INTRODUCTION
Melesse Zenebework
In the field of development, there is no perfect strategy
which can satisfy the needs of all the actors involved and solve the world
poverty likewise. All methodologies and approaches which have been implemented
so far have their own strength and weaknesses. However, what makes a
development strategy “best” is that it exerts potential capability to include
most of the needs and varieties of development obstacles from all sides
(donors, recipient countries and other development actors) and strive to achieve
better progress.
Various strategies were formulated
and implemented in different epoch since development became the global issue,
nevertheless, most of them failed to make happen the targeted goal in a given
period to our world. Various reasons can be raised for the failure of these
strategies, yet, their incompatibility with the nature and characteristics of
the real problems of each developing country is considered to be the main
factor. This problem still exists in the global development strategies like the
Millennium Development Goal, the High Forum for Aid Effectiveness and Poverty
Reduction Strategy Papers (which some scholars considered as the other face of
structural adjustment policies).
Typically covering a three to five-year planning horizon,
Poverty Reduction Strategy Papers (PRSPs) have become the prime vehicle for
both providing priorities for public expenditure by the governments of
developing countries and delivering international aid for poverty reduction.
According to the World Bank, these strategy papers are primarily formulated in
order to bring about country driven (of the developing countries) development
plans with broad participation of people and civil societies. In spite of its
influential dimension and structure, the Poverty Reduction Strategy Papers have
still faced strong criticism from various individuals and development actors.
They say, the PRSPs are no different from the former Structural Adjustment
Policies in the sense that they are set by the donors and thrown on to the developing
countries so that Highly Indebted Poor Countries (HIPSs) must ensure the
ownership (P. Tharakan and M. McDonald, 2004, pp.8).
11. Sustainable Development and PRSPs
In shaping the world’s development
understanding and policy making at the global level, sustainable development is
one of the hugely accepted and issue these days. The concept was first
introduced by three international NGOs in the world conservation strategy
(UNEP, 1980). The document was first mainly concerned with the ecological
issues and the conservation of living resources and directed little attention
to wider political, economic or social issues. However, the issue of
sustainable development was given more of the social meanings and became the
popularized by the Brundtland Report on the “Our Common Future” in the World
Commission on Environment and Development (Carter, Neil, 2010, pp. 209).
Sustainability is one of the
recent issues in the development field that most scholars are defining what a
sustainable development mean in a way, to some extent, closely related to each
other. Even though most development professionals clearly understand and define
the idea of sustainability, it is still very difficult and complex in order to
ensure the sustainability of development. The classic definition of sustainability,
based on Brundtland’s report (WCED, 1987: 54–76), “[s]ustainable development is
development that meets the needs of the present without compromising the
ability of the future generations to meet their own needs”. According to Daniel
Morrow, “sustainable development” is used to mean development that has
sufficient country ownership and broad participation so that societal
transformation can be sustained successfully over time (D. Morrow, 2001, pp.
14).
1.2. Poverty Reduction Strategy Papers (PRSPs): Definition
Despite all efforts
undertaken during structural adjustment, one should recognize that dismal
poverty persists unabated in many developing countries and the gap between the
rich and the poor is large and growing.[1] It is more and more apparent that
International Development Goals (IDG) –including reducing by half the
proportion of people living in extreme poverty by 2015— will not be met if
current trends are not reversed. Therefore, having this into consideration, the
Bretton Woods’s institutions and international community initiated and conducted
intense examination of the development policies, debt strategies and poverty
related issues. then, in September 1999,
it was determined that concessional lending, that traditionally has taken the
form of structural and sectoral adjustment loans, would be now negotiated under
nationally-owned participatory poverty reduction strategies, called PRSPs. These
strategies will be as well the basis for debt relief under the enhanced Heavily
Indebted Poor Countries (HIPC) initiative.
