FRONTESPIZIO - Cooperazione Italiana allo Sviluppo

Introduction: dermatology and human rights 1FRONTESPIZIO

2 Health Systems and Skin Diseases: the case of EthiopiaBIANCA

Introduction: dermatology and human rights 3Health Systems Sand Skin SDiseases: Dthe case ofEthiopiaEditors: Aldo MORRONE, Vincenzo RACALBUTOPART ONEHealth system and its challenges1. INTRODUCTION: DERMATOLOGY AND HUMAN RIGHTS(Aldo Morrone)2. THE ETHIO-ITALIAN COOPERATION PROGRAMME WITH SPECIALFOCUS ON THE HEALTH SECTOR (Andrea Senatori)3. THE ETHIOPIAN HEALTH SECTOR AND THE ITALIANCONTRIBUTION TO HSDP (Augusto Cosulich, Vincenzo Racalbuto)4. BUILDING THE NATIONAL HEALTH MANAGEMENT IN-FORMATION SYSTEM (HMIS) IN ETHIOPIA: TOWARDS EVI-DENCE-BASED DECISION MAKING (Sandro Accorsi, Nejmudin Kedir)5. HUMAN RESOURCES FOR HEALTH (HRH): A CRUCIAL EL-EMENT FOR ACHIEVING INTERNATIONAL MDGs. NATURE OFTHE CRISIS IN ETHIOPIA. (Carlo Resti, Yohannes Tadesse)6. USING INDICATORS TO MEASURE THE PHARMACEUTI-CAL SECTOR IN ETHIOPIA (Andrea Gardellin, Abraham Gebre Giorgis)7. HIV AND SKIN: AN OPERATIONAL RESEARCH (O.R.) INTIGRAY REGION, ETHIOPIA (Tigray RHB; T.M.A.; IISMAS onlus;Italian Cooperation – HSDP)8. OPERATIONAL RESEARCH IN TIGRAY REGION: REPORTOF THE FIRST YEAR OF ACTIVITIES 2005-2006 (MargheritaTerranova, Valeska Padovese, Aldo Morrone)PART TWOInfectious and non-infectious diseases1. INTRODUCTION: HEALTH SYSTEMS AND SKIN INFEC-

4 Health Systems and Skin Diseases: the case of EthiopiaTIOUS DISEASES. THE CASE OF ETHIOPIA (Aldo Morrone, GebreabBarnabas)2. PATTERN OF SKIN DISEASES AT THE FIRST DERMATO-LOGICAL HOSPITAL IN TIGRAY, ETHIOPIA (Aldo Morrone, ValeskaPadovese, Margherita Terranova, Silvana Trincone, Giuseppe Fontanarosa,Gebreab Barnabas)3. DERMATOSES DUE TO BACTERIA (Aldo Morrone, ValeskaPadovese)4. DERMATOSES DUE TO VIRUSES (Aldo Morrone, MargheritaTerranova )5. SEXUALLY TRANSMITTED INFECTIONS (Aldo Morrone, LuigiToma)6. TROPICAL TREPONEMATOSES (Aldo Morrone, Gennaro Franco)7. TROPICAL DEEP FUNGAL INFECTIONS (Aldo Morrone,Dagnachew Shibeshi)8. DERMATOSES CAUSED BY ARTHROPODS (Aldo Morrone,Valeska Padovese, Margherita Terranova)9. PROTOZOAN DERMATOSES (Aldo Morrone, MargheritaTerranova, Valeska Padovese)10. HELMINTHIC DERMATOSES (Aldo Morrone, Ugo Fornari)11. DERMATOSES DUE TO MALNUTRITION (Aldo Morrone,Tesfalem Hagos)12. ETHNODERMATOLOGY (Aldo Morrone, Gennaro Franco)13. EMERGING AND RE-EMERGING INFECTIOUS DISEASES(Aldo Morrone, Luigi Toma)14. NEGLECTED DISEASES (Aldo Morrone, Genet Fitwi)15. HEALTH SYSTEMS AND SKIN INFECTIOUS DISEASES(Emma Pizzini, Ottavio Latini, Aldo Morrone)16. ECONOMIC ASSESSMENTS AND TROPICAL DISEASES INDEVELOPING COUNTRIES (Aldo Morrone, Lorenzo Nosotti, OttavioLatini)

Introduction: dermatology and human rights 5Part one

6 Health Systems and Skin Diseases: the case of EthiopiaBIANCA

1. Introduction: dermatology and human rights 71. INTRODUCTION:DERMATOLOGY AND HUMAN RIGHTSAldo MorroneToday’s real borders are not between nations,but between powerful and powerless, free andfettered, privileged and humiliated. Today, nowalls can separate humanitarian or humanrights crises in one part of the world fromnational security crises in the other.Kofi Annan, UN Secretary-General,in his acceptance speech upon receivingthe 2001 Nobel Peace PrizeIntroductionThe WHO Constitution states that “The enjoyment of the highest attainablestandard of health is one of the fundamental rights of every human beingwithout distinction of race, religion, political, economic or social condition”.Although in 1987 the WHO adopted the strategic goal “Health for All by theyear 2000”, Health for All documents have largely ignored the skin and itscontribution to a socially and economically productive life. In 2003 Healthfor All has not been achieved. Or better, we have good health, but only in theNorth of the World…and not everywhere.What about the South? What about Healthy Skin for All?Skin diseases represent the greatest problem of public health care in all developingcountries. Specifically:1.Over 30% of all the diseases observed in the rural medical centres of developingcountries involve cutaneous disorders.2. In tropical developing countries 90% of skin diseases are diagnosed andtreated by health workers who have no dermatological knowledge.Skin diseases are amongst the five most common causes of death and/or lossof working capacity among rural populations.3. About 3.4 billion people – over half the population of the planet – live inareas with no access to basic skin treatment.

8 Aldo Morrone4. Increase of uncontrolled tourism in tropical countries, related to sexualabuse, particularly of children, has led to uncontrolled increases in malaria,STDs and AIDS.5. Child labour most often causes cutaneous allergies and systemic damagedue to toxic or allergizing substances.Children and skin diseasesWhat is tragic is that the bulk of the population suffering from skin diseasesare children. It is estimated that children form 50% of the total populationin developing countries, and of these 75% have skin diseases. The majorityof the children population has no access to essential dermatological drugs.Children face unusually high health risks as they grow. The obstacles to optimalhealth are greatest for children born into poverty. Across the world,children are at higher risk of dying if they are poor. For millions of childrentoday, particularly in Africa, the biggest health challenge is to survive untiltheir fifth birthday, and their chances of doing so are fewer than they were adecade ago. Although approximately 10.5 million children under 5 years ofage still die every year in the world, progress has been made since 1970, whenthe figure was more than 17 million. Although child health has improvedoverall, three of the ten most important conditions of the diseases of greatestglobal burden are still diseases of childhood: the perinatal conditions closelyassociated with poverty, those arising in the perinatal period, including birthasphyxia, birth trauma and low birth weight; diarrhoeal diseases; pneumoniaand other lower respiratory tract conditions. Overall, 35% of Africa’s childrenare at higher risk of death than they were 10 years ago.Iinternational migration and childrenInternal conflicts, poverty and the disintegration of nation-states has resultedin significant population movements, particularly with respect to immigrants,refugees, asylum seekers and displaced persons. People are increasinglyon the move for political, humanitarian, economic and environmental reasons.This population mobility has health and human rights implicationsboth for migrants and for those they leave behind. Migrations often face seriousobstacles to good health due to discrimination, language and culturalbarriers, legal status, and other economic and social difficulties. Human migrationhas always represented a complex social and political problem, withparticular impact on medical and health services. The reality of immigrationfrom developing countries, has only recently begun to affect Europe.

1. Introduction: dermatology and human rights 9According to the most recent United Nations’ estimate, there were at least175 million immigrants worldwide in 2003, of whom six out of 10 were settledin the industrialised countries. There were more than 20 million legalimmigrants in Europe at the beginning of 2002. Almost 16 million peoplewere recognised in 2000 as refugees. In addition, there were 7 million displacedpersons, almost 1 million asylum seekers and repatriated refugees inthe world. Most of them are children.Italy is the largest country of emigration in modern history, with 28 millionpeople emigrating between 1861 and the beginning of this new century. Italyis the most important Mediterranean Euro-member state in transition frombeing a country of emigration to one of immigration.The “Italian model” of immigration had become important most obviouslybecause of its size. At the beginning of 2003, the total number of residencepermit holders in Italy was 2.500.000, approximately 4.0% of the Italianpopulation, or1 immigrant for every 38 Italian citizens.Children are one of the most significant indicators of stable immigration inItaly. The number of minors grew from 126,000 at the end of 1996 to278,000 at the end of 2000. Including new births (more than 25,000) andthose entering through family reunion, their number already exceeds300,000, one-fifth of the immigrant population. There are almost 30.000births annually to couples both of whom are foreign citizens. The term “bambinostraniero” (foreign child) is also incorrect, because we are often talking ofchildren born in Italy. Their number reached 100,000 only four years ago,and grew to 147,000 during the school year 2001-2002 and 182,000 in thefollowing year. Six out of ten are enrolled at primary or nursery schools. Theyare now less than 2% of the resident population; in 2017, according to a governmentestimate, their number could rise to 529,000, or 6.5% of the schoolpopulation.ResultsIn our Department, in the last three years, we visited 1,137 foreign children,255 of them had the double nationality and 50% of them were under 14. Weobserved a high prevalence of skin infectious diseases (67.3), odontoiatric diseases(24.4%), traumatic diseases (10.2%) and gastroenteric diseases (6.2%gastritis and duodenitis, 6.1% liver diseases) and also skin tuberculosis andHIV/AIDS. Many little girls are affected by different forms of FemaleGenital Mutilation (FGM) and we observed 127 girls with FGM, comingfrom the sub-Saharan Africa. We examined 654 abandoned children in the

