmaceuticals

and regulating them respectively. Annual pharmaceutical distribution value has increased

by more than ten-fold in less than a decade. Seventeen modern warehouses are almost

completed raising the national storage capacity to 320,000 metric cub from 30,000 metric

cub and the old chain capacity has grown to 600 metric cub from 50 metric cub five years

ago. However, stock outs of essential supplies are still reported particularly at the lowest

level of the tier system mainly due to inadequate distribution capacity to the lowest service

delivery points. Capacity building efforts are required in forecasting, quantifying, storage

and distribution of medicines, lab reagents, medical equipment and supplies.

Following an extensive Business Process Reengineering work address the challenges,

PFSA has concluded that an efficient and modern pharmaceuticals supplies management

information system is urgently required. This system will enable PFSA manage the

forecasting of pharmaceutical needs, procurement, storage and distribution and support

process. PFSA has identified the need to convert its existing paper-based and semi -

automated system, which has been in use for some years to fully automated electronic

based pharmaceuticals supply information system. This project will serve as a cornerstone

for a modern Integrated Pharmaceuticals Fund and Supply Management Information

System, IPFSMIS. Thus, it shall become a Data Warehouse for the execution of Federal

and Local Government pharmaceutical services. Furthermore, it will process and manage

human resource and the Agency’s property.

While PFSA focuses on procurement, storage and distribution of pharmaceuticals including


medical equipment, FMHACA plays the regulatory functions to ensure safety of citizens in

receiving health services. Practices, Premises, Professionals and Products (4Ps) of health

services are regulated by the agency and similar arrangements at regional and lower

levels. FMHACA is fully in charge of registration, regulation, inspection, quality control and

supervision, and has authority to take necessary remedial actions regarding

pharmaceutical and health products. FMHACA’s responsibility for quality control includes:

pre-shipment inspection; following process of manufacturing goods; and checking the

quality of pharmaceutical and health products. It also has a mandate for licensing and

registration of drugs and health commodities procured or donated from abroad.

Among the regulatory functions of the agency is pharmacovigilance to ensure quality and

safety of products by closely following up of adverse effects of drugs and post marketing

surveillance of drugs (Annex_2).

3) Health Information System

Quality data is a key factor to generate reliable health information that enables monitoring

of progresses and make decisions for continuous improvement. Ethiopia has undertaken

reform of the health management and information system. Health information technology

initiatives are in place with various level of implementation to improve access and quality of

health services using appropriate technology. The initiative covers a wide range of

applications including telemedicine, tele-education, mobile health, electronic HMIS

(eHMIS), Electronic Medical Records (EMR), Geographic Information System (GIS) and

Human Resource Information system (HRIS). Besides, CHMIS has been designed to make

the information system and decision making effective at the grass root level. Owing to the

family centred provision of health services, a family folder (FF) was put in place to record

health information related to members of the family from birth to death as well as housing

conditions. Though implementation of FF started in 2010/11, its implementation so far

reached coverage of 64.5%.Application of technologies in digitizing FF is expected to

transform the CHIS in particular and the health information system in general7.

These initiatives have a huge potential to produce quality data and are means of minimizing

labours burden of manually operated systems. However, much work is needed to build

capacity and scale up of the programs. A Routine Data Quality Assessment (RDQA) was

conducted in 2014 covering 91 districts, 2 health offices and 214 health facilities in all

RHBs and MoH. The following figure is the summary of the finding of the assessment

7 HSDP IV performance report, 2013/14 (page 63, 83, 84)


indicating the need to improve in all components of HMIS performance.

The figure below (Figure 3) show the summary of system component as an index from 1 –

3 in accordance with WHO standards. The information use component is included as it is

believed to increase demand for quality data. Hence, there is a need to focus more on

resource component (index of 1.28)-inputs/resources include HMIS unit, budget, card

room size, availability of card room worker and runner, standard shelves, computer

and receipt of supervision with feedback, M&E structure & capability (1.632) and

information use (1.63).

Figure 3: Summary of HMIS performance by system components at health facility level8

4) Service Delivery: Laboratory System

Laboratory diagnostics capacity is improving from time to time. However, its contribution in

diagnosing diseases and follow up of patients is affected by suboptimal laboratory capacity

and referral system. Main limitations include infrastructure related challenges that require

renovation, suboptimal networking of laboratories and capacity in maintenance of medical

equipment. Sample transportation for quality assurance and backing up each other in case

of failure to provide service in one facility are sub optimal. There is no well-established

8 Special Bulletin 16th Annual Review Meeting 2014, page 48-55


laboratory information network that eases exchange of information between referral and

peripheral laboratories (Annex_4).

5) Health Care Financing/Financial Management System

MoH has placed mechanism that can improve mobilization and efficient utilization of

resources including health care financing reform; signing IHP+ compact with development

partners, annual resource mapping exercise under woreda (district) based national

planning as well as strengthening the financial system through placing dedicated grant

management unit, internal audit and implementing Integrated Financial Management

Information System (IFMIS) (Annex_5).

According to the recent National Health Account (NHA V), per capita health expenditure

increased to USD 21 in 2010/11 from USD 16 in 2007/08. This figure is far less than the

WHO’s recommended USD 34, revised to USD 60 by 2015.

Figure 4: Trend in Per capita Health Expenditure in Ethiopia

The health sector is financed by government treasury, households and donors. About 34%

of the source of health expenditure in 2010/11 were households, that are burdened by high

Out-of-pocket costs for health incurred at the time of sickness. Cognizant of this fact,


introduction of prepayment mechanisms and insurance are being placed to pool risks

between the healthy and the sick as well as the poor and the better-off With this regard, the

country has adopted two financial mechanisms namely community-based health insurance

and social health insurance. The community based health insurance has now been scaled

up to 161 districts from 13 districts in four regions. The social health insurance is organized

for formal sector including pensioners to ensure access to health care services9.

Though good progress has been observed in mobilizing and utilizing more resources for

the health sector from various sources, there is still a need to mobilize more resources to

significantly reduce preventable and avoidable morbidity and death of children, mothers

and productive citizens. Besides, recording and reporting the use of available resources is

critical using reliable mechanisms such as grant management and IFMIS. There is broad

agreement that a fully functioning IFMIS can improve governance by providing real-time

financial information that financial and other managers can use to administer programs

effectively, formulate budgets, and manage resources. Sound IFMIS systems, coupled with

the adoption of centralized treasury operations, can not only help developing country

governments gain effective control over their finances, but also enhance transparency and

accountability, reducing political discretion and acting as a deterrent to corruption and

fraud10.

c) Process of reviewing and revising the national health strategy

The management arrangement of the national strategy is clearly stated in the current

strategic document (HSPD IV). This arrangement is expected to continue in the upcoming

strategic period (HSTP) with some amendments if need be.

Health planning

The Ethiopian health planning is composed of two planning cycles. The first and most

significant reference of planning cycle is the currently five year strategic planning. The next

five year strategic plan, the Health Sector Transformation Program (HSTP 2015/16-

2019/20), is underway. It serves as a guiding blueprint on which all other plans are

developed, e.g., Regional Health Plans, etc. The second is the annual planning cycle that

translates the five year HSDP/HSTP into the annual Plan of Work with details of achievable

targets, strategies and interventions under the different levels of the health care system.

The current HSDP has less than a year to run. The follow up strategic plan, HSTP, is

9 HSDP IV annual Performance report, 2013/14 (page 85-87; 89-90) 10 IFMIS, a practical Guide, 2008; http://pdf.usaid.gov/pdf_docs/PNADK595.pdf


underway with draft ready for wider consultation in few months and endorsement. High

level discussion has been conducted at the executive committee of MOH and its agencies

as well as Joint steering Meetings (JSC) between MoH and RHBs. The consultation is

going on at different level of the government structures including other sectors. Partners

have been informed of the progress and providing their inputs. A 20 year envisioning

exercise (post MDG framework for the Ethiopia’s health system) is awaiting endorsement

after a wider consultation is done with the participation of civil societies, professional

associations, international and local NGOs, local universities, donors and other relevant

stakeholders. The strategic documents (HSTP and the 20 year strategic framework) are

expected to be endorsed well before the end of the current HSDP (July 7-2015).

Performance Monitoring and Evaluation

The monitoring plan for the health strategy will draw significant lessons from the previous

experiences, which suffered from insufficient and poor quality of information for planning,

monitoring and evaluation purposes. In order to improve M&E, the monitoring and

evaluation system is designed as part of the Policy, Planning and M&E Core Process and

is being implemented at all levels of the health system.

