ANNEX C: GHI and Ethiopia (Illustrative)

Background and Health Situation:

Ethiopia has a population of nearly 80 million people, with 84% living in rural areas and 45% under 15 years of age. Ethiopia has enormous unmet health needs and is prone to drought, famine, and epidemics. Its fertility rate is one of the highest in the world and modern contraceptive use is only about 14%. One out of every 27 women dies during child birth with only 28% of women receiving antenatal care. Under-five mortality remains high, with most child deaths caused by preventable and treatable conditions such as malaria, pneumonia, diarrheal diseases, and malnutrition. Almost half of Ethiopian children are stunted and more than 1 in 10 are acutely undernourished. HIV prevalence among adults is 2.3% and 1.1 million people are living with HIV in Ethiopia. Ethiopia is among the 22 countries with the highest TB burden, and only 32% of cases are detected. It is also one of 57 countries WHO identifies as having a health workforce crisis.

The U.S. government health portfolio has been closely guided by the MOH's Health Sector Development Program. During the past few years, Ethiopia has greatly expanded access to basic health services, has strengthened their HIV/AIDS and malaria programs and improved the modern contraceptive prevalence rate (CPR) among married women. For example, CPR increased from 6.3% in 2000 to 14% in 2005.

GHI Implementation in Ethiopia:

Building on existing programmatic platforms and partnerships, an intensified GHI focus will scale-up activities outlined in the national health program while ensuring that special attention is given to monitoring and evaluation to assess progress and to capture lessons learned.

Collaborate for impact: The Government of Ethiopia (GOE) is strongly committed to improving the health of its population. The GOE maintains strong ownership of a multi-partner effort to increase the coordination and integration of national and international development to achieve more efficient, effective and sustainable public health results. Potential activities include:

• Strategically integrating currently discrete activities (e.g., PEPFAR, PMI and MCH, family planning, EPI) into a full package of comprehensive health services for women, newborns and children.
• Linking GHI health programs with other efforts in the education, agriculture, and food security sectors to address undernutrition.
• Collaborating with GAVI, the Global Fund, the World Bank, UN, and others to support Ethiopia's efforts to achieve its health strategy goals.
• Building the capacity of and fostering ownership by local institutions, including the Ministry of Health, Ethiopia Health and Nutrition Institute, universities, professional associations, and non-governmental organizations.
• Coordinating GHI activities in country across the full complement of U.S. government agencies on the ground.

Doing more of what works: Support Ethiopia's own efforts and plans to scale-up proven public health interventions in an integrated, focused, and strategic manner. Potential interventions for scale-up include:

• Integrating and expanding MCH, immunizations, family planning, TB, HIV/AIDS, and nutrition programs in targeted rural and urban settings, including though the MOH's new "Urban Health Extension Worker" initiative, with particular focus on linking PMTCT services with antenatal and obstetric/neonatal care.
• Expanding the PMI-supported malaria prevention and treatment programming from the Oromia region to other malaria-prone areas nationwide.
• Using existing platforms such as schools to deliver treatments to reduce the burden of neglected tropical diseases such as worms.
• Increasing access to safe water, sanitation, and hygiene by using point-of-use water treatment solution in schools, high-risk households, and rural healthcare facilities; protecting water sources and rehabilitating water supplies; and promoting sanitation and hygiene in communities.

Innovating for results: Assess and introduce new, high impact technical innovations, for example:

• Implementing Rapid Diagnostic Tests (RDTs) for malaria to ensure that children with fever are appropriately-treated.
• Introducing new point of care diagnostic technologies as they emerge, such as CD4 count for HIV/AIDS.
• Using lipid-based nutritional supplements for the prevention of severe under-nutrition.
• Expanding new approaches in MDR-TB diagnosis and treatment.
• Expansion of community-based health insurance to rural areas to reduce the financial burden associated with serious illness.

Expanding existing platforms to foster stronger systems and sustainable results: Ethiopia now has a broad platform of health facilities to provide MCH, TB, family planning, HIV/AIDS, malaria, and other services as well as a network of 30,000 community Health Extension Workers (HEWs) now allowed to administer appropriate drugs and vaccines. In addition to major progress with task shifting, Ethiopia is also addressing its severe health worker shortage through innovative strategies to train and retain more nurse midwives, health officers, doctors, managers, epidemiologists, and others. GHI support could potentially further strengthen the health system through:

• Expanding community case management of malaria, diarrhea, and pneumonia, and the availability of community-based family planning services through HEWs.
• In conjunction with the Feed the Future Initiative, expanding coverage of Community Management of Acute Malnutrition along with community-level promotion of breastfeeding and infant and young child feeding. Integrating relevant tuberculosis and HIV/AIDS services to increase TB case detection and treatment among people living with HIV/AIDS.
• Rolling-out a sound health finance program (including outsourcing, fee waivers and exemptions, performance-based financing, and health insurance for the community) to improve health worker retention and increase access to quality health services.
• Using successful behavior change communication approaches to reduce the risk of HIV infection and transmission, increase use of safe water and hygiene, improve nutrition, and increase service utilization.
• Along with other donors, support the Government of Ethiopia's health systems strengthening programs including: the implementation of the Government of Ethiopia's Logistics Master Plan to improve the delivery of commodities; implementation of the Human Resources for Health Strategy, strengthening of the National Health Management Information System to improve the use of data for decision making; and implementation of the National Laboratory Master Plan to expand and integrate laboratory capacity for HIV, TB, malaria, and infectious disease surveillance.
• Conducting implementation research to provide a local and international evidence base to inform decision-makers to develop policies and programs that lead to broad sweeping public health improvement.