10 Aldo Morronelast three years. They are often victims of various kinds of exploitation (theft,illicit trading, begging). They come to Italy without their families and for thisreason they are easy victims.DiscussionAll countries of the world have pledged to reach the MillenniumDevelopment Goals set at the United Nations Summit in 2000.These includeambitious targets for nutrition, maternal and child health, infectiousdisease control, and access to essential medicines. Three of the eight goals aredirectly health-related; all of the others have important indirect effects onhealth. Twenty-five years ago, the Declaration of Alma-Ata challenged theworld to embrace the principles of primary health care as the way to overcomegross health inequalities between and within countries. “Health for all”became the slogan for a movement. It was not just an ideal but an organizingprinciple: everybody needs and is entitled to the highest possible standardof health. The principles defined at that time remain indispensable for a coherentvision of global health. This entails working with countries not onlyto confront health crises, but to construct sustainable and equitable healthsystems. Foreign residents have equal rights with Italians in relation to accessto public national health service. Urgent or essential hospital treatment isprovided free of charge to illegal migrants who do not have the means to payfor it, together with care in relation to pregnancy and for minors, vaccinations,diagnosis, and treatment of infectious diseases.Almost 57 million people died in 2002, 10.5 million (nearly 20%) of whomwere children under 5 years of age. Of these child deaths, 98% occurred indeveloping countries. Of the 20 countries in the world with the highest childmortality, probability of death under 5 years of age, 19 are in Africa. Fifteencountries, mainly European but including Japan and Singapore, had childmortality rates in 2002 of less than 5 per 1000 live births. Many countries ofthe Eastern Mediterranean Region and in Latin America and Asia have partlyshifted towards the cause-of-death pattern observed in developed countries.Here, the perinatal conditions have replaced infectious diseases as theleading cause of death and are now responsible for one-fifth to one-third ofdeaths. Such a shift in the cause-of-death pattern has not occurred in sub-Saharan Africa, where perinatal conditions rank in fourth place. In 2002,more than 4 million African children died. About 90% of all HIV/AIDS andmalaria deaths in children in developing countries occur in sub-SaharanAfrica, where 23% of the world’s births and 42% of the world’s child deaths

1. Introduction: dermatology and human rights 11are observed. Here, malnutrition, malaria, higher respiratory tract infectionsand diarrhoeal diseases continue to be among the leading causes of death inchildren, accounting for 45% of all deaths. The malnutrition contributes directlyor indirectly to 60% of the more than ten million child deaths each year.For every child born today to have a good chance of a long and healthy life,there are minimum requirements which every health care system should meetequitably. These are: access to quality services for acute and chronic healthneeds, effective health promotion and disease prevention services. The reinforcementof health systems should be based on the core principles of primaryhealth care as outlined at Alma-Ata in 1978: universal access and coverageon the basis of need; health equity as part of development oriented tosocial justice; community participation in defining and implementing healthagendas; and cross-disciplinary approaches to health. These principles remainvalid, but must be reinterpreted in light of the dramatic changes in the healthfield during the past 25 years.ConclusionsThe migration, like all major social phenomena, brings with it problems aswell as benefits. It is important to discuss immigration as a resource for thepeople involved. Immigration is a phenomenon that concerns the whole ofItalian society, though as yet not all parts of society see it this way. Acceptingimmigration also means accepting the country’s history. Since the past andpresent are closely linked in a country’s history, immigration needs to be acceptedas a permanent feature of Italian society which therefore requires investmentin policies of integration. Despite the health reforms of recentdecades, inadequate progress has been made in building health systems thatpromote collective health improvement. Extending health promoting conditionsand quality care to all is the major imperative for health systems.

12 Aldo MorroneReferences1. Morrone A, Fazio M, Leone G et al. Constatations cliniques et épidémiologique chez 587enfants immigrés en provenance de pays hors de la Communauté Européenne, durant les septderniéres années. Nouvelle Dermatologiques, vol. 11, pag 863, 1992.2. Morrone A, Hercogova J, Lotti T. Stop female genital mutilation: appeal to the internationaldermatologic community, Int J Dermatol., 2002 May; 41(5):253-63.3. Morrone A. The skin and the catastrophes, J Eur Acad Dermatol Venereol. 2002May;16(3):207-9.4. Moy J.A., Sanchez M.D., The cutaneous manifestations of violence and poverty, ArchDermatol. 1992,128:829-39.5. UNDP (2003), Human Development Report 2003 Millennium Development Goals: Acompact among nations to end human poverty. Oxford University Press.6. UNFPA (2003).“Population and Poverty: Achieving Equity, Equality andSustainability”. PDS Number 8, New York.7. WHO. Poverty and health – Evidence and action in WHO’s European Region. Copenhagen,WHO Regional Office for Europe, 2002 (EUR/RC52/8)8. WHO. The World Health Report 2003. Health Shaping the future, Geneva.9. World Bank (2002) World Development Report 2003: Sustainable Development in aDynamic World: Transforming Institutions Growth and quality of Life. Washington,World Bank.

2. The ethio-italian cooperation programme with special focus on the health sector 132. THE ETHIO-ITALIAN COOPERATION PROGRAMMEWITH SPECIAL FOCUS ON THEX HEALTH SECTORAndrea SenatoriIntroductionThe aim of the Italian Development Cooperation is mainly to help developingcountries reduce poverty. As a signing party of the Universal HumanRights Declarations, Italy also encourages good governance, respect for humanrights and democratic participation in economic and social developmentfor all members of society, without discrimination.Cooperation with developing countries allows Italy to contribute to effortscoordinated by the United Nations to alleviate world poverty: the eightMillenium Development Goals (MDGs), approved by the United NationsGeneral Assembly in September 2000, are the fundamental points of referenceboth for Italian Development Cooperation and International Aid.MDGs at a Glance1. Eradicate extreme poverty and hunger by 20152. Achieve universal primary education by 20153. Promote gender equality and empower women4. Reduce child mortality5. Improve maternal health6. Combat HIV/AIDS, Malaria and other diseases7. Ensure environmental sustainability8. Develop a global partnership for developmentApproximately 40% of Italian aid is distributed to the 50 countries, out ofwhich 34 are in Africa, that the UN classifies as Least Developed Countries.Along with other G8 countries and the OECD (Organisation for EconomicCo-operation and Development), Italy welcomed in particular the NePAD(New Partnership for Africa’s Development) initiative started by Africancountries, aimed at extending democracy in the continent as an importantfactor of developmentBased on the commitments for the MDGs, on the “Monterrey Consensus”(2002, International Conference on Financing for Development), on theBarcelona European Council (2002) and according to the G8 agenda, Italy is

14 Andrea Senatoricommitted to increasing its Official Development Assistance (ODA) /GDPratio and to adopting suitable measures for increasing aid to developingcountries and improving quality and effectiveness.Partnerships with developing countries is the guiding principle for ItalianDevelopment Cooperation. It works in accordance with the model laid downin the Cotonou Agreement between the EU and the ACP (Group of AfricanCaribbean and Pacific States), signed in June 2000, in respect for the principleof consistency in donor policies and coordination.Italian Development Cooperation also builds on collaboration and synergywith other relevant Italian actors: NGOs / Civil Society Organisations,Universities / Research and Training Centres, Decentralised Cooperation,Trade Associations.Italian Development Cooperation can boast a solid tradition of support forcollaboration between Italian universities and scientific Institutions and thosein developing countries, in Africa in particular.Health Development CooperationThe Italian Government fully supports the basic principles of the WorldHealth Organisation (WHO) constitution. The Italian interventions inhealth have been based on the principles of the Alma Ata declaration and followingdevelopments, where the objective is Health for All and the strategyis the Primary Health Care (PHC).Principles of the Alma Ata Declaration (1978)• Universal accessibility and coverage on the basis of need.• Community and individual involvement and self-reliance responsibilityof individuals and communities• Intersectorial actions for health• Appropriate technologies and cost-effectiveness in relation toavailable resources.The Italian Development Cooperation has given its technical and financialassistance to the Health Sector Reform processes in several countries, aimedat improving efficiency, equity and quality of health systems, with the PHCapproach. In the last decade, with the AIDS epidemic dramatically exasperatingthe already existing problems, Italy has increased its commitment, alsoby contributing to the institution and funding of the “Global Fund to fightAIDS, Tuberculosis and Malaria”.

2. The ethio-italian cooperation programme with special focus on the health sector 15Health is a fundamental human right. The Italian Development Cooperationworks toward the realisation of this right, with strong commitment in theglobal community and direct technical and financial support to many differentcountries. Ethiopia is one of the priority countries for the ItalianDevelopment Cooperation.The Ethio-Italian Development CooperationOverviewThe Italian Development Cooperation in Addis Ababa coordinates theItalian Government’s assistance programmes for Ethiopia. Currently,Ethiopia is one of the biggest beneficiaries among developing countries thatreceive Italian aid. Between 1981 and 2005, the country was awarded 676million euros in grants.A wide ranging programme of Italian aid, covering areas of fundamental importancefor the wellbeing of the Ethiopian people, is being fully implementedin areas such as health, education, industrial development, and food security& rural development. The ongoing programme, which also includes thepromotion of the private sector as an engine for economic growth, has a globalvalue of about 322.5 million Euros; out of this amount, 220 million Eurosis a soft loan while the rest is a grant.The Government of Italy shares the vision of a strong, healthy, and prosperousEthiopia with the citizens of this country, and therefore, will continue tosupport development initiatives that will put Ethiopians on the right path todevelopment.Historical backgroundThe history of cooperation between Ethiopia and Italy goes back to severaldecades. The first cooperation agreement was signed on April 5 th , 1973 betweenthe government of Italy and the imperial government of Ethiopia.Later, an agreement signed on October 24 th , 1986 between the two countries,led to the establishment of the Italian Development Cooperation office– Technical Cooperation Unit within the Italian Embassy of Addis Ababa.Since then, the development cooperation between Italy and Ethiopia hasbeen strong. For over a decade now, Ethiopia has been topping the list of beneficiarycountries of Italian aid. Italy is one of the main contributors towardthe country’s fight against poverty, supporting important initiatives in educa-

16 Andrea Senatorition, health infrastructure development, rural development and good governance.Development indicators show that Ethiopia is still one of the poorest countriesin the world. Over the past few years, there have been encouraging socio-economicindicators signaling improvement both in the school attendancerate and the basic health coverage.However, a further effort and commitment on the side of internationaldonors is needed to sustain Ethiopian development. The per capita aid receivedby Ethiopia was only 18.4 USD in 2004 compared to the 32 USD averagefor Sub-Saharan Africa.In response to the severe situation the country faces, the EthiopianGovernment is committed to effective development and poverty reductionexpressed in the Poverty Reduction Strategy Paper (PRSP. The latest, 2006-2010, named PASDEP, Plan for Accelerated and Sustained Development toEnd Poverty).The Poverty Reduction Strategy Paper has become a blue print for channellingaid by donors. It also help to harmonise and integrate the efforts putforth by international bodies toward the goals set by the document.The Ethio-Italian Country ProgrammeThe ongoing Country Programme of the Italian Development Cooperationin Ethiopia is designed within the framework of Ethiopian PovertyReduction Strategy Paper (PRSP). It was signed in Addis Ababa on June 21 st ,1999 by the Ethiopian Ministry of Finance and Economic Development andthe Italian Ministry of Foreign Affairs.In conjunction with the main multilateral organizations and donors countries,Italy has introduced innovative approaches within the ongoing countrycooperation programme with Ethiopia. A good example is the Italian sectoralcontribution to the health and education sectors. This kind of financing, bymaking adequate technical assistance available and by supervising accomplishedresults, allows Ethiopia to harmonize the external funds by whichboth education and health sectors are financed.Currently Italy is supporting Ethiopia in areas of education, health,HIV/AIDS, TB and malaria, infrastructure, private sector, women and children,rural development & food security, good governance & capacity building.channels.