Revision of HMIS is done and being implemented including reporting from the private

health facilities. Community HMIS is being scaled up to make use of information from

community based activities for timely decision making and continuous improvement.

In addition to the JSC meetings with RHB every two months and bi-weekly Executive

Committee Meetings with agencies of MoH, Joint Review Missions are conducted annually

in collaboration with development partners to review performance which usually followed up

by Annual Review Meeting of the sector (ARM).

There is a Joint Consultative Forum (JCF) which serves as a joint forum for dialogue on

sector policy and reform issues between GoE, Development Partners and other

stakeholders. In-addition to these review and dialogue platforms, the Global Fund Country

Coordinating Mechanism (CCM) and the coordination mechanism for the EPI activities

(ICC), will remain as is and strengthened in the future.

Evaluation of midterm reviews of HSDPs has been done by independent reviewers for all

rounds that informed areas of focus and recommendations on remaining periods and

beyond. Program specific reviews and assessments are done periodically including TB,

HIV/AIDS and malaria. Their findings are highly considered in strategic and operational

plans. Four Midterm Reviews (MTR) of the HSDP has been done in the last couple of

decades showing half-way progresses of each strategic period followed by revisions of


plans and programs accordingly to achieve the targets.

SECTION 2: FUNDING LANDSCAPE, ADDITIONALITY AND SUSTAINABILITY

To achieve lasting impact against the three diseases, financial commitments from

domestic sources must play a key role in the national strategies. Global Fund allocates

resources which are far from sufficient to address the full cost of technically sound health

systems strengthening. It is therefore critical to assess how the funding requested fits

within the overall funding landscape for health system strengthening and how the national

government plans to commit increased resources.

2.1 Overall Funding Landscape for Upcoming Implementation Period

In order to understand the overall funding landscape for health systems strengthening and

how this funding request fits within this, briefly describe, as relevant to this request:

a. The priority health system strengthening areas or initiatives currently receiving

financial support, and main funding sources (government and/or donor). Highlight

any areas that are adequately resourced (and are therefore not included in the

request to the Global Fund).

b. How the proposed Global Fund investment will encourage the commitment of

additional resources to the specific HSS areas being requested.

c. The health system strengthening areas that have significant funding gaps, and the

planned actions to address these gaps.

1-2 Pages

a. The priority health system strengthening areas or initiatives currently

receiving financial support, and main funding sources (government and/or

donor). Highlight any areas that are adequately resourced (and are

therefore not included in the request to the Global Fund).

NB: The funding landscape for this concept note assumed the current trend of

funding landscape will continue for the next three to five years.

The health services in Ethiopia are financed from federal and regional governments, grants

and loans of bilateral and multilateral donors, NGOs and private contribution. MoH conducts

periodic assessments to estimate the flow of health resources through the NHA. Five NHAs


were conducted since 1995, the recent one was published in 2014 referring to health

expenditures of the 2010/11 fiscal year. The NHA-V showed an incremental trend in health

spending in both nominal and per capita terms. Nominally, the national health expenditure

(NHE) increased from USD 1.2 billion in 2007/08 to over USD 1.6 billion.

Percentage Share of the Public Health Budget Allocation from the Total Budget

In 2013/14 (EFY 2006), the percentage of total budget allocated in the health sector at

regional level was 10.30%, which was higher than in 2012/13 (9.75%) (Figure below). The

regional block grant budget allocated to the health sector ranged from 5.6% in Harari to

15.6% in Gambella in 2013/14. Figure 6: Percentage of public health budget by region in

2010/11

Figure 5: Public health budget allocation by regions, 2012/1311

Contribution of Development Partners (DP)

The contribution of DPs is one of the major sources of funding for the Ethiopian health

sector. In 2013/14, a total of USD 558 million was committed and a little more than 100 %

disbursed. The share of the DPs disbursement is seen in figure below. Global Fund

accounted 50.4% of the total, followed by DFID (23.4%), GAVI (6.2%), World Bank (5.8%),

UNICEF (5.3%), WHO (3.6%) and others (5.5%). Considerable amount of resource

provided by US government partners through channel 3 modality are not captured in MOH’s

11 HSDP IV annual Performance report, 2013/14; page 92


financial monitoring system.

Figure 6: Percentage distribution of disbursement by development partners/2010-11

In the framework of the Ethiopia IHP+ Compact, the MDG Performance Fund (MDG PF) is

in place according to the GoE’s preferred funding modality for scaling up development

partners assistance in supporting the HSDP.

Figure 8: MDG PF Disbursement 2007/8 – 2013/4


Majority of the health service delivery, community health systems, leadership &

governance, vaccines and essential supplies, expansion and rehabilitation of health

facilities, PHCU strengthening efforts are relatively easier to be financed by GoE,

community contribution and development partners. Hence, much of the subcomponents of

the health system building blocks are not requested in this funding request as the above

mentioned trend of funding landscape is expected to continue covering a sizable cost of the

health sector. Hence, some activities of the following health system modules are requested

in this concept note.

1. STRENGTHEN HUMAN RESOURCE DEVELOPMENT FOR HEALTH

The FMOH recognizes that the successful implementations of the various health reforms

are dependent on the availability of adequate number and skill mix of clinical, public health

and administrative personnel. Hence, strengthening the human resource for health is

identified as one of the major means for achieving the priorities and targets set under HSDP

IV and beyond. Evidences have demonstrated that the performance and level of human

resource strengthening initiatives has the potential to determine and impede the progress

toward health-related MDGs and targets set beyond MDGs. The recruitment, training,

deployment, and retention of qualified human resource are among the main functions of

HRD.


HRD has been a key component in the successive Ethiopia HSPDs. In HSDP III, the main

HRD objective was improving the staffing level at various levels as well as establishing

implementation of transparent and accountable Human Resource Management (HRM) at all

levels. HSDP IV has focused on ensuring demand driven production of human resources

and maximizing use of available resources in producing key categories of health workers for

which there is scarce supply.

The 2012/13 Annual health sector review report has indicated the need to strengthen the

human resource to ensure the challenges faced in the implementation of the targets. This

review has indicated the need for recruitment, enrollment, deployment and retention of

additional HEWs and HITs.

2. STRENGTHEN PHARMACEUTICALS SUPPLY CHAIN MANAGEMENT

SYSTEM

A well-functioning medicines supply management system is the backbone for effective

implementation of all health programs by assuring un-interrupted supply of essential

medicines that are efficacious and of good quality, physically accessible and used

rationally. Having understood this important fact the Government of Ethiopia has taken a

very important step by establishing federal organ called the Pharmaceuticals Fund and

Supply Agency (PFSA) in accordance with the Drug Fund and Pharmaceuticals Supply

Agency Establishment Proclamation No. 553/2007. The establishment of the agency marks

the Government’s ambition to supply quality assured essential pharmaceuticals in a

sustainable manner to the public.

The supply management of pharmaceuticals in Public sector of Ethiopia is currently guided

by the Integrated Pharmaceuticals Logistics System (IPLS). IPLS is a system designed to

integrate the management of commodities of the various programs; including ARVs and

pharmaceuticals for TB, Leprosy and Malaria programs and essential drugs managed

through Revolving Drug Fund. For proper implementation of IPLS and to operate an

effective logistics system key logistics area need to be strengthened. These include

construction of distribution outlets accessible to all public health facilities, efficient fleet

management and a robust Logistics information management system. Towards this end, in

the past three years modern warehouses are being built and the old ones were being

renovated to increase their storage capacity, vehicles of different size were procured to

strengthen the distribution capacity of the agency. When the constructions of all new

warehouses are completed the number of PFSA’s distribution Hubs will reach seventeen.

(IPLS SOP, March, 2014 & PFSA annual report, June 2014).


In the face of the above efforts there is still a need to construct and equip additional hubs in

some corridors to attain the objective of having distribution hubs accessible to health

facilities within 160- 180 Km radius and additional vehicles to enhance the distribution

capacity of all hubs as per the design envisaged in the logistics master plan. Further

Furthermore, a robust Integrated Pharmaceuticals Fund and Supply Management

Information System (IPFSMIS) that furnish improved National forecasting on re-supply

requirement planning, Procurement, storage and distribution, Fund management, cost

recovery works of all pharmaceuticals. Besides, it will process and manage Human

resource and the Agency’s property in harmonized way. IPFSMIS is expected to replace

the existing paper-based and semi -automated system.

