Lessons from COVID-19 Response in Ethiopia and Beyond

 Creating Resilient PHC System: Lessons from COVID-19 Response in Ethiopia and Beyond

Introduction

National responses to the corona virus disease 2019 (COVID-19) have tested the strength of primary health care (PHC) systems throughout the world. It may be through this PHC system that patients visit or consult trusted providers for medical advice and presentation concerning symptoms. PHC systems may also lend a critical framework for governments to implement large-scale testing and public health communications efforts in the wake of COVID-19.

The Declaration of Alma-Ata, Health for All, and Universal Health Coverage (UHC)

The Declaration of Alma-Ata, a set of principles affirmed during the International Conference on PHC in 1978, formally adopted PHC as the means for achieving Health for All through comprehensive, universally accessible, equitable and affordable health care services for everyone in all countries (Hall & Taylor, 2003). The Declaration was indeed a paradigm shift away from the Western facility-based curative model of health care that had dominated the developing world up to that time.

 The core principles of the PHC approach included (WHO, 2003):

• Universal access to basic and essential care; 
• Commitment to health equity (giving priority to those in greatest need) as part of development that promotes social justice; 
•  Community participation in defining and implementing health agendas; 
•  Intersectoral approaches to health (affirming the importance of nutrition, clean water and sanitation, and education to good health) 

The Alma-Ata PHC approach takes into account the need for a broader approach to the improvement of health beyond simply the provision of curative medical care, as shown in the following eight priorities of PHC defined in the Declaration of Alma-Ata in 1978 (WHO, 2003). 

1.   1.       Promotion of food supply and proper nutrition 
2.      An adequate supply of safe water, basic sanitation
3.      Maternal and child care, including family planning 
4.      Immunization
5.      Prevention and control of locally endemic disease
6.      Health education concerning prevailing health problems, and methods of                                prevention/control
7.      Treatment for common diseases and injuries
8.      Provision of essential drugs

While the Alma-Ata approach to health discussed in the Declaration of Alma-Ata looks beyond solely curative care, curative care is still part of a comprehensive approach to health that encompasses promotion, prevention, treatment (curative care) and rehabilitation. The Declaration of Alma-Ata calls for both selective services (immunizations and family planning, for instance) together with comprehensive services (treatment of common diseases and injuries) that are part of a functional referral system. (WHO, 2003).

 Primary Health Care and the Health System Building Blocks

The Declaration of Astana on Primary Health Care and the accompanying Vision for Primary Health Care in the 21st Century reinforce the commitment of countries and international partners to make concerted efforts to orient health systems towards primary health care (PHC) for accelerated progress on universal health coverage and the health-related Sustainable Development Goals (SDGs).

The Vision for Primary Health Care in the 21st Century described the three components of PHC, that is, “what” needs to be delivered, and also proposed a set of levers to help countries to advance across the components of PHC. Expanding on the health system building blocks, these levers address key elements of the health system that can be used to accelerate progress on PHC. Of note, they do not repeat the technical or programme aspects of PHC in the Vision for Primary Health Care in the 21st Century (WHO, 2020)

Although all levers are interdependent and interrelated, the levers are separated into ones that primarily function at the core strategic and operational levels. Core strategic levers can pave the way for actions around other levers, but any sustainable improvement around the operational levers is unlikely without a strong grounding in the strategic levers. Actions and interventions around each lever are thus not intended to be carried out independently, but should be mutually and comprehensively considered throughout inclusive national health planning processes.

Overview of PHC in Ethiopia’s Health System

While PHC is now the foundation of Ethiopia’s health care system, this was not always the case. In 1972, 92% of government expenditure for health care was allocated for hospitals, with most being spent in large cities.

For example, Addis Ababa and Asmara spent an estimated 22 and 12 times more, respectively, per capita than the rest of the country (Kloos, 1998). This changed in 1993, with PHC taking a central role in Ethiopia’s health system as a result of it being integrated into health policy, a change since health policies were highly influenced by physicians who were focused on highly specialized, curative care.