2. The ethio-italian cooperation programme with special focus on the health sector 17Health and HIV/AIDSThe Ethiopian government developed a Health Sector DevelopmentProgramme, with the goal to achieve a heath care system that gives a comprehensiveand integrated primary health care at the community level emphasizingon disease preventive aspects without neglecting the curative aspects ofmedicine.Italian Contribution to the Health Sector Development Programme inEthiopia.In the framework of the Ethio-Italian Development Cooperation CountryProgramme, the Italian and the Ethiopian Governments entered into a bilateralagreement, in September of 2002, to finance the Ethiopian HealthSector Development Programme (HSDP).On the basis of this agreement, the Government of the Italy is supporting theHSDP through the provision of 15.75 million Euros in the form of a grant.The major areas of support include: Human Resource Development (HRD),Health Management Information System (HMIS), Strengthening thePharmaceutical Services, Hospital Management, Medical EquipmentSupport and Healthcare Financing.Besides the large commitment in the framework of the “Italian Contributionto the Health Sector Development Programme”, Italy also funds other healthinterventions and some iniziatives which contribute to the fight against HIVin Ethiopia.Multilateral Cooperation with WHO for the fight against HIV,Tuberculosis and Malaria. Through the channel of multilateral cooperationwith WHO, Italy is currently contributing to the fight against Tuberculosis(“Stop TB Partnership”, 1.8 million ?), to the “Global Programme onMalaria” (3 million ?), as well as within the “WHO-Italian Initiative onHIV/AIDS in sub-Saharan Africa” (6 million ?): all the three programmes,focused on a number of African countries, include Ethiopia. Launched in2001, as technical partnerships between the Italian DevelopmentCooperation and the World Health Organization, the projects aim to addresspriority gaps in the response to the three epidemics and to contribute to theoverall purpose of controlling and reducing the impact of the diseases in Sub-Saharan countries. The country plans are being implemented through thetechnical cooperation between the Ethiopian Health and HIV/AIDSAuthorities, WHO and Italian Development Cooperation. The funds are

18 Andrea Senatoricommitted to improve the quality of healthcare and to maximize the use ofother internationally provided resources.The Italian contribution to the Global Fund: Ethiopia is among the countrieswho receive aid from the Global Fund to fight AIDS, Tuberculosis andMalaria. Thus far, Ethiopia has received 71 million USD for actions againstTuberculosis, 215 million USD for Malaria, and 541 million USD for AIDS,up to 2010. Out of those large allocations, almost 254 million USD are currentlyutilized in the country in the diseases control programmes (15 millionfor TB, 130 for HIV, 108 for Malaria).To date Italy has contributed 433 million USD to the Fund. 6.5% of themoney currently available worldwide through the Global Fund is provided bythe Italian contribution: currently about 16.6 million USD in Ethiopia,funding the fight against the three diseases.The NGOs. Significant health interventions are also implemented by someexperienced Italian NGOs with the co-financing of the Italian DevelopmentCooperation, particularly in the fields of Primary Health Care, HospitalCare, HIV Prevention, Care and Support in rural settings. Currently thereare 12 Italian NGOs working in Ethiopia, on grass root level, side by sidewith the beneficiaries and community members, often in some remote areaswhere basic services are weak or completely missing. The ItalianDevelopment Cooperation currently contributes 7.3 million ? toward theprojects promoted by these NGOs. The Italian civil society remains the mainfunder for many of the NGOs activities.Commitment in Pediatric AIDS Care: within the framework of the ItalianContribution to the HSDP a project is being realized in the specific field ofPediatric AIDS care and ARV treatment: Italy provides support, focused onhuman resources and technical assistance, in a partnership with the Minitryof Health and the Asco Children Centre in Addis Ababa, as well as in a developingnetwork of public and private Institutions involved in paediatricAIDS care.Commission on HIV/AIDS and Governance in Africa (CHGA): is a UNsystem wide initiative established in order to assess the complex and longterm implications of HIV/AIDS on government capacity and economic developmentin Africa. The initiative also aims at making African Governments

2. The ethio-italian cooperation programme with special focus on the health sector 19and their citizens aware of the nature of the HIV threat. Italy has contributedabout 250, 000 USD towards this project.Italy – UNAIDS Cooperation: in June 2004 the Italian DevelopmentCooperation and UNAIDS signed an agreement in order to mobilize andsupport broad-based and multi-sectoral responses against the HIV epidemicin four African countries - Ethiopia, Burkina Faso, Mozambique, andUganda. The agreement is being implemented in Ethiopia with a commonand coordinated effort in Monitoring and Evaluation and Partnership development.Italy – ILO Collaboration: A collaboration between Italy and InternationalLabor Organization (ILO) to fight HIV/AIDS is active in Ethiopia, Uganda,and Zambia. In this framework, a project focuses on prevention of HIV andmitigation of the epidemics impact in the world of work, specifically in ruralcooperatives and transport workers. The project is being implemented byILO and the Ethiopian Ministry of Labor and Social Affairs.Mainstreaming of the fight against HIV in different sectors: within itsProgrammes on Education and on Rural Development (ESDP and ABRDP),the Italian Cooperation is undertaking different initiatives of analysis, information,education, social mobilization about HIV issues and health educationin specific contexts.Experts and Consultants: The Italian Development Cooperation Office inEthiopia relies on Health and HIV experts to follow up and advice on relatedpolicy issues in the country. The availability of these human resourcesguarantees the active participation of Italy in different fora and committees,constituted by donors and government institutions, even with relevant responsibilities.The Italian Development Cooperation, with its HealthExperts, is currently serving as a co-chair, together with the British DFID, ofthe “Health, Population and Nutrition Donors’ Group” and as a co-chair togetherwith UNICEF, of the “HIV/AIDS Donors’ Forum”.Moreover, technical contributions are given to the definition of country plansof international organizations and global public-private partnerships.

20 Andrea SenatoriBIANCA

3. The ethiopian health sector and the italian contribution to HSDP 213. THE ETHIOPIAN HEALTH SECTOR ANDTHE ITALIAN CONTRIBUTION TO HSDPAugusto Cosulich, Vincenzo Racalbuto1. Programme) to achieve universal primary health care coverage by year2008;2. to reduce U5 mortality rate from 140 to 85 per 1000 population and infantmortality rate from 97 to 45 per 1000 population;3. to reduce maternal mortality ratio to 600 per 100,000 live births from871;4. to reduce total fertility rate from 5.9 to 4;5. to reduce the adult incidence of HIV from 0.68 to 0.65 and maintain theprevalence of HIV at 4.4;6. to reduce morbidity attributed to malaria from 22% to 10%;7. to reduce case fatality rate of malaria in age groups 5 years and above from4.5% to 2% and case fatality rate in under-5 children from 5% to 2%;and8. to reduce mortality attributed to TB from 7% to 4% of all treated cases.Objectives, Strategies and Key Activities of HSDP-IIIHSDP has been divided into components in order to facilitate the planningand budgeting process. HSDP-III will thus cover:1. Health Service Delivery and Quality of Care.2. Access to Services: Health Facility Construction, Expansion andTransport.3. Human Resource Development.4. Pharmaceutical Service.5. Information Education and Communication.6. Health Management Information system and Monitoring and Evaluation.7. Health Care Financing.

22 Augusto Cosulich, Vincenzo RacalbutoUS$(2004 constant $)35302520Step 5Scale-up strategy andHealth outcomesStep 5: Further decrease of:∞ child mortality,∞ maternal mortality,∞ HIV MTCT,Provision of HAART ,multi-drug resistant TBand severe malariatreatmentStep 4: Further decrease of:∞ child mortality,∞ maternal mortality,∞ HIV MTCTMDGs reachedReduced maternalmortality by 75%Step 415Step 310Step 2Step 15Current HealthExpenditures02005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015Step 3: Further decreaseof:∞ child mortality,∞ maternal mortality,∞ malaria, morbidity &mortality, TBStep 2:∞ decrease in childmortality, reduction inMTCT,∞ reduction of deathsdue to pregnancy by40%,∞ reduce malariamortality/ morbidity,∞ reduce childmalnutritionStep 1:∞ decrease in childmortality due to HIV,malaria, diarrheadiseases,∞ reduced HIVtransmission,∞ reduced malariamorbidity andmortality eReduced malariamortality by 50%,Increase TB DOTScoverageReduced infant andchild mortality bytwo thirdsReversed trend inHIV incidence andstabilized trend inHIV prevalenceFigure 4.1 Costs of Scaling-up Health Services in Ethiopia to reach the Health MDGsComponents and Targets of HSDP-IIIHSDP has been divided into seven components in order to facilitate theplanning and budgeting process. These are:1. Health Service Delivery and Quality of Care: - This subcomponent focuseson strengthening the preventive, curative and promotive aspects ofhealth care mainly through the implementation of HSEP. Maternal andchild health services, HIV/AIDS, Malaria, Tuberculosis and personal andenvironmental hygiene will also be given due attention.Accordingly, DPT3 coverage is expected to increase from 70% to 80%,contraceptive prevalence from 25% to 60% and the proportion of deliveriesattended by skilled health workers from 9% to 32% during the pro-

3. The ethiopian health sector and the italian contribution to HSDP 23gramme period. In addition by the end of the programme period, VCTservices will be provided in 100% of Hospitals & Health Centers andPMTCT service at 100% of the Hospitals and 70% of the HealthCenters. It is also planned to increase the number of People Living withHIV/AIDS (PLWHA) on Antiretroviral Therapy (ART) from 13,000 to263,000; the proportion of households utilizing 2 bed nets from 2% to100%; and tuberculosis treatment success rate for smear positives from76% to 85%.2. Health Facility Construction, Expansion, Equipping and Access: -The component aims at increasing access and improving the quality ofhealth services through the rehabilitation of existing health facilities andconstruction of new ones and provision of the necessary inputs such asmedical equipment and furniture.Thus, the potential health services coverage will be increased from 72% to100 % during the programme period through construction of new healthfacilities and upgrading of the existing ones. 80% of the health facilitieswill also be equipped and furnished as per the standard; and 30% of theHealth Centers will be upgraded to enable them to provide EmergencyObstetric Care Service.3. Human Resource Development: - The HRD component aims at trainingand deploying of relevant and qualified health workers of different categoriesfor the whole sector and improving the management of human resourcewithin the public sector in order to enhance the efficiency of thehealth workers, retaining them with in the sector and maintain a high levelof professional ethics.Hence, all health facilities will be staffed according to their respective standardsand Regional Health Bureaux (RHBs) and District Health Offices(DHO) as per the demand of the organizational structure. Through theseintervention, the ratio of HEWs to population is expected to reach1:2,500; and the ratio of midwives to women of reproductive age groupwill increase from 1:13,388 to 1:6,759. Health Human ResourceDevelopment Strategy will be developed and implemented in order to addressboth the production and retention of staff in the sector.4. Pharmaceutical Service: A well functioning pharmaceutical service is thecorner stone for any worthwhile health service. Thus, this intervention