Current major challenges in pharmaceutical supply chain management include the need to

have robust Logistics management information system. The Agency identified lack of

harmonized comprehensive system that integrate efficient management of pharmaceuticals

including forecasting, procurement follow-up, inventory management, warehousing, finance,

Human resource and fleet management. Accessibility of PFSA distribution hubs within a

defined distance to all public health facilities in the country is also an area that calls

attention. Furthermore, Lack of handing and warehouse security equipment (CCTV camera,

Bar-coding), poor inventory management, limited number of vehicles for distribution of

pharmaceuticals from Hubs to all health facilities including the last miles (heath post) are

also among the bottlenecks that needs immediate intervention.

With relation to pharmacovigilance, more emphasis will be given on awareness creation of

Adverse Effects of Drugs including drugs of HIV/AIDS, malaria and TB as well as

strengthening the laboratory of FMHACA in its effort of ensuring quality of imported

medicines and post market surveillance.

3. IMPROVE HEALTH INFORMATION SYSTEM

Routine health service statistics is the main source of data to analyze health service

coverage and to take appropriate decision for program improvements. Because of its

importance, Ethiopia has invested a lot to improve Health management information system

and routine health service data quality.

Shift from paper-based HMIS to electronic HMIS and Medical Record System (e-HMIS and

EMR) has been initiated and there is a need for rapid scale up of e-HMIS and digitalizing

family folder of the community health information system (CHIS) in the country. Besides

this, FMOH has completed the revision of the HMIS indicators, recording and reporting

formats.


4. STRENGTHEN SERVICE DELIVERY THROUGH ENHANCING LABORATORY

CAPACITY AT ALL LEVELS

The 4th Health Sector Development Program (HSDP IV) envisioned the attainment of the

health related millennium development goals (MDGs) by 2015. The review of performance

of HSDP III has identified challenges & gaps of HSDP III & linkages to HSDPIV. This

process has showed that weak laboratory diagnostic services is one of the challenges and

gaps in the implementation of targets set for major communicable disease prevention and

control initiatives including Malaria, Tuberculosis and HIV/AIDS. For this effect the 4th

Health Sector Development Program has prioritized to enhance laboratory capacity at all

levels through upgrading laboratory networks, establish & strengthen laboratory equipment

maintenance workshops and strengthening laboratory information system.

The recent evaluation of the health sector has revealed the need to strengthen quality and

accessibility of laboratory services at all levels. The 2005 EFY health sector review report

identified and prioritized; strengthen sample transportation to effectively utilize available

high-tech diagnostic facilities; production and use laboratory service information for local

decision making and decreasing the laboratory instrument down time to be acted in the

coming consecutive years.

5. IMPROVE FINANCIAL AND GRANT MANAGEMENT CAPACITY

The fourth Health sector development program and subsequent disease specific strategic

documents have envisioned the attainment of ambitious and resource intensive targets

through increasing harmonization and efficiency in resource allocation and utilization.

Strengthening health system and providing quality and equitable health care to all of its

citizens remains a priority for the government of Ethiopia and all stakeholders in the health

sector. Due to the success of preventive focused government health policy, financial

resources committed both from government and donors’ side has increased in the past

decade. Presently the health sector receives significant financial resources from multiple

sources through different channels.

However, the financial management capacity of the health sector needs to be enhanced

with the increasing financial resources and the entailed sustainable financing strategy.

HSDP IV has set a target of 90% utilization of financial resources through implementation of

innovative initiatives. Hence, it becomes more important for FMOH to design and

implement different grant and financial management reforms/initiatives that are able to

catalyze timely grant fund utilization and reporting capacity at different levels. To this effect,


improving the coordination of grant implementation and scaling up of automated financial

reporting (IFMIS) is prioritized in the HSDP IV targets to improve resource utilization and

included as part of this Health System Strengthening support. IFMIS is expected to be the

single source for national consolidated financial information, with all stakeholders accessing

government financial information from a unified source. The project is expected to adopt

global best practices and ensure that data are entered only once, avoiding data entry

repetition during consolidation, therefore ensuring harmonization and integration between

different departments. In this perspective, GoE has purchased an internationally recognized

enterprise resource planning software (Oracle). The health sector represent by FMoH has

been participating in the national project since 2011/12. However, the pace of enrollment at

regional level and below is slow. Hence, the MoH is highly interested to cease this funding

opportunity and speed up the scaling up of IFMIS in collaboration with Ministry of Finance

and Economic Development (MoFED).

6. LEADERSHIP AND GOVERNANCE

As a priority intervention, training of district heath management training has been supported

by government and previous global fund grants.

b. How the proposed Global Fund investment will encourage the commitment

of additional resources to the specific HSS areas being requested.

Most of these priorities areas were identified during disease specific concept and national

strategic plan developments which include different agencies of MoH, RHBs and Partners.

These HSS interventions have significant funding gaps even after considering partners

contribution. However, the partners and different stakeholders are convinced that without

well-functioning program specific investments will not have adequate return of investments

they are making. And these HSS interventions have also been priorities for HSDP and are

continued to be for the upcoming health sector strategy (HSTP), which have buy-in from

domestic and international partners and The stakeholder and development partners are

willing to invest more on HSS. In addition, the Global Fund modality of disbursing 15% of

the allocated amount ($90m) upon the domestic increment in investment (willingness-to-pay

(WTP)) is another encouraging investment on health system. This will increase the

domestic financing for health, in which areas to be financed with this increased financing

include prioritized HSS components.

c. The health system strengthening areas that have significant

funding gaps, and the planned actions to address these gaps

For those HSS intervention that prove to have significant funding gaps,

planned actions to address these gaps include


Maximizing the community ownership and participation to improve the health

system.

Proactive resource mobilization from domestic and international

funding partners

prioritization of actions so that they are realized in a logical

sequencing, if need be, while not compromising the overall

effectiveness of the program in reaching its goals

Finally, reprogramming of available resources may be considered

as an option that could have greater impact on disease specific

targets.

Table 2: Summary Funding Landscape for priority HSS areas

Priority HSS areas Total Funding

need ($)

Commitment

($)

NFM

Allocation

($)

Funding

Gap ($)

Human Resource (For HEWs

upgrading, HIT training & IRT)

60,995,000 38,718,460 12,037,140 10,239,400

Supply chain management 17,023,730 3,889,000 8,694,319 5,140,411

Health Information System 18,043,986 3,469,960 10,367,826 4,206,200

Laboratory System Strengthening 29,511,190 10,259,000 8,618,145 10,634,045

Financial Management 6,063,590 3,000,000 3,063,590 0

District Health Management 3,213,522 300,522 2,913,000 0

Total 134,451,018 59,636,940 45,694,020 30,220,056


SECTION 3: FUNDING REQUEST TO THE GLOBAL FUND

This section details the request for funding and how the investment is strategically

targeted to strengthen health systems and achieve greater impact on the diseases. This

section requests an analysis of the key programmatic gaps which in turn forms the basis

upon which the request is prioritized. The modular template organizes the request to

clearly link the selected modules and interventions to the goals and objectives of the

request, and associates these with indicators, targets, and costs.

3.1 Programmatic Gap Analysis

A programmatic gap analysis needs to be conducted for the three to six priority

HSS modules within the applicant’s funding request.

With respect to each of the three to six priority HSS modules within the funding request,

briefly describe (i) the types of programs currently in place, (ii) the populations or groups

involved where relevant, and (iii) the current funding sources and resource gaps.

If any of the three to six priority modules are easily quantifiable, complete a

programmatic gap table (Table1) instead of the narrative description below. Ensure

that the coverage levels for the priority modules selected are consistent with the coverage

targets in section D of the modular template (Table2).

2-3 PAGES

SUGGESTED

Six priority cross-cutting HSS modules are identified in this concept note based on the

reviews of the current health system performance and consultations with stakeholders on

HSTP and envisioning exercise and during disease specific concept note preparation

country dialogues and discussions. As the upcoming health sector strategy (HSTP) is

being developed, it is not easy to quantify the priority modules with exact figures. Hence,

the funding request is justified with the following qualitative gap analysis.

Human Resource

Resource need: $60,995,000

Commitment: $38,718,460

NFM Allocation: $12,037,140

Above Allocation: $10,239,400


One of the focus areas in HRD is upgrading of HEWs to level IV with the aim of meeting

the increasing demand for quality health services. About 5000 HEWs were enrolled and

graduated as of 2013. Additional 5000 HEWs are expected to be enrolled in 2014/15. The

remaining 22,000 HEWs will be upgraded over the coming three years. It is anticipated

that GoE and MDG PF contributes to cover the cost of upgrading HEWs while this funding

request is to cover the remaining gap.