Poverty Reduction Strategy Papers (PRSPs) is a document
which outlines a national development program for poverty reduction which is
the foundation for landing programs with the IMF and the World Bank and for
debt relief for Heavily Indebted Poor Countries (HIPCs). It is the bases for
all HIPCs to prepared and submit the document in order to gain foreign aid from
any of the developed countries. It is also the document the bank and the fund
must approve of so that the developing countries can gain access for
concessional lending and other financial aid from the international financial
institutions (Bretton woods, 2003).
1.1. Background: Ethiopian Health Sector Development
Ethiopia is known to have one of
the lowest health statuses in the world. This is mainly due to backward socio- economic
development resulting in widespread poverty, low standard of living, poor environmental
conditions and inadequate health services. Realizing this state of affairs, the
Federal Democratic Republic of Ethiopia, embarked on a rapid economic development
and a multi-pronged poverty reduction programs. In line with this strategy, it
took a number of measures in the health sector including the design of an appropriate
sectoral policy, strategy and a twenty-year rolling health development program.
In response to the prevailing and newly emerging health problems as well as in recognition
of the weaknesses of the existing health delivery system, the first phase of Health
Sector Development Program (HSDP I) was launched in 1998. It was designed explicitly
to respond to the health care needs of the rural population who constitute 85% of
the total population. The sectoral program demonstrates the priority that the
Government accords to health, and backed by a firm commitment to allocate the necessary
internal and external resources to facilitate HSDP implementation.
The need for broad partnership between, and active involvement
of all potential partners involved in the financing, delivery, management, and
use of health services was also recognized at an early stage, and HSDP I was
therefore developed through a broad consultative process.
The overall goal of
the HSDP is to improve the health status of the peoples of Ethiopia. The
linkage between improved health and general development are increasingly being acknowledged.
This relationship was well defined in the HSDP I where the linkages has been articulated
between the impact of improved health status on productivity of the adult population,
reduced household expenditures on health thus freeing resources for productive use,
and the resulting contribution to reduced poverty and support to the overall socio-economic
development of the country. The priorities in the health care interventions were
the preventive and promoting aspects of care and the expansion of health facilities
in order to deliver a comprehensive, integrated and equitable primary health care.
1.2. Policy Framework
of the HSDP II.
Establishing an
effective and responsive health delivery system is an integral component of a
National Development policy that aims to reduce poverty and achieve economic
growth and development. Here are some of the components of the health sector
development policy framework components.
• Policy on
decentralization: proclamations No. 7/92 and No. 41/93 should be taken into
consideration with the adoption of health and health related polices in 1993:
Health Policy, National drug policy, National population policy, and National
policy on Ethiopian women. This should go with Agricultural Development Led
Industrialization (ADLI) strategy in EFY 1993 and Policy on HIV/AIDS, 1998.
• Poverty Reduction
Strategy (PRSP)-2000 and Capacity Building Strategy and Civil Service reform-
2002 must go parallel in addition to consideration of the Millennium
Development Goals and the Global Fund against AIDS, Malaria and TB (GFTAM)
initiative.
1.3.The main
Objectives of the Health Development Sector Program II.
Having the policy framework
for the health sector development program, government has stated a few
objectives which can tell the focus areas where much investment and efforts
should be exerted in order to achieve the expected success in the HSDP II.
However, for it takes much time and space to discuss on the objectives for this
study, I brought only two of the objectives. Thus, the focus of this study
paper concentrates on the following two Policy Objectives.
·
Implementation
of Health Extension Package on pilot basis using existing primary health care
workers and gradually expands the services using the newly trained Health
Extension Agents.
·
Train
and deploy motivated and adequate number of technical and managerial health
workers at all levels of the health system.
1.4.Critical Discussion
on the Policy Objectives of the HSDP II
According to the
PRSPs of the Ethiopian government issued in 2002, the health sector development
program has been designed based on the principle of SWAP (Specific, sector
Wide, Applicability, and Participatory). The program is under implementation
under the wider policy frameworks of the country that includes the sectoral
development program, agricultural development led industrialization and the
millennium development goals. However, are the strategies to accomplish this
development policy effective enough? This paper will try to critically analyze
them based on their relevance, formation, the type of actors they chose,
implementation and monitoring and accountability.