24 Augusto Cosulich, Vincenzo Racalbutoaims at ensuring regular and adequate supply of effective, safe and affordableessential drugs, medical supplies and equipment in the public and theprivate sector and ensuring their rational use.A comprehensive Logistic Master Plan will be developed and implementedduring HSDP-III. The plan is to increase availability of essential drugsfrom 75% to 100% in all public health facilities; to scale up the supply ofimported and locally produced drugs; increase safety, efficacy and qualityinvestigation from the present 40% to 100 %; and to reduce the overalldrug wastage from 8% to 1%.5. Information, Education and Communication:- This component aimsat improving the Knowledge, Attitude and Practice (KAP) on personaland environmental hygiene and common illnesses and their causes; andpromotion of political and community support for preventive and promotivehealth services through educating and influencing planners, policymakers, managers, women groups and potential end users.Hence, the main targets are provision of appropriate health communicationmaterials to 100% of the HEWs and equipping 100% of the Kebelesimplementing HSEP with portable IEC equipment; increasing the KAPof the population on HIV/AIDS, Malaria and TB by 50% of its 2005 status;and to increase adolescent awareness and knowledge on HIV/AIDSand Sexually Transmitted Infections from 77% and 30% to 95% and80%, respectively.6. Health Management Information System and Monitoring andEvaluation:- The HMIS and M&E component aims at informed policyformulation, planning, programme implementation, monitoring andevaluation and at improving the knowledge and skills of health managersin these areas. It also aims at enhancing community involvement in themanagement of health facilities and public health interventions. The objectivesof this component, is thus to implement the Civil Service ReformProgramme in the health sector to ensure efficient, effective, transparent,accountable and ethical service delivery at all levels of the health system;to develop and implement a comprehensive and standardized nationalHMIS and M& E System so as to ensure evidence based planning andmanagement of health services; and to harmonize the donor-governmentefforts in planning, reporting, monitoring and evaluation.

3. The ethiopian health sector and the italian contribution to HSDP 257. Health Care Financing:- The health care financing component aims atmobilizing increased resources to the health sector; promoting the efficientallocation of resources and developing a sustainable health care financingsystem. The targets set under this component are increasing overallhealth expenditure per capita from 5.6 USD to 9.6 USD; doubling theshare of health as a proportion of total Government budget; and expandingthe Hospital based of Special Pharmacies from 82% to 100% and thatof Health Centers from 58% to 100%. In addition social health insurancewill be designed and implemented for employees in the formal sector andcommunity health insurance will be designed and pilot tested.Strategies of HSDP-IIIIn order to achieve the aforementioned goals and objectives, HSDP-IIIhas adopted the following strategies:• Vigorous implementation of the Health Service Extension Program forthe effective prevention and control of communicable disease and promotionof healthful living;• Improving the quality of health care through provision of adequate resources,implementation of a two way referral system, enhancing the capacityof HEWs for the detection, referral and follow-up of patients, andstrengthen secondary and tertiary hospitals, and referral laboratories;• Improving the number, skills, distribution and management of healthworkers; ensuring the planned training of health managers in adequatenumber and appropriate knowledge and skills;• Mobilize adequate financial resources, ensure efficient utilization, andstrengthen sustainable financing mechanisms for the health sector;• Improving the health information system and the capacity for effectivemonitoring and evaluation;• Improving the logistic management system;• Ensure full community participation in the planning, implementation,monitoring and evaluation of health care;• Promoting intersect oral collaboration, harmonization and alignment,and coordinate the activities of the public sector, private sector, internationalorganizations and NGOs in health interventions.Programme Implementation Arrangements of HSDP-IIIThe programme implementation arrangement of HSDP-III will be similarto that of HSDP-II as summarized below.

26 Augusto Cosulich, Vincenzo Racalbuto• Expanding and strengthening the scope of governance of HSDP atDistrict level.• Strengthening collaboration among the FMOH, RHBs and DHO.• Widening the role of community and NGOs in planning, implementationand governance of health care delivery activities, particularly atDistrict level.• Strengthening Government, Donor, NGOs and Private sector collaboration.• Harmonizing the planning, implementation, monitoring and evaluationsystem among the different stakeholders.• Enhancing the effectiveness and linkage of implementation, monitoringand evaluation of HSDP at all levels of the health system.Seventeen key indicators have been selected to monitor the progress of HS-DP-III at national level. These indicators are in line with the PASDEP objectivesand targets of the MDGs.Harmonisation in the Health Sector in EthiopiaExperience of aid instruments – a brief overviewBudget supportMany Governments agree with Ethiopia’s – that budget support is the bestway to provide aid, because it works through existing channels and concentratesthe Government/donor policy dialogue on priority issues.Many donors, however, are unable or unwilling to provide budget support.In many cases their reasons for doing this are not trivial and need to be respectedand understood. Reasons include:• A lack of agreement on the overall pattern of Government spending andpriorities. The Medium Term Expenditure Framework (MTEF) is generallyseen as the key instrument for planning and describing public expenditurepriorities.• An unwillingness to rely on Government’s administrative and financialsystems. These systems are rarely perfect – and indeed may be weak.Budget support involves a risk that funds may not be channelled and managedas intended.• Macro-economic stability. It is generally thought that an economy needsto be reasonably stable for budget support – i.e. with reasonable and sustainableeconomic growth, supported by a stable exchange rate and lowinflation.

3. The ethiopian health sector and the italian contribution to HSDP 27• Budget support funds all government activities. It can be argued that thisdilutes support to priority areas such as primary health care.• Budget support money goes into one general pot of funds. Some donorswant attribution – i.e. they can explicitly link their inputs to activitiesand outcomes.• Fungibility – when money is all put into one large pot, it is impossible tospecify that the “extra” money is spent on a specific sector (or sectors), becauseno-one can say what the allocation to that sector would have beenwithout the extra money. This is explained in Box 1 below.Box 1 Fungibility 1If financial support is fungible it means that it may simply be used as asubstitute for existing spending.The diagram below illustrates how donor support for the health sector displacescurrent government expenditure, so that the government reallocatesthe money it would have spent on health to another sector - say, defence. Thedonor would argue it is funding the health sector (1) – but the case can bemade that it is allowing the government to increase defence expenditure (2).1) 2)HealthsectorHealthsectorDonarsupportDonarsupportDefencesector1 This box and other parts of this section draw heavily on Brown A and Waddington C.Reproductive Health Commodity Security and Aid Instruments. HLSP Institute,November 2004. Paper commissioned by UNFPA

28 Augusto Cosulich, Vincenzo RacalbutoAn explanation of Fungibility 2Fungibility is the idea that aid pays not for the items against which itis accounted, but for the extra expenditure it makes possible. Considerthe example of a government with $100 million to spend. There aretwo projects to choose between: rehabilitating rural health clinics orbuying a new fleet of tanks. Both cost $100 million. After much deliberationthe government decides to rehabilitate the clinics. But before itdoes so a donor comes along offering $100 million for some suitablyworthy project. The government cannot ask the donor to buy the tanksso it says to the donor “our rural health clinics are in desperate need ofrehabilitation, but we cannot afford to do it”. So the donor pays for thehealth clinics. The government can now use its money to buy the tanksafter all...aid has in effect paid for the tanks even though it is accountedagainst health clinics.Programme approachesGiven these doubts about budget support, a large variety of programme approacheshave developed as half-way measures between budget support andprojects. These programme approaches pool resources and systems, and worktowards one agreed plan. The plan may only be for part of a sector – e.g. healthposts and their outreach work. The pooling may not be through governmentsystems, but does involve donors to some extent using shared systems.The sector-wide approach is explained in some detail here, as it raises issuescommon to all programme approaches.The sector wide approach (SWAp) is a method of working between governmentsand donors which aims to improve the capacity of government to delivereffective public services. The impetus for the development of the SectorWide Approach came from increasing disillusionment about the failure ofproject based instruments to make significant in-roads into poverty, especiallyin countries which were very aid dependent and which relied on a plethoraof donors to ensure even basic services.2 Alba, A and Lavergue, R. (2003). LENPA Glossary of Frequently-Used Terms UnderProgram-Based Approaches. CIDA. Alba and Lavergue sourced this quotation from White,H. (1999). Budget Support as an Emerging Aid Modality: The Experience of the ZambianHealth SIP and its Relevance for Japanese Aid. Institute of Development Studies.

3. The ethiopian health sector and the italian contribution to HSDP 29There is no ‘official’ definition of what a SWAp is, but it is usually defined asan approach in which:• All significant funding (including both government’s and donors’) supportsa shared, sector wide policy, strategy and implementation planwhich have clear sector targets and are focused on results.• A medium term expenditure framework or budget supports this policy,strategy and plan.• Government provides leadership in a sustained partnership with donorsand other contributors, including the non-governmental sector.• Shared processes and approaches for implementing and managing the sectorstrategy and work programme are agreed, including reviewing sectoralperformance against jointly agreed milestones and targets.• There is commitment to move to greater reliance on Government financialmanagement and accountability systems as well as implementationsystems.Funding modalities for SWAps vary according to the donors that participate,their own internal rules, the way that they wish to apply conditionality, andthe capacity of government to manage more flexible forms of funding. In orderto meet the objectives of improving co-ordination and government ownershipand reducing transaction costs however, SWAps generally aim to haveat least some element of ‘pooled’ or ‘basket’ funds (see Box 2) and/or sectorlevel budget support.Box 2 Pooled fundingPooled funding involves donors putting money into a common fundor “basket”. These funds are then used for agreed activities accordingto agreed procedures. Different approaches can be taken:• The pool can be earmarked to fund certain activities at different levelsor be completely un-earmarked.• The funding pool may use Government procedures and be integratedinto the budget or may use a single set of donor procedures - e.g.World Bank. Or it may be somewhere in between, with money heldin a separate account at the Ministry of Health.Different donors have different attitudes towards pooling. Pooledfunding often takes place alongside project funding.