All the HEWs require refresher trainings on all IRT modules once every two years.

Previous grants of the Global Fund have supported the Integrated refresher training for

HEWs by leveraging resource from USG, UN agencies and other partners support. This

funding request will cover the training of modules I (ICCM), II (RMNCH), and IV (TB/HIV) of

the IRT for all HEWs.

To address the need for improved quality health information from increasing number of

health facilities, training and deployment of Health Information Technicians (HIT) among

the priorities of HRD. By the end of 2014, there will be total of 3,798 HITs with total need

of training more than 6000 HITs over the coming three years. This activity has been

supported by USG, CDC, MDG PF and government. In addition, previous GF grants

supported the training of these cadres and similar trend is expected with this funding

request.

Procurement and Supply Chain Management:





As indicated earlier, the main gaps in procurement and supply chain management of the

health system are lack of reliable information flow in the forecasting and quantification,

procurement, storage and distribution of commodities, fund management, cost recovery

works of pharmaceuticals &medical equipment and limited capacity for bulk logistics

transport and storage at national level. This entails the need for completely efficient and

modern Integrated Pharmaceuticals Supplies Management Information System (IPFMIS)

to generate timely information which is required to ensure uninterrupted supply of essential

pharmaceuticals and supplies. Besides strengthening the logistics information system,

there is also a need to enhance the storage and distribution capacity at national and sub-

national levels. The Pharmaceutical Supply and Fund Agency (PSFA) has received funding

mainly from USAID, UNICEF, UNFPA, Clinton Health Access Initiative (CHAI), GAVI and


Global Fund to improve its procurement, storage and distribution capacity.

Through support of this funding request, the pharmaceuticals and logistics information

system will be strengthened by installation of Enterprise Resource Planning /ERP/ software

at regional hubs, training of end-users on the new IPFMIS software. More than 500 end

users will receive change management and end-users training on the software with the

support of funding through this concept note.

Storage and distribution capacity of PFSA will be further enhanced through procurement of

heavy trucks with Trailers, Medium Trucks, Forklifts, GPS equipment for all trucks, and

equipping newly constructed PFSA warehouses. Total of 17 Heavy Trucks to deliver

pharmaceuticals from Center to 17 Branches each with 250 quintals, 85 Medium Trucks to

deliver pharmaceuticals from PFSA 17 Branches to Health Facilities with 100 quintals

capacity, 17 forklift to unload from Truck one for each Branch and GPS for 270 vehicles

are required in this concept note period and 15 trucks need to be replaced. Five heavy

trucks, 17 medium trucks and 9 forklifts were procured by the GAVI, GF and UNFPA are

procuring respectively. And 48 medium trucks are in the process of procurement through

the GF. Hence, the gaps are requested in this concept note.

Besides, quality assurance of health commodities will carry out by FMHACA through

strengthening its quality assurance laboratory, awareness creation and reporting of

Adverse Event of Drugs.

These interventions will assist in meeting the goal of PFSA and FMHACA to deliver quality

assured health commodities to all public health facilities in the grant period of this funding

request which in turn improves the supply management system of the country.

Health Information System





The health information technology initiative of the MoH covers a wide range of applications

including electronic HMIS (e-HMIS), The national health management information system

(HMIS) has been revised recently with inclusion of additional indicators and will be reported

electronically. Training of health care workforce and program staffs across the health tier

system on the e-HMIS recording and reporting tools has begun with funding from GoE.

However, there is a financial gap to train adequate number of health care providers and

program staffs on the revised HMIS and e-HMIS. Besides, this funding request would be


an opportunity to attract more funding to Community health information system (CHIS) by

covering some of the cost of tablet computers and operational trainings for digitizing the

family folder. More resources will be mobilized from GoE and development partners to go

for full scale up of digitizing family folder covering more than 16,000 health posts in the

grant period.

Service Delivery: Laboratory System Strengthening





The health care system in Ethiopia relies upon a tiered network of laboratories and

reference laboratories, with an increasing degree of specialization at each tier. As part of

this design, specialized instruments have been placed at various laboratories throughout

the country, including Culture systems, TB liquid culture facilities, automated analyzers for

hematology, chemistry, and CD4; molecular diagnostics like DNA-PCR; and additional

molecular diagnostic laboratories. In order to utilize this network effectively, it is essential

that communications and data systems are established between laboratories.

An efficient laboratory network requires that samples be transported from small

laboratories (e.g. district, health center) to larger laboratories (Regional or National) for

specific tests. A system for reliable and safe sample collection, transport, and delivery will

be established for all sites that require tests to be conducted at other laboratories. Sample

stability has a significant influence on the design of a transportation system. In addition to

this unavailability of advanced Laboratory test at each heath facility level, poor

communication between the upper and lower level laboratories; and postal office, lack of

awareness on sample transportation for advanced specific testing and using postal office

(for both health professional and postal officers) and lack of follow up at regional and

federal level

Also, logistics systems must be in place to ensure that samples requiring specialized

testing can be referred from one tier to the next. In the event of an instruments breakdown

or sample backlogs, nearby laboratories must be able to refer samples to others where

back-up services are provided. Sample transportation services have been implemented at

some levels of the system, but they have not been uniformly effective throughout. They

have also been implemented with varying degrees of effectiveness. In order to upgrade

laboratory networking, strengthen the sample referral network, and facilitate laboratory


activities information flow the following activities will be implemented:

Among the challenges in laboratory services is suboptimal focus on infection control. There

is a need to renovate the laboratories of high volume facilities from the infection control

perspective. Frequent laboratory equipment breakdowns, weak sample referral and weak

laboratory information system has been among the key gaps affecting priority health

programs such as HIV/AIDS, TB and Malaria.. There is a national plan to improve medical

and laboratory equipment maintenance through establishment of regional maintenance

workshops, training and deployment of biomedical technicians and engineers. With the

support of GAVI funding in MDG PF, 12 maintenance workshops with tools will be

established. Initiatives to improve laboratory information system and laboratory networking

have also begun to be implemented with the domestic resources and with some support

from US Government (USG) partners. Close to 50 laboratories in high volume hospitals are

enrolled to be accredited through Strengthening laboratory Management Towards

Accreditation (SLMTA). Specimen transportation and EQA system is being supported by

(USG) implementing partners. However, there is no adequate resource to renovate

laboratories of high volume hospitals to improve infection control, patient flow and quality of

laboratory services. In this concept note, renovation of 50 high volume laboratories and

support to specimen referral system are requested,

Financial Management




Above Allocation: $0

Despite very good progresses in resource mobilization for health, the current financial

management capacity of the health sector is challenged by delayed liquidation of funds,

poor at regional and lower levels. This requires for financial management reforms/initiatives

with focus on improvements in the financial information system and grant management

capacity. The rollout of Integrated Financial Management Information System (IFMIS) is

aimed at addressing the gaps. The funding source for this program is the GoE so far.

Through this concept note, the pace of IFMIS project implementation at federal and

regional level will be speed up through end-users training on IFMIS, procurement and

installation of IT supplies, mentoring and supervision of its implementation. Technical

assistance through deployment of regional and zonal grant/finance officers and financial

management trainings will enable the roll out of IFMIS in a much faster rate than

implementation by Ministry of Finance and Economic Development (MOFED). MOFED

has already procured the IFMIS software which is oracle based application and is paying


more than a million dollar annually for maintenance. The health sector is one of the few

sectors selected by MOFED in earlier phase of phased-in implementation at federal level.

However, the pace of implementation by MOFED is slow as there are many sectors at

federal and lower level to roll out the system. Hence, the MoH in collaboration with MOFED

would accelerate the implementation of IFMIS in the health sector through this funding

request.

Leadership and Governance:


Commitment: $300,522


Above Allocation: $0

Strengthening District Health Management is essential in the decentralized health system

where PHC is the main approach in service provision. The district health offices are

responsible to implement essential health service programs by developing operational

plans, allocating resources, monitoring and evaluating progresses with their PHCUs.

Hence, the leadership and governance skill of district health mangers need to be

capacitated to meet the expectation. The district health system is where most of the PHCU

and community based activities are consolidated to maximize impact. When a considerable

size of woredas (districts) is transformed, the country as a whole will be transformed in

which equity will be addressed. Hence, institutionalizing district health management

capacity building efforts will be instrumental to continuously train and provide supportive

supervision to district health managers. GoE and partners such as WHO and GF are

supporting trainings of district health managers so far. GF is requested to continue

supporting this training in this funding request. MOH is building a training center in which

trainings of such kind will carried out in a well-established training institution to ensure

sustainability.


