Decentralisation has been used as an important instrument for the full realisation of the rights and powers of the diversified population.  The health policy has also emanated from a commitment to democracy and gives strong emphasis to the fulfilment of the needs of the less-privileged rural population.

Arguably, the most significant policy influencing the design and implementation of the Ethiopian Government's Health Sector Development Plan (HSDP) is the policy on decentralisation.  This is well articulated within the constitution and in a number of major and supplementary proclamations, and provides the administrative context in which health sector activities take place.

Important steps have been taken in the decentralisation of the health care system.  Decision-making processes in the development and implementation of the health system are shared between the Federal Ministry of Health (FMOH), the Regional Health Bureaux (RHBs) and the Woreda Health Offices.  As a result of recent policy measures taken by the Government, the FMOH and the RHBs are made to function more on policy matters and technical support, while the woreda (district) health offices play the pivotal roles of managing and coordinating the operation of the primary health care services at the woreda level.

A Primary Health Care Service should include preventive, promotive and basic curative services.  In order to realise this, a four-tier system for health service delivery was introduced, characterised by a primary health care unit (PHCU), comprising one health centre and five satellite health posts, and then the district hospital, zonal hospital and specialised hospital.  A PHC-unit has been planned to serve 25,000 people, while a district and a zonal hospital are each expected to serve 250,000 and 1,000,000 people respectively (see ‘Ethiopia Health Structure' for further details).

Table 1-2 shows the number of health facilities and health facility-to-population ratio per region in 2003/04.  These figures include government institutions, non-governmental organisations (NGOs) and the private sector; the population figure is based on Central Statistical Agency projections.  However, it is important to note that the distribution of both the public and private health facilities is skewed towards the urban areas.  The growing size and scope of the private health sector, both for profit and not-for-profit, offers an opportunity to enhance the health service coverage.  An increasing number of indigenous and international NGOs are currently involved in various aspects of service delivery and there are currently an estimated 1,299 private clinics and 18 private and NGO-owned hospitals in the country.  In addition, there are 275 pharmacies, 375 drug shops and 1,563 rural drug vendors.

Responsibility for logistical support is shared between FMOH and the RHB.  A Health Management Information System (HMIS) has been established for routine reporting of activities and health service utilisation, and structures are in place for periodic monitoring and evaluation of the health system as a whole.

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Potential Health Service Coverage is calculated by multiplying the total number of PHC facilities (i.e. Health Centres, Health Stations and Health Posts) by the respective standard number of population to be served, i.e. 25,000 for HC, 10,000 for HS and 5000 for HP, and dividing the sum of these numbers by the total population.  The overall potential health service coverage in 2004 was estimated at 64.02%.  However, this varies substantially among the regions depending on their topographic and demographic characteristics.

Geographical distance from a health facility and socio-economic factors are the major obstacle for the majority of the Ethiopian population.  However, the trend over time shows that there is a steady increase both in coverage and utilisation.  The potential health service coverage has increased from 45% to 57% and then 64.02% during 1997, 2002 and 2004 respectively.  The per capita health service utilisation that was 27% until 2000 has increased to 36% in 2004.

Coverage in terms of health workers remains poor.  The existing number of health workers and health worker to population ratio for 2003/4 is shown in Table 1-3.

As can be seen in the table, the physician to population ratio is much lower than the WHO minimum standard of one physician for 10,000 people.  However, it is important to note that the figure is mainly based on health workers in the public sector due to the lack of complete reporting from the private sector, while a substantial number of physicians working in the private sector are also providing services to the public.  In addition, health assistants are known to work at all levels of the health system and their duties are more or less similar to that of the nurses.  Despite the noticeable improvement in distribution of human resources as a result of actions taken in the last decade, there is still some concentration of health workers in regional capitals and places perceived to offer better facilities than others.

Health services in Ethiopia are financed by four main sources.  These are government (both federal and regional); bilateral and multilateral donors (both grants and loans); non-governmental organisations; and private contributions.

The National Health Accounts exercise for financial year 2000/01 revealed that the major contribution is that of households' contribution (36%), government (33%), and bilateral and multilateral donors (16%)(1).

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