30 Augusto Cosulich, Vincenzo RacalbutoBox 3 illustrates funding for a SWAp, with the ‘Pool’, supported by donor(1), operating through a Ministry of Health account, and earmarked for specificactivities only. Donor (2) is providing general budget support whichneed not necessarily be spent on health. Donor (3) is providing non-earmarkedsector level support. Donor (4) is continuing to provide parallelfunding to a project which fits within the Sector Wide Approach. The projectcan be said to fit in the SWAp because it is within the sector plan and itsbudget appears within the government budget, even though it does not usegovernment systems for disbursement.Donor 2Ministry ofFinanceDonor 3Donor 1OthergovernmentexpenditureMoHexpenditure‘Pool’Donor 4Public sector expend.in healthDefined groupof activitiesHealth Sector Plan and BudgetHarmonisation in the health sector in EthiopiaProjectBox 3 Funding for a SWApThe section above describes the current situation with respect to donors.There is a general recognition amongst Government and donors that the currentsituation is too fragmented and that greater harmonisation is required.What might this more harmonized health sector look like?The central idea of harmonisation is that Government is in the “driving seat”.This means that Government provides direction on priorities and ways ofworking – for example “we want development partners to work in timeframesthat match the SDPRPs, with new plans in 2005 and 2010.” This is not somuch about particular activities, but is a way of thinking and a way of working.Government and donors are to start their negotiations and plans withGovernment priorities and procedures at the centre.

3. The ethiopian health sector and the italian contribution to HSDP 31The excellent phrase “one plan, one budget, one report” has been used to describeharmonisation. In the health sector, the “one plan” is the HSDP3. Inpractice this means that donors should respect the contents of the plan, andthat Government should invite frank and unhurried dialogue about it. Thereare inevitably tensions in this relationship – but the idea is that the discussionsfocus on important policy issues, rather than on more minor issues suchas individual donor procedures.Within HSDP3, Government has requested donors to concentrate on theHealth Service Extension Programme (and the related Essential HealthServices Package). The HSEP has variously been described as the “flagship”or the “centre of gravity” of HSDP3. Concentrating on the HSEP provides auseful focus for donors – there must be a continuing and mutually respectfuldialogue about issues within this Programme, such as its projected cost andhow it relates to woreda planning.There are three aspects to the “one budget” part of the description of harmonisation:(1) all inputs to the health sector should be captured in one paper budgetand expenditure report, and this should be actively used as a tool forplanning and co-ordination. This includes all inputs from multilaterals,bilaterals and global initiatives. Funding for NGOs is money for developmentof the overall health sector in Ethiopia and should not be regardedas “second-best” in this exercise.The exact nature of the “one budget” idea in the federal context ofEthiopia needs to be clarified. Budgets (and expenditure returns) comefrom various sources – i.e. woredas, regions and the federal level. Ideallyat some point these should all be consolidated into one health sectorbudget – so that overall spending patterns can be reviewed – but this isundeniably a difficult and slow process.(2) The number of single-donor funding streams should be kept to a minimum- resources should be pooled wherever possible. Pooling can bedone in many ways – for TA, drugs, woreda support etc.(3) Similarly, the number of financial management systems should be keptto a minimum – at the very least, donors should agree on one parallelsystem if the Government system is not acceptable in the short term. Allaccounts should follow the Ethiopian fiscal year and there should beagreement on the chart of accounts to be used.“One report” requires both multi-partner reviews and an agreed short-list ofindicators to be used. The HMIS requires ongoing work – a crucial first step is

32 Augusto Cosulich, Vincenzo Racalbutoidentifying a very limited number of pieces of information that are required ateach level of the system and specifying how they will be collected, by whom. Thecentral importance of information and indicators is reflected in the Code ofConduct. (See Annex 2.)Returning to the “one budget” aspect of decentralisation – particularly thecombined “paper budget” reflecting all inputs – brings into focus another vitalissue currently being debated in the health sector in Ethiopia. For the sakeof argument, assume that there is agreement that $4 additional health expenditureper capita will fund the basic Health Extension Package, not includingAnti-Retrovirals. (Of course it is perfectly legitimate to debate the correctnessof these figures, but they are a good starting-point.) Further assume that ofthe $4, $1 will come from individuals’ out of pocket expenditures, mostly ondrugs. The $3 has to come from the public sector, and requires a steady increasein budget support and a doubling of inputs from other donors. Is thisrealistic? If not, what can be done? Is there too much money going to someareas and not enough to others?This is a concrete example of how donors working together can focus on thebig issues facing Government, rather on their own, smaller, donor-specificconcerns.Interesting work related to “one plan, one budget, one report” has been happeningin some regions – notably Tigray and SNNPR – already. Activity 5below is about learning lessons from this useful exercise.Italian contribution to the HSDPGeneral frameworkThe Italian contribution to HSDP amounts to 15,750,000 Euro over threeyears, which corresponds to approximately 3% of the whole HSDP II budget.The initiative is structured in three components:1. Direct financial support to the Ministry of Health (12,510,050 Euro);2. Italian Technical Assistance (2,250,000 Euro).3. Funds directly managed locally by the Project Monitoring Unit (989,950Euro);Components n. 2 e n. 3 are directly managed by the Italian Ministry ofForeign Affairs, while the Ethiopian Ministry of Health (MOH) is responsiblefor the management of the first component.

3. The ethiopian health sector and the italian contribution to HSDP 33Funding modalitiesChannel I(through Ministryof Finance)Channel II(through sectorinstitutions)Channel III(directimplementation)Federal Ministryof FinanceFederal Ministryof Health (MoH)Regional FinanceBureauRegional HealthBureau (RHB)Woreda FinanceOfficeWoreda HealthOffice (WoHO)The Italian support focuses in four Regions: Tigray, Oromia, Afar andSomali. Moreover, support is provided to the Federal MoH and to DACA,with a total of six beneficiary institutions.The Italian contribution foresees a specific support and provision of technicalassistance to the following HSDP components:• Human Resource Development;• Pharmaceutical Services;• Health Management Information System.For each of these components a specific technical assistance is provided to localcounterparts in the preparation of Plans of Action and execution of activities;for strengthening professional and managerial capacities; monitoringand evaluating the activities. Moreover, ad-hoc consultancies have been providedto the MOH in the following fields:• Hospital management, with particular focus on Asella hospital;• Definition of technical specifications and cost estimate for the medicalequipment to be purchased by the 4 beneficiary Regions.

34 Augusto Cosulich, Vincenzo RacalbutoHuman Resource DevelopmentHuman Resource Development (HRD) is an important component of HS-DP. Ethiopia has one of the lowest ratio of physicians to population in theworld (1 : 35.000). In Oromia Region that is the largest and more populatedregion of the country, the ratio is estimated to be 1 : 55.000. The ratio ofnurses (all cadres) to population is not much better being 1 : 5.000 – 10.000and showing a lot of differences between rural and urban areas.Yet, the health care force is male-dominated. Only about 13 percent of physicians,11 percent of health officers and 39 percent of nurses are female. In addition,the large majority of female health-care workers are located in the urbanareas. As a consequence, rural areas where the need for maternal andchild care is high are mostly served by men.The Government has launched at the beginning of 2004 a new training strategyfor the first 2780 Health Extension Workers, all female, in the frameworkof the new policy of the “Health Extension Package”. Training curricula fornurses has been revised and the old health cadre of “Health Assistant” receiveda special upgrading training.Main constraints in improving the number and quality of health workforceare the following:• lack of a human resource management and development strategy;• maldistribution and internal migration towards urban settings;• lack of polivalent well trained personnel at grassroots level;• lack of adequate teaching institutions and teaching aids;• low female literacy rate and consequent gender unbalance in health workforce;• poor teaching / learning quality in nursing school and career pathway,causing migration to private sector for better remuneration and fuelling“brain drain”;• vastity of the country combined with a poor communication and transportationnetwork;• lack of managerial skills especially at district level.36 per cent of the total budget will be given to 4 beneficiary Regions and tothe central level for HRD and training activities specifically targeted to preserviceand continuing education of mid-level health cadres. A contributionof about 4.5 million Euro will fund training of nurses, midwives, technicians,health assistants and health extension workers.About 0.5 million Euro will be directly managed by the PMU.In addition, another component of the Italian Contribution (1,1 million

3. The ethiopian health sector and the italian contribution to HSDP 35Euro) is allocated for rehabilitation and expansion of Schools and nursingcolleges in all the beneficiary Regions.ObjectivesSpecific objectives are aimed to improved quantity and quality (“knowledge,attitude, practice”) of personnel through pre-service and in-service training.The expected results are:• Increased capacity of teaching institutions through expansion and rehabilitationof 5 nursing schools;• Improved teaching skills and quality of teaching/learning activities in preservicetraining;• Strengthened the regional training institutions for continuing educationof health personnel;Activities and resultsThrough specific Plans of Action, prepared with the regional planning authoritiesof Tigray, Oromia, Somali and Afar, 43 activities for HRD componenthave been implemented so far under four main areas of intervention.• Purchase of vehicles, furniture, teaching aids, textbooks and teaching materials;• Pre-service and in-service training courses at regional level;• Rehabilitation and expansion of nursing schools;• Recurrent costs support for supervision and training activitiesSo far 1,966 health workers have been trained and 560 nurses attended theiracademic yearly course with the financial contribution of the intervention.Priority areas for in-service training have been identified and some coursesstarted (HIV –AIDS, malaria, tuberculosis, obstetric emergencies, healthmanagement, teaching methodology, prevention and control of communicablediseases).• Goods have been procured through both international and national tendersfor the beneficiary schools (8 in Oromia, 2 in Tigray, 1 in Somali and1 in Afar);• Most of the first year planned training activities have been accomplishedor are on progress;• Regional health training department offices have been strengthened andjoint monitoring of activities started;• Assessment of training needs has been carried out during outreach visitsin the Regions;

36 Augusto Cosulich, Vincenzo Racalbuto• Contribution for recurrent costs has been provided to the nursing schoolsof Oromia Region;• A technical working group on HRD has been established in order to assistthe MOH in designing and developing a sound HRD strategy.Pharmaceutical ServicesThe objective of the pharmaceutical services component of HSDP is to ensurea regular and adequate supply of effective, safe and affordable essentialdrugs, medical supplies and equipment and ensuring their rational use.In Ethiopia the shortage of drugs at HFs level is a consequence of the followingmain constrains: scarcity of available resources (the national drug expenditurefor person is 0,18 USD per year), scarcity of human resources, inefficientdistribution, complex and lengthy drug procurement system, substandardstorage facilities, inadequate transportation system, and poor inventorysystem (650,000 Euro of expired drugs in the year 2000), presence of substandardor counterfeit drugs in the local market (22% of the importeddrugs), scarcity of local production of drugs (only 13% of the total) . Oncethe drugs reach the health unit, they are dispensed in an often non-scientificway, based sometimes on inaccurate diagnosis and inapproximate therapeuticcriteria.The recent restructuring of the pharmaceutical system at central level and theestablishment of the autonomous body DACA (Drug Administration andControl Authority) would reinforce the entire sector.The activities and the results of the Italian contribution to HSDP regardingthe pharmaceutical sector are the following:Activities and ResultsDACA1. Strengthening of the Drug Quality Control and ToxicologyLaboratory:• A two months training for three people in South Africa has been realizedfor the personnel involved in the drug quality control;• Within few weeks the equipment for the quality control analysis just arrivedin the custom of the airport will be installed;• The inventory of equipment and instruments, reagent and referencestandard has been made. Standard Operation Procedures have been developed;• The resource of the laboratory have been strengthened providing: office