3.2 Applicant Funding Request

Provide a strategic overview of the applicant’s funding request, including both the

proposed investment of the allocation amount and the request above this amount. The

overview should give a clear description of the health system strengthening objective(s) of

the request, how these are linked to the national health strategy priorities, and how they

address the gaps and constraints described in sections 1, 2 and 3.1. If the Global Fund is

supporting existing programs that will continue into the requested funding period, explain

how they will be adapted to maximize impact on the objectives of the program.

4-5 PAGES SUGGESTED

The following six main objectives will be addressed through this cross-cutting HSS

Concept Note funding request:

1. Improve human resource capacity that enhance community and health information

system

2. Improve pharmaceuticals supply chain management system

3. Strengthen national health management information system

4. Improve service delivery through strengthening the laboratory services

5. Improve financial resources management system

6. Improve leadership and governance of district health management

1. Human resource development

In this funding request, $12,037,140 million is requested mainly to contribute for

Upgrading of more than 22,000 HEWs to level IV, refresher training of 30,000 HEWs and

more than 6000 HITs. The global fund contribution covers a quartet to a third of the

estimated costs.

Prioritized Intervention 1.1: Upgrading of health extension workers

HEP was introduced in 2002/03 with a fundamental philosophy that if the right health

knowledge and skill is transferred, households can take responsibility for producing and

maintaining their own health. Substantial investments in human resources, health

infrastructure, pharmaceutical supplies and operational costs have been made for the

successful implementation of the program.


The increased health seeking behavior of the communities as a result of improved

educational status of the community, economic growth and health programs such as the

HEP has created additional demand for community health services. This has indicated the

need to improve the capacity of HEWs through upgrading to level IV competency. In the

past two years, Global fund round 8 and 9 grants supported the training of 3,638 level 4,

3,943 level 3 and 1210 urban HEW. In this funding period (2015-17), about 22,000 Level

III HEWs will be upgraded to level IV. The Global Fund is requested in this concept note to

leverage resources with GoE and other development partners.

Prioritized Intervention 1.2: Integrated refresher training for health extension

workers

Following the initial rounds of pre-service trainings for HEWs (EFY 1996/7), gaps in HEW

skill and service delivery were identified. It was seen that the pre-service training need to

be refreshed periodically to keep the core competencies of the HEWs expected by HEP.

The MOH and RHBs periodically coordinates and provide a standardized IRT for HEWs to

avoid frequently pulled out of HEWs from their posts for various trainings required by

various programs including HIV/AIDS, TB and malaria. This training has alleviate the

uncoordinated training effort by our partners to support the HEWs and improved

efficiency. Partners supporting the HEP pool resource to conduct IRT in an integrated and

coordinated manner in modular forms.

Previous GF grants supported these trainings. All the HEWs will be trained during this

concept note period and close to $28 million is required to train all HEWs. The TOT and

some of the cascading training will be covered by USG and MDG PF. This funding

request will cover a portion of the cascade trainings by leveraging resources with GoE and

development partners.

The HEP is the pillar of the primary health care in Ethiopia. Hence, the IRT training

improves the competency of the HEWs to provide quality HEP packages which will

contribute in improved coverage of high impact interventions.

Prioritized Intervention 1.3: Pre-service training for health information technicians

Information quality and use remain sub-optimal within the health sector, particularly at the

peripheral levels, The HMIS 12 strategic plan depicts the need to improve quality

information use (Annex_3). A number of initiatives are in place to address data quality

12 HMIS strategic plan


including use of technologies, regular data quality assessments, training of health workers

and data mangers on revised HMIS, CHIS and supportive supervision. Building the

capacity at all levels particularly at the lower levels of the health sector in quality, timely

and complete data collection, analysis and use for local decision-making is found to be

critical. This could be carried out through short term need based training of health workers

and increase the number of health information technicians through training of additional

level 4 trainees. Health Information Technicians (HITs) play a pivotal role in ensuring data

are captured electronically in a timely manner, analyzed with relevant program focal

persons and present reliable information to decision makers at the point of data collection

and beyond. HIS are deployed at health centers and hospitals and 10,500 HITs are

needed to cover all health centers and hospitals. 2,532 are currently deployed in health

facilities. The premier activity is being supported by different partners including GF and

the training of additional health information technicians (HIT) is included to be part of this

HSS Concept Note funding request. This request includes the training of additional 1,500

level 4 HITs training out of 6000 required to be trained in three years and deploying them

in Zonal and Woreda health office level based on the need. Global Fund, through Round 8

HSS grant, has supported the training of 600 Level 4 HIT. This funding request considers

continuation of the Global Fund in contributing resource in HIT training.

2. Strengthening Supply Chain Management

$8,649,319 is requested for this module mainly focusing on ICT plat forms to

improve supply management information system, enhance storage and distribution

capacity and strengthen pharmacovigilance activities.

Prioritized Interventions 2.1 Improve supply management system through

ICT platforms

Introduction of Enterprise Resource Planning (ERP) is being carried out at PFSA

which involves procuring hardware and software, assessing the existing situation

in terms of IT infrastructure and HR, end-users training and capacity building to IT

staff and managers of PFSA. Some of the expenses are covered by the US

government funded implementing partners while this request and GoE is

anticipated to cover the remaining costs.

Enterprise resource planning (ERP) systems are designed to address the problem

of fragmentation of information or “islands of information” in business

organizations. ERP systems promise to computerize an entire business with a

suite of software modules covering activities in all areas of the business.


Furthermore, ERP is now being promoted as a desirable and critical link for

enhancing integration between all functional areas within the enterprise, and

between the enterprise and its upstream and downstream trading/business

partners13. ERP provides an integrated view of core business processes, often in

real-time, using common databases maintained by a database management

system. ERP systems track business resources—cash, raw materials, production

capacity—and the status of business commitments: orders, purchase orders, and

payroll. The applications that make up the system share data across the various

departments (manufacturing, purchasing, sales, accounting, etc.) that provide the

data 14 . ERP facilitates information flow between all business functions, and

manages connections to outside stakeholders.15 Hence, the application of this

system is expected to significantly improve the performance of PFSA and then the

country’s health commodity management at large.

Other interventions that help to improve the supply chain management system

such as distribution and tracking of commodities, monitoring stock out and

capacity building activities are being supported by government, USG/ Deliver,

UNICEF, UNFPA and MDG PF.

Prioritized Interventions 2.2 Enhance pharmaceutical storage and

distribution capacity

The other rationalized activities to address the gaps on warehousing, inventory

management and distribution will be procuring of heavy trucks with trailers,

medium trucks, forklift, procurement and installation of GPS and related

equipment for all trucks, procurement of CCTV security camera and adoption of

Bar-code for all warehouses and, procurement of warehouses auxiliary materials.

It is also propose to strengthen transportation means for delivering essential health

commodities to HC to strengthen the PHCUs. GoE’s and GF’s support with regard

13 International Journal of Operations & Production Management Vol. 23 No. 8, 2003; pp. 850-87

14 http://searchsap.techtarget.com/definition/ERP

15 Jump up^ Bidgoli, Hossein, (2004). The Internet Encyclopedia, Volume 1, John

Wiley & Sons, Inc. p. 707.

http://searchsap.techtarget.com/definition/ERP

http://en.wikipedia.org/wiki/Enterprise_resource_planning#cite_ref-2


is complimented by other development partners including USG, UNICEF, UNFPA

and other partners of MDG PF.

Prioritized Interventions 2.3 Strengthen pharmacovigilance

With the support of this funding opportunity, FMHACA’s laboratories will have

sufficient equipment and supplies as well as inspectors of Good Manufacturing

Process Practice (GMP) will be well trained and prepared to carry out QC at all

levels. Reporting of Adverse Events of Drugs will be strengthened through

awareness to health workers and the public.

3. Improving health information system

The PR requests $10,367,826 to strengthen the health information system mainly to

digitize the family folder, scaling up e-HMIS and capacity building efforts of health

information technology initiatives.

Prioritized Intervention 3.1: Strengthen the CHIS through digitizing Family

Folder

Availability of reliable, relevant, comprehensive and timely health information is widely

recognized and recounted as an essential foundation for any public health interventions.