Launch of Ethiopia’s Health Extension Program (HEP)

The Health Extension Program (HEP) is one of the strategies aimed at expanding the reach of PHC services to the community and household levels. The HEP focuses on disease prevention and health promotion through a package of services executed by full-time, salaried and trained community health extension workers (HEWs). Since its launch in 2003, the HEP has become the hallmark of the Ethiopian PHC system, delivered by 40,000 HEWs deployed in 16,440 health posts (FMOH, 2015).

The Essential Health Service Package

 Launched in 2005, the Essential Health Service Package (EHSP) comprises preventive, promotive, curative, and rehabilitative services, with a major focus on PHC. This package of services is intended to be available to everyone in the population through the government’s various service delivery strategies and facilities.

The EHSP is organized into five major components that are somewhat different from HEP, giving slightly more emphasis to curative care: family health services, communicable disease prevention, and control services, hygiene and environmental health services, health education and communication services, basic curative care, and treatment of major chronic conditions (FMOH, 2005). The EHSP is currently under revision in response to the changing epidemiological landscape in Ethiopia and ongoing changes in the health system.

The MOH has recently added two more packages - mental health and non-communicable diseases - to keep up with the growing importance of these health problems in the Ethiopian population.  

Reorganization of the Tier System 

A reorganization of the health system from six-tiers to three-tiers began in 2010, giving special attention to PHC and the delivery of a balanced mix of promotive, preventative, curative, and rehabilitative services (Figure 1). 

Figure 1: Ethiopia’s three-tier health system along with the population size it sees

In rural areas, each woreda should ideally have one primary hospital, 4-5 health centers, 20-25 health posts, 40 - 50 HEWs, and around 4,000 Health Development Army (HDA) volunteers, serving a population of approximately 100,000 people. PHC is delivered at the home and through these health posts, health centers, and primary hospitals, with HDA volunteers providing health promotion and referrals. 

Health Development Army (HDA)

Working under the guidance of HEWs, the HDA volunteers offer services related to community mobilization and health promotion (Exemplars in Global Health, 2020).

They provide an effective mechanism for linking every household in every community with PHC services and for providing peer support to mothers in each household for the uptake of household behaviors to improve maternal and child health services and to improve household hygiene and sanitation.

Successes, Challenges and Lessons Learned from Ethiopia’s PHC System

Ethiopia’s investment in PHC in the past years has paid dividends. Significant improvements have been made in maternal and child health indicators. Mainly driven by making readily available to rural households and communities the delivery of a package of basic and essential promotive, preventive, and curative health services. The HEP is central to these improvements through its implementation of high-impact and cost-effective interventions, such as improving sanitation and personal hygiene, immunizations, family planning, prevention and treatment of malaria, and treatment of diarrhea and pneumonia in children younger than five years of age.

Ethiopia’s effort to expand PHC services has not been devoid of challenges. Most notable has been the inability to fulfill human, material and infrastructure needs at the pace with which the rapid expansion of PHC facilities was occurring. Other challenges include: limited coverage of improved water and sanitation services, a high burden of neglected tropical diseases such as trachoma and soil-transmitted helminths (STH), a growing burden of non-communicable diseases, limitations in the quality of health care services, the lack of water and electricity for many PHC facilities, supply chain bottlenecks, inadequate data quality, and use, and gaps in leadership and management.

To address these challenges, the government has made substantial investments in the production and deployment of mid-level health professionals and community-based HEWs. Also, a revolving drug fund was established and a parastatal entity—the Ethiopian Pharmaceuticals Supply Agency (EPSA) has been set up to improve efficiency in the procurement and delivery of health commodities, with encouraging results.  

Important lessons can be drawn from Ethiopia’s experience with PHC. Among the key ingredients for Ethiopia’s success have been strong political will and commitment, substantial investment in health care infrastructure and midlevel and community health care workers, community mobilization and engagement, leveraging vertical programs for building stronger health systems, and building capacity at the decentralized woreda level.

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