3. The ethiopian health sector and the italian contribution to HSDP 37furniture, computer, printer/scanner, photocopier, LCD projector, networkingapparatus, stationery and material for the documentation andactivation of data;• A database of essential reference books for the quality control of pharmaceuticalshas been realized;• An expert in pharmaceutical services has been seconded in the laboratoryto implement the activities and monitoring the initiative.2. Financing the construction of an incinerator for proper disposal ofdrug unfit for use:• One month training in Zimbabwe and in South Africa for four peopleof DACA, regarding the disposal of pharmaceutics, has been realized;• The technical design and specifications of the incinerator is on processin DACA.Oromia Region1. Establishment and organising of Special Pharmacies:A partial solution to improve the availability of drugs at HF level may bethe establishment of so called “special pharmacies”. These are drug shopslocated inside a public health service (hospital or health centre) and runby its own staff, where medicines are sold to everyone (i.e. no exemptionis applied) for a widely affordable price.• Thirty HCs in twelve different health zones of Oromia have been selected;two training for four days for 150 people have been conducted;• Drugs, furniture and vouchers and printed material have been procurefor start the activity;• A first activity of monitoring and evaluation has been conducted withthe Oromia RHB (July and August 2004), in the first 20 HCs wherethe initiative is already started and a monitoring report has been realisedand disseminated to DACA and to other donors involved in the sameinitiative;• An expert is providing the technical assistance and the monitoring ofactivities since the beginning of the programme.2. Asella Hospital• In the framework of the assistance regarding the management of AsellaHospital, the technical assistance has been made, related to the technicaland cost/effective evaluation of the IV Fluid Production Unit andthe provision of the technical specifications for the procurement of anew autoclave for the Unit;

38 Augusto Cosulich, Vincenzo RacalbutoOther activitiesDonor’s technical groups: “Pharmaceutical Technical Group” and“Malaria Technical Group”Two technical groups on Pharmaceutical Services and Malaria Control havebeen started with the contribution of bilateral donors, international agenciesand NGOs in order to assist the drug Authority and the MoH in developinga master plan for the pharmaceutical sector and to control malaria inEthiopia (the major health problem in the country). One Italian expert regularlyattends those meetings on monthly basis.Health Management Information System (HMIS)The primary purpose of an HMIS is to support informed strategic decisionmakingby providing quality data which help managers and health workersin planning and managing the health services; monitoring disease trends andcontrol epidemics; provide periodic evaluation towards agreed targets.The Ethiopian HMIS, though, presents several conceptual and structuralproblems, which limit its usefulness. In the last few years, various workshopsand system reviews consistently identified some of the major ones:• Lack of integration - The HMIS is cumbersome and fragmented. The informationcollected are too many and redundant, which yields to inaccuracyand incompleteness in recording and reporting.• Absence of standards and guidelines - There are no manuals and guidelinesfor processing and interpreting the data. Standard diagnostic andclassification criteria are not available.• Inadequate staffing – The staff responsible for information managementare mostly people with inadequate skills in data collection, analysis and interpretation.• Poor ownership – There is insufficient understanding, both in producersand users of data, of their respective information needs, value and application.Health workers spend a good part of their time in recording andreporting information for which they do not see any practical use.Up to now, the attempts to rationalize the system did not yield the expectedresults. Moreover, in absence of guidance and coordination from the FMOH,various Regions have developed their own information systems which are nothomogeneous and cannot communicate with each other, with consequentfurther fragmentation of the system.

3. The ethiopian health sector and the italian contribution to HSDP 39ObjectivesThe specific objective of this component is to increase the quality of managementof the health system by developing a functional HMIS which providesquality information that can be used at all levels of the health system for planning,managing, monitoring and evaluating their respective activities.Considering the crucial role played by the FMOH, it has been decided tostrengthen its capacity through provision of additional resources and technicalassistance. At the same time, the four intervention Regions have been targetedfor HMIS implementation in order to create coordination and synergybetween central and peripheral levels.Results• A representative of the Italian Cooperation is a member of the HMISNational Advisory Committee, which coordinates all the initiatives relatedto the development of the HMIS, participating in the development ofthe National HMIS Policy and Strategy;• An expert in information systems has been seconded to the Statistical Unitof the FMOH to assist the local counterpart in revising and developingthe HMIS and the RHB in formulating a comprehensive regional HMISstrategic plan and implementing the system;• The FMOH resources have been strengthened through the rehabilitationof the physical infrastructures and the purchase of furniture and equipmentfor the Statistical Unit and the Information and DocumentationCentre;• The resources of the four Regions of intervention have been strengthenedin terms of staff capacity, infrastructures, equipment and recurrent costsincurred in the management of the HMIS.Operational ResearchThe project foresees also the implementation of Operational Research activitiesthat may offer indications and suggestion on new effective approaches inkey healthcare components. The PMU has identified three possibleOperational Researches, which started during 2005 and are now in full implementation:• “Correlation between dermatologic and systemic diseases in Tigray Region” incollaboration with the ONLUS International Institute for Medical SocialAnthropology Sciences – I.I.S.M.A.S. (Roma);• “Delivery of primary healthcare to pastoralist populations in Libaan Zone –

40 Augusto Cosulich, Vincenzo RacalbutoSomali Region” in collaboration with the NGO Comitato CollaborazioneMedica. (CCM) – Torino.• “Care, treatment and support for children affected by HIV/AIDS in AddisAbaba” in collaboration with the Federal Ministry of Health, theMissionaries of Charity Centre “Gift of Love”, the Black Lion Hospital,and the University of Brescia.

4. Building the national health management information system (HMIS) in Ethiopia 414. BUILDING THE NATIONAL HEALTH MANAGEMENTINFORMATION SYSTEM (HMIS) IN ETHIOPIA:TOWARDS EVIDENCE-BASED DECISION MAKINGSandro Accorsi, Nejmudin Kedir1) IntroductionIn the current situation of growing and competing demands for health care,coupled with scarce resources, increasing need for evidence-based decisionmaking has put information high in demand. Setting health priorities involvesdefining and quantifying the health problems, assessing the efficacyand cost of interventions, and translating this information into action. In thiscontext, Health Management Information System (HMIS) is defined as aroutine and systematic collection of data, integrated into information to supportmanagement decision-making.Health Management Information System (HMIS) and Monitoring andEvaluation (M&E) are top in the agenda of the sector and they are one of theseven components in HSDP (Health Sector Development Programme) IIIStrategic Plan. As stated in the HSDP III: “the objectives of M&E are to improvethe management and optimum use of resources of programme and to maketimely decisions to resolve constraints and/or problems of implementation”. Themain concern is to be able to use health status, health service and health expendituredata for planning and evaluation purposes as well as to account forresources in terms of achievements in order to ensure the required public accountabilityfor the health funds.However, this upsurge in demand for information has not been adequatelymet because there has been insufficient investment in building a streamlinedHMIS able to generate timely and reliable data to support decision-makingat all levels.The challenges are to improve the quality of routinely collected data, to developdata analysis, and to find ways of translating the output of the informationsystem into evidence-based decision-making. This is clearly stated inthe HSDP III Strategic Plan: “challenges faced in relation to HMIS are lack ofcoordinated effort and leadership, lack of strategy and policy, shortage of skilledhuman resources and lack of guidelines. The timeliness and completeness ofHMIS reporting remain poor, and such delays contribute to the failure (at all levels)to use data as the basis for informed decision-making in planning and man-

42 Sandro Accorsi, Nejmudin Kediragement. In addition, parallel reporting mechanisms persist with programmaticand donor-supported initiatives resulting in multiple reporting formats and anincreased administrative workload”.Therefore, information in the health sector is basically affected by two categoriesof problems:i) the inadequate quality, completeness and timeliness of data producedthrough the routine health recording and reporting procedures based onparallel systems; andii) the insufficient use of available data for planning, implementation, servicemanagement, monitoring and evaluation.These two problems are inter-related: in fact, little use of information is a majordeterminant for the poor quality of data collected: staff is required to doexcessive data recording and reporting and is overwhelmed by data demands,whereas a quality assurance system is not in place and little use of data is donefor planning and decision making. As a result, too much information is collectedbut it is poorly analysed and interpreted, not easily comparable and oftennot used. Therefore, data are often inaccurate, untimely, unrepresentative,and sometimes of such poor quality that confidence in the entire informationsystem is undermined.2) HMIS in Ethiopia: current situation and way forwardAlongside the challenges, many new opportunities to reform HMIS are nowemerging. These include the development of a comprehensive approach todata management, with a shift of focus from data collection to data analysisand information use (Figure 1), with improved tools and methods for epidemiologicsurveillance and performance monitoring, and innovations suchas information technologies and geographic information systems, all of whichhave the potential to significantly improve both HMIS coverage and dataquality. Important opportunities are also emerging from the process of healthsystem decentralization and accompanying demands for locally relevant anduseful health information. In response to the increasing decentralization ofmanagement functions and resource allocations to the woredas, HMIS strategyis increasingly focused on the capture, storage, analysis and interpretationof data for local decision-making in a decentralized and accountable healthsystem, with structures, processes and organizational culture developed to theextent that performance and accountability are encouraged.However, decentralization has led not only to new opportunities, but also tofurther challenges in building the national HMIS. On one side, there is the

4. Building the national health management information system (HMIS) in Ethiopia 43COMPREHENSIVE APPROACH FROM DATACOLLECTION TO INFORMATION USEData Handling ProcessInfo-needs/indicatorsDataCollectionResourcesDataDataDataTransmissionProcessingAnalysisManagementOrganizationalRulesUSE OF INFORMATIONFOR DECISION MAKINGFigure 1: The process of data management.need to ensure greater reliance on locally relevant information to support decisionmaking at the point of data collection (Figure 2), while, on the otherside, it is necessary to develop the national overarching information architecturethat defines the data elements, processes, and procedures for collection,collation, presentation, and use of information for evidence-based policy andFOCUS ON USE OF INFORMATIONAT THE POINT OF DATA COLLECTIONStrategic InformationPolicy-MakingGlobalProgramMonitoring & EvaluationPatient CareFacility ManagementCountryRegionsWoredasCommunity FacilitiesFocus on woredalevelIntegrate routineand other datasourcesFigure 2: Focus on use of information at the level where data are generated.