1.4.1.
Relevance of the Strategies
According to the
Ethiopian Ministry of Health report under the IMF, most of the causes for the
death of children under the age of five are diarrhea, pneumonia and other
communicable diseases. These type of diseases as the report mentions can be
controlled with better coverage of the health service throughout the country
(IMF, 2004). For a country like Ethiopia with a population over 90 million,
large coverage of health service is the first mandatory task to be applied.
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Figure
1
Distribution of causes of death among children aged <5 years (%) in Ethiopia
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Therefore,
the Ethiopian government’s plan to handle this problem by executing health
extension package on pilot basis using existing primary health care workers is
the most fundamental work to take. Moreover, the ethnic, cultural and
geographical phenomenon of the country also needs the pilot basis of program
implementation throughout the country. Even
though the program is decentralized in the way the country
set, it still need much work on the provision of health workers and health
centers from the federal to community level. As the report stated, encouraging
improvements have been shown in HSDP I both in health service coverage and
unitization of services at all level of health care system of Ethiopia.
Therefore,
in terms of physical health facilities, improvements have been the construction
of additional 3,135 New Health Posts reaching 2899 in 2003/04. This was from a
weak of 76 HPs in 1996/97. The number of Health Centers has also increased from
the 1996/07 level of 243 to 519 in 2003/04. Similarly the number of Hospitals
has increased from 87 in 1996/97 to 126 in 2003/04 (MOH, 2002). Having all these, it is relevant to produce more health
workers at all the constructed health sites during the HSDP II where the
program has required the training and deployment of all female HEWs and by the
end of the program, there have been 2,800 trained and deployed HEWs with 7,138
already enrolled for training in 2004/5. This number can change the service
provision by large throughout the nation.
As most of
the least developed nations, Ethiopia has little potential to cover all the
needs of health services by the trained and professional health worker in all
level of development. Therefore, there has to be other means which can handle
the same problem at lower cost and within a short period of time. That is
producing the Health Extension Agents (HEAs) through the Health Extension
Program. According to a report from the MoH, the program was introduce under
HSDP II 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 (MoH, 2002). Therefore, women who completed at
least grade 10th were selected from
each Kebele (of 500 households) and trained for eight continuous training on
prevention communicable diseases and provision of primary health care services
at their own community using their own language to communicate the society.
This increases the nation’s capacity to prevent communicable diseases.
1.1.1.
Formation
Looking at the formation of the strategies for the HSDP II,
two points can be raised in terms of their capacity to be understood by the
concerned actors in all levers, and whether the strategies can mobilize the
people to work towards their implementations. Therefore, thorough the health
extension program, the two strategies can easily achieve this requirement as it
is stated above. The government has made the program having the people at the
community level as a direct participant in the implementation process. In order
to avoid misunderstanding, a serious of eight months of training is given so
that the trainees go out and act upon the problem as planned. This
is
one of the most successful programs which pushed the whole health sector
development forward so far.
Similarly, the program has been formulated in a way to
mobilize the community to some extent. The health extension program has 340
health professionals and selected public and NGO based drug outlet institutions
and trained 3000 HEWs from five regions. This number has increased to 5000 HEWs
in the HSDP II according to the report.
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Figure
2 Health extension program implementation cycle at the community level
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Ethiopia is a federal state where
different states have their own ways of regional policies programs in
development. The national (federal) government has a mandate to implement
nationwide development programs and the states are always obliged to accept and
implement as well. The HSDP II is one of the nationwide development programs
and it has to be implemented throughout the country. The states have the
responsibility to handle the progress of programs of this kind. Therefore,
Ministry of Health has formulated the program at the national level and it has
to be disseminated to all the regions. In addition to the
community level participation (Health Extension Workers), the strategies allow
non-governmental organizations, government institutions, private hospitals and
foreign NGOs. The strategies are implemented in all of the 9 regional states,
62 zones and 523 Woredas (districts). This tells how participatory the strategies are.