Improved data and monitoring tools are also crucial for devising appropriate policies and

interventions needed to achieve the Millennium Development Goals16. The HMIS reform

was initiated by FMOH in collaboration with other health partners in 2008 all over the

country after piloted with few sites. The family folder was developed as a data collection

tool to be used at the health post level to collect household health data. It was designed

as a comprehensive data collection and documentation tool to be used by HEWs17. This

reform moved the multiple registers to a family folder based community health

information system. Prior to the reform, there were many registers ranging from 7 to 12

to document different health services as indicated in one of the assessments published

in Journal of Health Informatics18. The family folder coverage has now reached 64.5% in

2013/14. Digitizing the folder using tablet computers is expected to transform the CHIS

in particular and the HIS in general. In this funding request, procurement of tablet

16 ] World Health Organization (WHO), Millennium Development Goals. 2013, http://www.who.int/topics/millennium_development_goals/about/en/index.html 17 FMOH. Health Management Information System (HMIS)/Monitoring and Evaluation (M&E) Strategic Plan for Ethiopian Health Sector. Federal Ministry of Health, Addis Ababa, Ethiopia, 2008 18 Zufan D, and Amsalu S. , Journal of Health Informatics in Developing Countries, Vol. 7 No. 2, 2013 (www.jhidc.org)

http://www.jhidc.org/


computers to HEWs is requested alongside solar chargers and operational trainings.

Financial support in scaling up e-HMIS and supportive supervision are among the

requests in this funding opportunity. Global Fund through previous grants, partners of

MSG PF, USG and GoE are among the partners that leverage resources in HIS.

Prioritized Intervention 3.2: Improve data quality through supportive supervision

and Regular Data Quality Assessment (RDQA)

Data quality is critical to generate health information to base decisions upon. Hence, a

number of data quality improvement mechanisms are in place including use of technology

in collecting and analyzing data. Regular supportive supervision and systematic data

quality assessment are among the data quality assurance activities of the MoH that needs

to be strengthened substantially. Hence, funding for Regular Data quality Assessment

(RDQA) is requested in this concept note.

4. Service Delivery: Laboratory strengthening

$8,618,145 is requested in this concept note to contribute for strengthening the service

delivery through renovation and upgrading 5o high volume hospital laboratories, improving

the laboratory maintenance system, enhancing the laboratory information system and

networking and specimen referral.

Prioritized Intervention 4.1 Strengthening Service delivery through renovation of

high volume health facilities and maintenance of laboratory equipment

The service delivery of priority diseases and health conditions through improving the

laboratory service provision of high volume health facilities is one of constrains of the

health care delivery system. The priority facilities will also serve as a referral and back up

laboratories for peripheral laboratories as well as conduct regular External Quality

Assurance programs to their respective catchment health facilities. Among the priority

activities requested in this concept note include renovation of the laboratories from

infection control perspective, specimen referral and networking through laboratory

information system. The rest of the laboratory components will be covered by the GoE,

Global fund in diseases specific grants and the USG.

Prioritized Intervention 4.2: Strengthen laboratory information system and

laboratory networking and specimen referral system

An effective referral system ensures a close relationship between all levels of the referral

system and helps to ensure people receive the best possible care closest to home. It also

assists in making cost-effective use of regional laboratories, laboratories of hospitals and

primary health care services. Support to such system helps build capacity and enhance


access to better quality care.

Infection control is among the critical components in transporting samples. All patient

specimens should be treated as potentially hazardous and handled accordingly. Hence,

the request in this concept note is geared towards improving transportation and infection

control through procuring transportation means and equipment for specimen handling.

Electronic LIS enables laboratories to efficiently capture, store, analyze, interpret and

communicate laboratory information. LIS greatly improves laboratory workflows and

efficiency of processes. LIS, as an important component of Hospital Information System

(HIS), is an ideal tool to enhance interdepartmental communications through interfacing

with other administrative and technical software packages like Electronic Medical Record.

Furthermore, laboratories with functional electronic LIS can be easily networked along or

across tiers facilitating information flow within the network which is particularly important

for the improvement of referral testing services and collection of laboratory related

program indicators at different levels of management thus favorably augmenting the

function of the bigger Health Management Information System.

5. Improve financial management capacity

The funding request to this component is $3,063,590 to improve capacity of grant

management and speed up rollout of IFMIS.

Prioritized Intervention 5.1: Scale up of the Integrated Financial Management

Information System (IFMIS) initiative

The Integrated Financial Management Information System (IFMIS) is one of the

major financial reform programs in the public sector, which is expected to come up

with an enhanced financial information system for all public bodies in a uniform

platform. Full rollout of the IFMIS is expected to automate the financial reporting at

all levels and creates a system that financial utilization and reporting status at

different level can be monitored centrally. In order to speed up the rollout of

EFMIS, training of the end users and procuring related inputs such as computers

and their accessories are required.

IFMIS will ultimately improve and create real-time timely financial utilization

reporting so as to decrease the rate of non-liquidated advances at regional and

district level. Therefore, the following key activities will be implemented to scale

up the IFMIF initiative at different levels;

i. Conduct end users training and change management orientation


session on IFMIS

ii. Procurement of computers, accessories and other networking

supplies for IFMIS implementation at regional level

iii. Purchase Woreda net internet fee and conduct IT infrastructure

assessment

Prioritized Intervention 5.2: Improve grant management capacity through

technical assistance at different levels

Effective grants management is a process of adequate oversight and monitoring of

grants from pre-award stage until close out stage of the grant that includes a cycle

of activities related to planning, implantation coordination, program and financial

reporting and grant closeout.

The newly established grant management unit has conducted a rapid assessment

to identify the challenges related to coordination of the grant implementation

between program and finance departments at different levels; Federal, regional,

Zonal and Woreda level.

The current experience has demonstrated there is sub optimal coordination

between Program and finance units with regard to properly and timely liquidation

and reporting of the grant funds.

The ultimate effect of sub optimal coordination and communication coupled with a

need to understanding about the principles of grant management has created

delayed fund liquidation of grants. Hence, there is a need to provide technical

assistance

Majority of the grant funds are being utilized at the Woreda level where the

financial system operates in a pooled system. The district finance Bureaus are

responsible to financial management of all sectors in the district. Inadequate

staffing, both in number and quality, of the regional finance department is the other

bottleneck contributing for delayed financial reporting and high un-liquidated

advances. The financial reporting sent from the Woredas to the RHBs are not

being timely sent to the FMOH finance as the small number of finance staffs at the

RHB level is always busy with other urgent day to day activities related to handling

the daily transaction. Hence, providing technical assistance by deploying grant


management and finance officers to the zonal and regional level facilitates

coordination of Zonal and Woreda Finance with Zonal and Woreda Health offices

to timely liquidate and report grants according to the grant agreement.

The financial recording and reporting of all grant funds at Federal Ministry of

Health level is based on software packages like Peachtree. Only 5 of the 11

regional Health bureaus and one of the four agencies use software packages for

financial recording and reporting. The other regions and agencies uses manual

recording and excel based recording.

A total of 80 technical assistance are requested to be deployed; 54 of them at

zonal level to mentor finance officers of districts. The regional zonal health offices

will be further supplied with electronic equipment (Eg. Computers, financial

recording software’s, fax machines, etc) needed for timely financial reporting.

6. Leadership and governance

Intervention 6.1. Training of district health management

$2,913,000 is included in this concept note for supporting the training of district

and PHCU program managers. Being the main implementers at the grass root

level, building the capacity of the district health management team will significantly

improve program planning, implementation and reporting. This will address the

health system constrains and gaps through proper planning and implementation

of health programs. This training has been supported through GF round 9 HSS

grant. The district health management team will be oriented and trained on the

general sector strategies and program strategies. This will create a platform

where there will be a sector wide understanding the set targets and strategies and

expected outcomes.

Summary of allocated budget for HSS

New Funding Model cross-cutting Health System Strengthening Allocated budget

Total allocated $53,265,094

On pipeline from Round 9 HSS $2,571,074

Reallocated for HIV/AIDS $5,000,000

Allocated for the Concept note period $45,694,020


Summary of Funding Request per module

Priority Module Interventions requested to be

covered through HSS Concept note,

allocation amount

Amount of Funding

request ($)

Human resource Upgrading of HEWs

IRT

HIT Pre-service training

12,037,140

Supplies chain

management

IPFSIS Rollout

ERP Supplies

End-user training

Storage and distribution capacity

Pharmacovigilance

8,694,319

Health Information

System

e-HMIS scale up

Supervision

Training on CHIS

Printing of HMIS&CHIS

materials

10,367,826

Laboratory system

strengthening

Renovation of laboratories of

high volume health facilities

Equipment maintenance

Strengthening LIS

Strengthening laboratory

networking and specimen

referral

8,618,145

Financial Management Scale up of IFMIS project:

IFMIS Supplies

End-user training

Supervision

Grant management:

Deployment of grant officers

Training &

Supervision

3,063,590

District health

Management

District health management training 2,913,000

Total 45,694,020


3.3 Modular Template

Complete the modular template (Table2). To accompany the modular template, for both

the allocation amount and the request above this amount, briefly:

a. Explain the rationale for the selection and prioritization of modules and

interventions.

b. Describe the expected impact and outcomes, referring to evidence of effectiveness

of the interventions being proposed.

c. Explain the additional gains expected from the funding requested above the

allocation amount.