44 Sandro Accorsi, Nejmudin Kedirpractice throughout the health sector. This information architecture shouldalso ensure standardization for comparison across geographical units and overtime as well as integration of data elements from a variety of subsystems.HMIS reform is urgently needed. However, because of the delay in the designand implementation of the HMIS reform at the national level, uncoordinatedregional initiatives have emerged to improve data collection and reporting(and, to a minor extent, data use). While well-intentioned, these initiativesthreaten to further fragment an already fragile system. HMIS reformat the national level should take advantage of these regional experiences andbe built on the best practices existing in the country.It is imperative to capitalize on these best practices and to integrate health informationsystem reform with overall health system development.3) HMIS reform: from data collection to information useThe Federal Ministry of Health (FMOH) is committed to leading a comprehensiveHealth Management Information System (HMIS) and Monitoringand Evaluation (M&E) reform and envisions that all key stakeholders at federal,regional, woreda and facility levels are involved in the initiative. This isto ensure that they contribute to and use the revised HMIS and M&E thatprovide a reliable resource and platform for evidence-based planning, implementationand monitoring towards a more equitable, efficient and effectivehealth care system (Figure 3).CREATING A VIRTUOUS CYCLEUse ofinformationfor evidence -baseddecision -makingDecisionSupportSystemIncreasedDemandHSDP III,PASDEP, MDG,civil society,mediaFocus onbuilding a nationaland standardizedHMIS able torespond toinformation needsof the countryStakeholdersagreeto aligneffortsIncreasedCoordinationFMOH, RHB,programmes,private sector,other sectors,CSA etc .Figure 3: The virtuous cycle in building the national HMIS.Reform of HMIS has already started with simple and achievable objectives and introducingfurther changes in a staged and scaleable approach, enhancing capacity at each stage andensuring the engagement of all partners in the process. A complex set of activities should beimplemented in an integrated way, as outlined in the Health Metrics Network (HMN)framework, including:

4. Building the national health management information system (HMIS) in Ethiopia 45Reform of HMIS has already started with simple and achievable objectivesand introducing further changes in a staged and scaleable approach, enhancingcapacity at each stage and ensuring the engagement of all partners in theprocess. A complex set of activities should be implemented in an integratedway, as outlined in the Health Metrics Network (HMN) framework, including:1. Identification of information needs at national and subnational levels;2. Mapping of main producers and users of health information, methodsand products in HMIS, identification of best practices, and assessmentof overlaps, duplications, gaps and inconsistencies;3. Definition of a clear policy, legislative and regulatory framework supportingthe health information system at all levels of the health pyramid;4. Development, through a broad-based consultative process, of a comprehensiveHMIS strategy, including Information and CommunicationTechnology (ICT);5. Preparation of a detailed and costed health information plan, with definedtime framework, allocation of responsibility and accountability;6. Assessment of costs and mobilization of financial resources for health informationat all levels of the system;7. Development of human resources for health information, includingnumbers, training, deployment and motivation of health information officers;8. Identification of minimum data requirements and indicators at differentlevels and the production and dissemination of guidance for the generationof relevant indicators;9. Standardization of recording and reporting formats, procedures, definitions,classifications and coding systems;10. Development of thematic glossaries and data dictionaries;11. Establishment of standard criteria and guidelines regarding software,databases, data warehouse, and network in health related data management;12. Development of clear protocols regarding health information securityand confidentiality;13. Development of criteria and guidelines for data quality;14. Identification of criteria regarding accessibility to health related data andinformation at minimal possible aggregation level;15. Development of guidelines for sharing data across levels and sub-systems;16. Developmentof processes for data transmission, analysis and feedback;

46 Sandro Accorsi, Nejmudin Kedir17. Development of tools for data presentation and dissemination to diverseaudiences;18. Establishment of evaluation frameworks;19. Use of information for evidence-based health policy and practice.As it is stated in the HSDP III Strategic Plan: “the objective is to review andstrengthen the existing HMIS at federal, regional, woreda, health facility andcommunity levels to produce timely information for planning management andefficient decision-making”, while, concerning M&E, “the objective is tostrengthen the M&E system at federal and regional levels and establish a systemin all woredas”.The design stage is under way, with HMIS assessment and indicator selectionbeing already finalized, while the development of the HMIS strategy, withstandard format for recording and reporting and guidelines and manuals, willbe completed in November 2006. Pilot testing of the national HMIS andM&E system, based on a core set of cascaded indicators and standardizedrecording and reporting formats, is planned in ten selected woredas duringthe period November 2006-January 2007 in order to identify gaps and shortcomingsand to introduce the necessary modifications and revisions. Six mainoutputs are expected to be accomplished within this deadline:1. Situation analysis (including HMIS assessment, HR assessmentand identification of best practices) published and disseminated;2. Core set of cascaded indicators developed;3. HMIS and M&E strategy published and disseminated;4. Standardized recording and reporting formats developed andtested;5. HMIS and M&E implementation guidelines and manuals developedand tested;6. Electronic system for data collection, storage and processing developedand tested.Of note is the fact that the HMIS reform is part of a comprehensive approachto system development which will gradually include other population-basedand service-based sources within the overall Health Information System(HIS) framework (Figure 4). HIS comprises six key health information subsystems(census, household surveys, public health surveillance, vital eventsmonitoring, health service statistics, and resource tracking) (Figure 5). Forthis purpose, support has been obtained from Health Metrics Network(HMN), which is a new global partnership hosted by World HealthOrganization (WHO) and comprised of countries, multilateral and bilateral

4. Building the national health management information system (HMIS) in Ethiopia 47POPULATION -BASED AND SERVICE -BASED DATA SOURCESCensusAdministrativerecords systems(NHA etc.)VitalregistrationServicesrecords systemsPop basedsurveysHealth statusrecordssystemsPopulation -basedHealth services records -basedFigure 4: Integration of population-based and service-based data sources.Figure 4: Integration of population-based and service-based data sources.Figure 4: Integration of population-based and service-based data sources.INTEGRATION OF DIFFERENT SOURCESOF DATA FOR DECISION SUPPORTHEALTHCARE LEVELCATCHMENT AREA POPULATIONCOMMUNITY LEVELPRIMARYSECONDARYTERTIARYFacility -basedRHISNon -routinemethodsCommunity -based/Sectoral RHISPatient/Clientc o n t a c tReferredp a t i e n t sReferredp a t i e n t sReferredp a t i e n t sI N D I V I D U A LCAREM A N A N A G E M E N TFirst levelcare unitDistrictHospitalRegionalHospitalNationalHospitalUniversityHospitalHEALTH UNITM A N A G E M E E THEALTH CARE SERVICESDistrictHealth MgmtT e a mRegional HealthMgmt TeamMinistry ofHealthUniversitiesOther HealthInstitutionsSYSTEMM A N A G E M E N THEALTH SERVICES SYSTEMHEALTH SYSTEMFigure 5: Data sources in the Health Information System.NON -ROUTINE DATACOLLECTION METHODSDISTRICTLEVELREGIONALLEVELNATIONALLEVELOTHER SECTORS:-Environment-Civil Administr.-Transport-EducationFigure 5: Data sources in the Health Information System.Such a comprehensive Figure 5: design Data sources enablesin phased the Health systemInformation development, System. reduces redundancies,increases efficiency, and improves interoperability. Interoperability is critical to ensuring, forSuch a comprehensive design enables phased system development, reduces redundancies,example, that census data, vital statistics, and health facility data can be integrated to generateincreases efficiency, and improves interoperability. Interoperability is critical to ensuring, forrates, ratios, and other indicator estimates as well as to ensure data validation and triangulationexample, that census data, vital statistics, and health facility data can be integrated to generate(comparison of results from several different sources of data). Triangulation may also helprates, ratios, and other indicator estimates as well as to ensure data validation and triangulation(comparison of results from several different sources of data). Triangulation may also helpdevelopment agencies, foundations, global health initiatives, and technicalexperts that work to increase the availability and use of timely and reliablehealth information by catalyzing the funding and development of core healthinformation systems in developing countries. HMN support in Ethiopia focuseson three areas: i) HIS assessment and preparation of long term plan; ii)

48 Sandro Accorsi, Nejmudin KedirScale up of vital registration; and iii) Capacity building. The aim is to expandthe scope of data collection, analysis and interpretation, strengthening the evidencebase for action through a comprehensive HIS that includes all (routineand non-routine) data sources.Such a comprehensive design enables phased system development, reducesredundancies, increases efficiency, and improves interoperability.Interoperability is critical to ensuring, for example, that census data, vital statistics,and health facility data can be integrated to generate rates, ratios, andother indicator estimates as well as to ensure data validation and triangulation(comparison of results from several different sources of data).Triangulation may also help explaining the possible discrepancies betweensources of data, such as between routine administrative data and survey dataexplaining possible discrepancies between sources of data, such as between routinesources, therefore supporting the provision of the best possible estimate of theadministrative data and survey data sources, therefore supporting the provision of the bestindicators possible(Figure estimate of6).the indicators (Figure 6).INTEGRATION OF DIFFERENT DATASOURCESFigure 6: Integration of different types of data.Figure 6: Integration of different types of data.It mustIt mustalsoalsobebe recognized thatthatsimple,simple,conventionalconventionalperformanceperformanceindicators, usedindicators,isolationfrom the overall analysis framework, could provide misleading measures of efficiency in theused provision in isolation of health from care. the Differences overall in analysis availability framework, of resources, could quality provide of care andmislead-ing measuresdiseaseprofile acrossoftheefficiencysites shouldinbethe takenprovisioninto accountofinhealth evaluatingcare.performanceDifferencesacrossinregions.availabilityoutput of resources, (services) and quality outcomes of must care beand developed, disease and profile data analysis across must the be sites performed shouldTherefore, a comprehensive analysis framework of the health system relating input (resources),accordingly (Figure 7).be taken into account in evaluating performance across regions. Therefore, acomprehensive analysis framework of the health system relating input (resources),output (services) and outcomes must be developed, and data analysismust be performed accordingly (Figure 7).