1.1.3. Implementation
The bottom-up
strategies, Implementation of Health Extension Package on pilot basis using
existing primary health care workers and gradually expands the services using
the newly trained Health Extension Agents and provision of training and deploying
motivated and adequate number of technical and managerial health workers at all
levels of the health system,
can be applicable. These were actually implemented and successfully brought
changes in the HDSP I. Since the federal and regional health offices are very
much coordinated and the structure still goes further to the community level
having all the concerned local and national NGOs. It is also reported on the
PRSP document that implementation arrangements are set to expand the scope of
HSDP II governance to Woreda level with strong collaboration amongst the FMOH,
RHBs, and Woreda level health authorities. Widening the role of community and
NGOs in planning, implementation and governance of health care delivery
activities, particularly at the Woreda level, the program will enhance awareness
building and harmonization of standards and quality of services (IMF, 2003).
However,
few factors need to be taken in to consideration in order to avoid failure at
the implementation level. The first one is language. Training modules must be
translated in to local languages, trainees must effectively communicate with
their trainers, and while reaching the target community, the trainees must
apply their knowledge using the language of that community. The other factor is
culture, which is one of the most sensitive issues in a country like Ethiopia
with diverse ethnic minorities. In some ethnic groups scientific medical
service is cursed and trainees must know how to approach those people and even
the government should invest some on changing the mindset of the community
ahead of time. Politics is the other sensitive issue in Ethiopia that anyone is
handling government’s program may be considered as government cadre that those
areas which are politically sensitive with the government need more attention on
how to handle them.
1.1.4.
Monitoring
and Accountability
The
issue of monitoring, evaluation and accountability has been clearly stated in
the PRSP of the health sector to explain the authority that should handle the
monitoring and evaluation processes as well as the factors used to evaluate the
program in general. In order to monitor improvements in the delivery of quality
care, to evaluate the impact, effectiveness of programs, financial performance
and cost-effectiveness of the HSDP II, specific components has been mentioned.
Monitoring is conducted to guarantee the progress in the implementation of
different components of the HSDP II on quarterly basis so that the program
should expand its scope more at the Woreda level. All the regions are initiated
to prepare and distribute the health indicators booklet and also prepare
quarterly reports on the follow up and utilization of external funds. The FMOH
also established feedback mechanisms at all levels of to further develop and strengthen
the achievements of the progress of planned monitoring and evaluation activity
reports.
1.1.5.
Challenges
and Opportunities
It is usually difficult to establish Woreda level health
offices with core staff. This is due to lack of finance and man power. Creation
of strong leadership with clear mandate, responsibility and accountability is
also the other most difficult point to overcome. Since the program is very
wide, coordination and harmonization of HSDP II activities will be hard to
handle. Some Woredas are very large with over populated therefore it needs more
decentralizations of governance and that causes more challenges. Moreover,
creating strong collaboration amongst the FMOH, RHBs and Woreda health offices
is more difficult.
However, the increased utilization health facilities by the
HSDP I is a good opportunity for this program. In addition to enhanced
community participation, NGOs and private actors’ enhanced involvement in the
program can be another opportunity
Conclusion
All
in all, going through a complex and diverse society with less progress in
development takes much effort and dynamic understanding of the various essentialities
towards producing a good development policy and strategies. However, the
overall policy and specific strategies suggested by the Ethiopian government in
order to achieve better results in the health sector is appreciable. Since the
Ethiopian government has a plan on the prevention and control of communicable
diseases and other health problem, the strategies such as the implementation of Health Extension Package on
pilot basis using existing primary health care workers and gradually expanding
the services using the newly trained Health Extension Agents is purely
important. Moreover, doing the training and deploying motivated and adequate
number of technical and managerial health workers at all levels of the health
system is also relevant. The strategies are also participatory to the extent
that all the concerned development actors can productively act upon the program
on specific areas. Government’s accountability at all levels of development is
also impressive that the means of monitoring and evaluation in all levers are
productively implemented.
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