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a. Explain the rationale for the selection and prioritization of modules and

interventions.

The modules selected for funding under the allocated amount reflect a prioritization based

on expected degree of impact of the interventions to achieve the targets set by MoH.

Ethiopia has a decentralized health system and decision-making and community

empowerment and participation is the main goal of the health system. Improving the health

system enables to establish and maintain the confidence of communities that the

community needs are appropriately met and addressed. The modules selected reflect, as

priority, reinforcement of this approach and provision of essential services. Availability of

well-trained and knowledgeable health workers at the grass root level will improve delivery

of quality health services and improve community health seeking behaviour and help the

community own their health issues

Investing on pharmaceutical supply chain management is also selected as a priority

module in this concept note as quality supply system is very critical as programs without

products are not able to achieve their set targets. During this concept note period,

initiatives on supply and regulation of pharmaceuticals and other health products will be

given high priority to deliver quality services to the community. This will ensure that the

communities get appropriate treatment, care and support.

Improving and transforming health information system plays pivotal role for timely

generating of quality data for appropriate decision making and taking appropriate actions.

This ensures that the resources are invested based on evidence generated at local level.

Hence strengthening the information system is one of major priority of the health sector


and because the significant fund gas, it is also identified as a priority module for this

funding request.

Service delivery through strengthening laboratory system is critical for proper identification

of disease which leads to getting prompt and accurate treatment. Renovating and

upgrading high volume hospital laboratories, maintenance of laboratory equipment,

strengthening laboratory networking and specimen and strengthening laboratory

information system are critical to improve quality of diagnosis and referral linkage.

strengthening specimen transportation to effectively utilize available high-tech diagnostic

facilities; implementation of electronic technologies to capture, store, analyze and interpret

laboratory service information to be used for local decision making and working towards

decreasing laboratory instrument downtimes significantly improves health care delivery

and reduces the burden of major health problems such as HIV/AIDS, TB and malaria.

Accountability and transparency are notions of the health system in Ethiopia. Improving

the financial management system through implementing an efficient electronic based

financial recording and reporting and improving the capacity and workforce of finance and

grant management to improve resource mobilization, utilization and liquidation can not

only help to achieve resource need of the health system, but also improve transparency

and accountability at different levels of the health system. In addition, having good

leadership and governance play an important role for proper implementation of health

programs. So having well-trained and updated program managers on health strategies

and interventions at different levels helps to improve planning, implementation and

reporting of health programs. This will in turn increase the return of investments and

improve program impacts.

Good leadership and governance are important for improving the implementation of health

system plans. Then having well-trained and capable program managers at all levels of the

health system plays critical role in achieving the set goals and targets of HSPD and

upcoming health sectors strategy, HSTP. Training of district health managers is selected

as priority interventions for this effect.

b. Describe the expected impact and outcomes, referring to evidence of

effectiveness of the interventions being proposed.

The main priority goals of the health sector are significantly reducing under-five, maternal

mortality and significantly reduce burden of HIV/AIDS, TB and Malaria to meet the MDG

targets and beyond among other goals. Proposed modules/interventions are have proved

to have greater impact and outcome in achieving the set goals. Investing of community


level health extension works and upgrading their capacity will impact on quality service

delivery proper management of health problems. Strengthening pharmaceutical and other

health products supply system is critical to avoid stock outs, overstocks, and expires and

wastages and helps to avail quality assured pharmaceutical to the community in need of

such services. Hence improving this will profound impact of reducing the aforementioned

health outcomes.

Generating accurate and timely data can be achieved through scaling up and transforming

the health information system. Having an automated and timely data and information helps

to improved timely decision making and taking actions. This in turn improves positive

health outcomes through targeted delivery of appropriate interventions based on evidence

Improving service delivery through strengthening laboratory system is also important for

accurate and timely diagnosis and treatment of patients. Having well renovated and

equipped laboratories, properly functioning laboratory equipment maintenance, and

networking and specimen referral supported with an electronic laboratory information

system can enhance the service delivery and help reduce the major health problems

c. Highlight the additional gains expected from the funding requested above the

allocation amount.

Ethiopia has decentralized and community based health system and investing more on

this system to significantly improve the health outcomes and improve community

ownership and participation. If the above allocation amount is funded, there will be

significant improvement and this will encourage the community to invest on the health

system which is very critical for sustainability.


3.4 Focus on Underserved Populations and/or Highest Impact Interventions

This question is not applicable for Low Income Countries.

Describe whether the focus of the funding request meets the Global Fund’s Eligibility and

Counterpart Financing Policy requirements as listed below:

a. If the applicant is a Lower-Middle Income Country, describe how the funding

request focuses at least 50 percent of the budget on underserved populations

and/or highest-impact interventions.

b. If the applicant is an Upper-Middle Income Country, describe how the funding

request focuses 100 percent of the budget on underserved populations and/or

highest-impact interventions.

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SECTION 4: IMPLEMENTATION ARRANGEMENTSAND RISK ASSESSMENT

4.1 Overview of Implementation Arrangements

Provide an overview of the proposed implementation arrangements for the funding

request, including use of existing country systems and oversight mechanisms. In the

response, describe:

a. If applicable, the reason why the proposed implementation arrangement does not

reflect a dual-track financing arrangement (i.e. both government and non-

government sector principal recipients).

b. If more than one principal recipient is nominated, how co-ordination will occur

between PR(s).

c. The type of sub-recipient management arrangements likely to be put into place

and whether sub-recipients have been identified.

d. How coordination will occur between each nominated principal recipient and its

respective sub-recipients(s).

e. How representatives of women’s organizations, people living with the diseases and

other key populations will actively participate in the implementation of this funding

request.

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a. If applicable, the reason why the proposed implementation arrangement does


not reflect a dual-track financing arrangement (i.e. both government and non-

government sector principal recipients).

Proposed implementation arrangements do not reflect a dual-track financing arrangement.

Harmonization and alignment strategy, while harnessing the resources of a broad

representative partnership, seeks nevertheless to empower governments to address their

priorities through mutual accountability. Besides majority of the interventions includes in

this concept note are planned to strengthen initiatives under the government

implementation arrangements. Although the proposed implementation arrangements do

not reflect dual track financing, it is possible that sub-recipients, drawn from technical

panel partners, including civil society organizations (CSOs) will be used for targeted

interventions. Besides, FMOH is the PR of the funding for this Concept Note, in-country

partners and other sectors also contribute to achievement of the goals.

b. If more than one principal recipient is nominated, how co-ordination will occur

between PR(s).

Only one PR has been nominated.

c. The type of sub-recipient management arrangements likely to be put into

place and whether sub-recipients have been identified.

The CCM has agreed for one government PR and there are no sub-recipients (SRs)

identified.

d. How coordination will occur between each nominated principal recipient and

its respective sub-recipients(s).

Selected SRs will be required to report periodically on implementation based upon clear

and agreed targets for achievement, established timelines and related financial

parameters.

e. How representatives of women’s organizations, people living with the

diseases and other key populations will actively participate in the implementation

of this funding request.

Majority of the funding request under this concept note support are targeted on HEP

through deployment, skill development training of two community-based HEWs in each of

the health posts in nearly all of the estimated 16,000 kebeles/communities. This is

believed to empower the community and actively participate in implementation of the

funding request.

In addition, the health system strengthening modules included in this request will ensure

the procurement and distribution of drugs and supplies for HIV/AIDS, TB, Malaria and

other disease and people living with the three diseases are members of CCM where the


oversight of this grant implementation effected.

4.2 Ensuring Implementation Efficiencies

Complete this question only if the Country Coordinating Mechanism (CCM) is

overseeing other Global Fund grants.

Describe how the funding requested links to existing Global Fund grants and to any other

funding requests being submitted by the CCM.

In particular, from a program management perspective, explain how this request

complements (and does not duplicate) any human resources, training, monitoring and

evaluation, and supervision or other Global Fund financed activities.

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The pursuit of an integrated approach to grant implementation in this Concept Note builds

on the achievements of previous grants and maintains the gains they have provided. The

strategy is significantly dependent upon the HEP and the Health System that was

established with funding from the government and was further supported by the Global

Fund and other development partner grants.

Extensive opportunities have been realized to coordinate budgeting and assure that there

is no overlap or duplication of activities, and to maximize efficient use of resources. The

strategic and annual planning processes are very consultative and participatory. The

integration starts at the federal level and extends all the way to the community level.

The Government conducts an annual resource mapping exercise to inform annual

planning. Developing the map helps to rationalize use of resources, identifies synergies

and avoids overlap. Similarly, promotion of the three ones – one plan, one budget and

one reporting mechanism (HSDP), helps to assure a coordinated effort across multiple

parameters.

By empowering communities, the Concept Note links closely with other disease

components at the crucial intersection of communities and takes maximum advantage of

the integrated approach within the Ministry. The workers are trained to address integrated

primary health care solutions in proximity to communities, where it can be most relevant

and effective. Support to the HEWs at the Woreda/District level takes advantage of cross-

discipline training, comprehensive monitoring and evaluation and integrated supervision.

4.3 Minimum Standards for Principal Recipient (PR) and Program Delivery

Complete this table for each nominated PR. For more information on Minimum


Standards refer to the Concept Note Instructions.

PR 1 Name

Ministry of

Health

Sector Public

Does this principal recipient

currently manage a Global Fund

stand-alone cross-cutting HSS or

a disease component grant(s)?

Yes

Minimum Standards CCM assessment

1. The principal recipient

demonstrates effective

management structures and

planning

FMOH demonstrates effective management structures and

rigorous planning process. Since GF Round 1, FMOH has

been PR for 7 GF grants and has had no major issues

regarding management of GF grants.

2. The principal recipient has the

capacity and systems for

effective management and

oversight of Sub-Recipients

(and relevant Sub-Sub-

Recipients)

There is a long-standing, internal system for effective

management and oversight in the FMOH, including sub-

recipients. The current strategy relies on the structure of

the Ministry extending down to the regions and beyond

(see accompanying implementation structure). The

structure demonstrates clear lines of authority and

establishes organizational responsibilities for

implementation at all levels. Each level is effectively held

accountable for commitments to internal and external

partners. While administrative authority is decentralized for

efficiency, technical coordination remains with the FMOH

to assure coordinated action.

3. The internal control system of

the principal recipient is

effective to prevent and detect

misuse or fraud

There is a strong internal control system to prevent and

detect any misuse or fraud at all levels of the health

system. FMOH conducts internal and external audits

annually down to the regional level and subsidiary levels

are audited down the reporting structure. The system has

proven to be effective in detecting and avoiding misuse or

fraud.

4. The financial management

system of the principal

recipient is effective and

accurate

FMOH designed a new grant management system and

established a grant management unit at federal and

regional levels. The new grant management system has

been working to improve the coordination and

implementation of grant between different departments at


federal and regional levels. In addition, FMOH has started

to scale up Integrated Financial Management System

(IFMIS). The system provides multiple advantages for

performance improvement –

Timely, accurate and consistent data for management

and budget decision-making.

Information for budget planning, analysis and

government-wide reporting.

Facilitates reporting and auditing.

Closer linkages between FMOH, Regions and

implementing partners.

5. Central warehousing and

regional warehouse have

capacity, and are aligned with

good storage practices to

ensure adequate condition,

integrity and security of health

products

All warehouses are now strategically placed within

reasonable radius of all locations in the country for

assuring timely distribution of health products and

eliminating stock outs and avoiding treatment/program

disruptions.

6. The distribution systems and

transportation arrangements

are efficient to ensure

continued and secured supply

of health products to end

users to avoid treatment /

program disruptions

All warehouses are now strategically placed within

reasonable radius of all locations in the country for

assuring timely distribution of health products and

eliminating stock outs and avoiding treatment/program

disruptions.

7. Data-collection capacity and

tools are in place to monitor

program performance

There is a health management information system (HMIS)

and a logistics management information system (LMIS).

The HMIS and LMIS provide some data and reports that

are valuable for monitoring malaria program performance.

The Public Health Emergency Management (PHEM)

Directorate at Ethiopian Public Health Institute (EPHI)

assures the availability of data-collection capacity and

tools. It is within the responsibility of PHEM to provide

surveillance data and emergency response, for which it

must assure ongoing monitoring of program performance.

8. A functional routine reporting

system with reasonable

There is a routine paper based and electronic reporting

system from the community (health post level) up to the


coverage is in place to report

program performance timely

and accurately

central level.

9. Implementers have capacity

to comply with quality

requirements and to monitor

product quality throughout the

in-country supply chain

The Food, Medicine and Health Care Administration and

Control Authority (FMHACA) is charged with quality

assessment of all health inputs and holds accountable

concerned bodies if there are lapses in quality. In addition,

measures are proposed in this HSS support to further

improve capacity in quality assurance issues among

implementers.

4.4 Current or Anticipated Risks to Program Delivery and Principal Recipient(s)

Performance

a. With reference to the portfolio analysis, describe any major risks in the country, and in

the implementation environment, that might negatively affect the performance of the

proposed interventions including external risks, principal recipient and key

implementers’ capacity, past and current performance issues.

b. Describe the proposed risk mitigation measures (including technical assistance)

included in the funding request.

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a. With reference to the portfolio analysis, describe any major risks in the country

and implementation environment that might negatively affect the performance of

the proposed interventions including external risks, Principal Recipient and key

implementers’ capacity, and past and current performance issues.

The modules selected to be included in this HSS request are emanated from the recently

conducted Health sector development program IV performance evaluation. The HSDP

performance evaluation has clearly indicated for the need to keep and build on the good

progresses made with regard to the major building blocks of the Health system including;

human resource for Health, Health Information management, laboratory, pharmaceutical

and supply system, pharmacovigilance, financial management and governance and

leadership.

The review has also pointed the challenges that the system is facing with regard to health

care financing. The 2010/11 USD 20 per capita health expenditure is way less than the

WHO recommendation USD 60 by 2015. This indicates the need to mobilize more


resource in to the sector. The issue of predictability of donor funds in light of high donor

funded programs and the fact that households also incur lingering out of pocket expenses

is believed to pose a risk that needs to be addressed in the coming period.

b. Describe the proposed risk-mitigation measures (including technical assistance)

included in the funding request.

Efforts to mitigate the above risks related to Health Care Financing are seriously

considered during the preparation for the next chapter of health/HSTP (2015 – 2020). A

new Health Care Financing Technical working group has been established and the

revision of the health care financing strategy has already started. The revised Health care

financing strategy is expected to address the financial barriers of the community from

accessing the health services through different health insurance schemes.

To address the challenges of high out of pocket payments, the community and social

health insurance schemes are already in place. In 2014, the community health Insurance

schemes have scaled up in to 160 districts from the 13 only districts in the Agrarian region.

All the necessary preparation for implementation of the social insurance has also been

carried out.

Improving accountability and efficiency in the resource management is also highlighted to

be a priority to be strengthened during the period of this concept note as one of the steps

to maintain the predictability of donor funds. Appreciating the gaps in the financial

management, FMOH designed a new grant management system and established a grant

management unit at federal and regional levels. The new grant management system has

been working to improve the coordination and implementation of grants at federal and

regional levels. In addition, FMOH has started to scale up Integrated Financial

Management System (IFMIS). The system provides multiple advantages for performance

improvement, including timely, accurate and consistent data for management and budget

decision-making; information for budget planning, analysis and government-wide reporting;

and facilitates reporting and auditing and closer linkages between FMOH, Regions and

other implementing partners.

In general, there are mitigation measures developed for all the identified potential risks and

effort is being made to address those potential risks at the minimal during the

implementation of the concept note period.


CORE TABLES, CCM ELIGIBILITY AND ENDORSEMENT OF THE CONCEPT NOTE

Before submitting the concept note, ensure that all the core tables, CCM eligibility

requirements and an endorsement of the concept note, as shown below, have been filled

in using the online grant management platform or, in exceptional cases, attached to the

application using the offline templates provided. These documents can only be submitted

by email if the applicant receives Secretariat permission to do so.

☐ Table1: Programmatic Gap Table(s)

☐ Table2: Modular Template

☐ Table 3: List of Abbreviations and Annexes

☐ CCM Eligibility Requirements

☐ CCM Endorsement of Concept Note

concept note for cross-cutting health systems …

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