4. Building the national health management information system (HMIS) in Ethiopia 49DEVELOPING ANALYSIS FRAMEWORKHealthdeterm inantsHealthsystem inputsHealthsystemoutputsHealthoutcom eseconom iceducationalenvironm entalgeneticbehaviouralpolicylegalorganizationfinancialhum an resourceshealthinform ationcoveragequalityusesatisfactionm ortalitym orbiditydiseaseoutbreakshealth statusFigure 7: The analysis framework.Figure 7: The analysis framework.4) 4) Monitoring the performance of the of health the health sector: from sector: data to from indicators data to indicatorsHSDP III Strategic Plan states that “the key elements for a successful programme managementHSDPandIIIimplementation are thestates designingthatof a“theprogrammekey elementsbuilt on aforhierarchya successfulof objectives,programmetargets,management activities and and measurable implementation indicators: the are agreed the indicators designing areof thea most programme important management built on atools for monitoring, review and evaluation purposes”. Therefore, the selection of a core set ofhierarchysector-wideof objectives,indicators istargets, crucial foractivitiesperformanceandmonitoringmeasurableand benchmarking,indicators:whichthe agreedis theindicators identification are the of most “best-in-class” important performance management and analysis tools for of monitoring, the process by review which that andperformance is achieved.evaluationIt is for thispurposes”.reason thatTherefore, the process of indicatorthe selectionselectionofhasa beencoreundertaken,set of sector-widewith the followingindicatorscriteria is being crucial applied for forperformance the core set of sector-wide monitoring indicators: and benchmarking, which is∞ selected against the MDGs;the identification ∞ consistent with of the“best-in-class” HSDP III and PASDEP performance indicators; and analysis of the processby which ∞ limited that in performance number; is achieved.∞ derived mainly from routinely collected data;It is for ∞ this available reason an that annual the basis process for reporting of indicator the ARM; selection has been undertaken,with the ∞ defined following their criteria procedures being forapplied data collection for the ascore well set as for of reporting sector-wide through indicators: standardformat, with specification of definition, formula, data sources and interpretation of the• selected selected against indicator; the MDGs;• consistent ∞ able to measure with the key HSDP factors of III sector and performance PASDEP under indicators;the control of MOH;∞ providing scope for monitoring input, output and outcome.• limited Setting baselines in number; and targets is at the heart of the monitoring exercise as the standards contain• derived observable, mainly explicitfrom statements routinely of service collected performance, data; described in terms of achievement of atarget against which the performance can be measured. Therefore, baselines and targets enable• available the translation on of an policies annual into basis actions. for Setting reporting baselines to and the targets ARM; influences the selection of• defined performance in indicators; their procedures in fact: for data collection as well as for reporting1. only indicators for which a baseline estimate exists should be selected;through standard format, with specification of definition, formula, datasources and interpretation of the selected indicator;• able to measure key factors of sector performance under the control ofMOH;• providing scope for monitoring input, output and outcome.

50 Sandro Accorsi, Nejmudin KedirSetting baselines and targets is at the heart of the monitoring exercise as thestandards contain observable, explicit statements of service performance, describedin terms of achievement of a target against which the performancecan be measured. Therefore, baselines and targets enable the translation ofpolicies into actions. Setting baselines and targets influences the selection ofperformance indicators; in fact:1. only indicators for which a baseline estimate exists should be selected;2. only indicators for which we can expect at least one additional estimateduring the implementation period of the HSDP III should be selected;3. only indicators for which it can be reasonably expected that the HSDPIII could have some measurable impact in the space of its implementationshould be selected.In order to get standards agreed to, implemented and achieved, there has tobe local 2. only ownership indicators for and which national we can standards expect at least need one additional to be examined estimate during and the explicitlymade relevant to the local situation. There are different techniques to es-implementation period of the HSDP III should be selected;3. only indicators for which it can be reasonably expected that the HSDP III could havetablish some realistic measurable targets, impact based in the space on trends, of its implementation modeling, should benchmarks, selected. projections,In order to get standards agreed to, implemented and achieved, there has to be local ownershipor simulations. An example is provided below, with the target for infant andand national standards need to be examined and explicitly made relevant to the local situation.under There 5 are mortality different techniques reduction to by establish 2010 realistic being targets, based based on historical on trends, trend modeling, analysisbenchmarks, projections, or simulations. An example is provided below, with the target for(Figure 8) and on estimation of the impact of the implementation of HSDPinfantand under 5 mortality reduction by 2010 being based on historical trend analysis (FigureIII 8) and on other estimation intersectoral of the impact activities of the implementation aimed at ofimproving HSDP-III and child other intersectoral survival.activities aimed at improving child survival.TREND IN INFANT MORTALITY RATE(1991-2005, with projection to 2010)TREND IN UNDER 5 MORTALITY RATE(1991-2005, with projection to 2010)140130130220200211INFANT MORTALITY RATE (PER 1,000)12011010090807060504030209777Target 45in 2010UNDER 5 MORTALITY RATE (PER 1,000)180160140120100806040166123Target 85 in 2010102001991-1995 1996-2000 2001-2005 2006-201001991-1995 1996-2000 2001-2005 2006-2010YEARYEARFigure 8: Infant mortality rate and under-five mortality rate in 1991-1995, 1996-2000, 2001-2005 (fromFigure Ethiopia 8: Infant Demographic mortality Health Survey), rate and target under-five for 2010 (according mortality to HSDP rate in III). 1991-1995, 1996-2000,2001-2005 (from Ethiopia Demographic Health Survey), and target for 2010Therefore, the use of a core set of(according sector-wide to indicators HSDP is III). important in order to provide acomprehensive picture of the performance of the health sector, with explicit statement onplanned targets and measurement of actual achievements. The basic principles used forTherefore, the use of a core set of sector-wide indicators is important in order1) to Use provide a common a comprehensive set of sector-wide indicators; picture of the performance of the health sec-developing the monitoring system may be summarized as follows:2) Use common criteria for target setting;tor, with explicit statement on planned targets and measurement of actual3) Use standardized procedures for data collection and reporting as well as a common datadictionary;4) Relate resources available (inputs) with services provided (outputs) and outcomes achieved.As a result, the consolidated report to ARM is based on performance comparison across regionsand trend analysis over time, focusing on the implementation of the activities, and theintermediate steps that determine how inputs are transformed into outputs linked to the ultimate

4. Building the national health management information system (HMIS) in Ethiopia 51achievements. The basic principles used for developing the monitoring systemmay be summarized as follows:1) Use a common set of sector-wide indicators;2) Use common criteria for target setting;3) Use standardized procedures for data collection and reporting as well asa common data dictionary;4) Relate resources available (inputs) with services provided (outputs) andoutcomes achieved.As a result, the consolidated report to ARM is based on performance comparisonacross regions and trend analysis over time, focusing on the implementationof the activities, and the intermediate steps that determine how inputsare transformed into outputs linked to the ultimate outcome of interest.In this way, the 2006 ARM has become more strategic, comprehensive andsector-wide, through examining performance and reviewing direction and visionof the health sector. Few examples of such analysis are presented fordemonstration purposes. While upward trend over time is observed forMaternal and Child (MCH) indicators, stagnation is found for indicators reflectingclinical service use, such as outpatient attendance per capita (Figure9, 10 and 11). Wide variations are observed across regions and give clues forinterpretation (Figure 12).TREND IN ANC COVERAGE, PERCENTAGE OF DELIVERIES ATTENDED BYSKILLED HEALTH PERSONNEL AND PNC COVERAGE(ETHIOPIA, 1994-98 EFY)60555045444653Antenatalcarecoverage40PERCENTAGE3530253431Percentageof superviseddeliveries2015105017151610 101316107 71994 1995 1996 1997 1998PostnatalcarecoverageYEARFigure 9: Trend in antenatal coverage, percentage of assisted deliveries and postnatal coverageover the last 5 years (Ethiopia Fiscal Years 1994-98).Figure 9: Trend in antenatal coverage, percentage of assisted deliveries and postnatalcoverage over the last 5 years (Ethiopia Fiscal Years 1994-98).

52 Sandro Accorsi, Nejmudin KedirFigure 9: Trend in antenatal coverage, percentage of assisted deliveries and postnatal coverageover the last 5 years (Ethiopia Fiscal Years 1994-98).80TREND IN DPT3 COVERAGE, MEASLES COVERAGEAND FULL IMMUNIZATION COVERAGE(ETHIOPIA, 1994-98 EFY)79707068DPT3coverage606161PERCENTAGE5040305150424330 3252374449Measlescoverage2010Percentageof fullyimmunizedchildren01994 1995 1996 1997 1998YEARFigure 10: Trend in DPT3 coverage, measles coverage and percentage of full immunization over theFigure 10: Trend in DPT3 coverage, measles coverage and percentagelast 5 years (Ethiopia Fiscal Years 1994-98).of full immunization over the last 5 years (Ethiopia Fiscal Years 1994-98).TREND IN OPD ATTENDANCE PER CAPITA(ETHIOPIA, 1994-98 EFY)0.40.360.32NUMBER OF OPD VISITS PER CAPITA0.30.20.10.27 0.270.3001994 1995 1996 1997 1998YEARFigure 11: Trend in outpatient attendance per capita over the last 5 years(Ethiopia Fiscal Years 1994-98).Figure 11: Trend in outpatient attendance per capita over the last 5 years (Ethiopia Fiscal Years1994-98).

4. Building the national health management information system (HMIS) in Ethiopia 53Figure 11: Trend in outpatient attendance per capita over the last 5 years (Ethiopia Fiscal Years1994-98).DISTRIBUTION OF OUTPATIENT ATTENDANCEPER CAPITA BY REGION(ETHIOPIA, 1997 AND 1998 EFY)0.90.80.71997NUMBER OF OPD VISITSPER CAPITA0.60.50.40.3National average in 19980.219980.10TigrayAfarAmharaOromiaSomaliBenshangul/GumuzSNNPRGambellaREGIONHarariAddis AbabaDire DawaNationalFigure 12: Regional distribution of outpatient attendance per capita in the last two years (EthiopiaFiscal Years 1997-98).Concerning outcome measures, (Ethiopia HIV prevalence Fiscal Years among 1997-98). pregnant women attending ANC siteshas been quite stable in the last years (3.5% in 2006), showing wide regional variations (Figure13).Figure 12: Regional distribution of outpatient attendance per capita in the last two yearsConcerning outcome measures, HIV prevalence among pregnant women attendingANC sites has been quite stable in the last years (3.5% in 2006),showing wide regional variations (Figure 13).DISTRIBUTION OF HIV PREVALENCE BY REGION(ETHIOPIA, 1997 AND 1998 EFY)15121997HIV PREVALENCE (%) .96National Average in 1998199830TigrayAfarAmharaOromiaSomaliBenshangul/GumuzSNNPRREGIONGambellaHarariAddis AbabaDire DawaNationalFigure 13: Regional distribution of HIV prevalence in the last two years(Ethiopia Fiscal Years 1997-98).Figure 13: Regional distribution of HIV prevalence in the last two years (Ethiopia Fiscal Years1997-98).Per capita public expenditure, while increasing over time, is still too low (about 2 USD perperson/year), with wide variations across regions (Figure 14 and 15).

5) ConclusionsHMIS reform is part of the efforts to orient the sector in such a way that it truly becomes resultsorientedand performance-based. The challenge is to improve the quality of routinely collecteddata, to develop data analysis, and to find ways of translating the output of the information54 Sandro Accorsi, Nejmudin KedirPer capita public expenditure, while increasing over time, is still too lowFigure 13: Regional distribution of HIV prevalence in the last two years (Ethiopia Fiscal Years(about 1997-98). 2 USD per person/year), with wide variations across regions (Figure14 and 15).Per capita public expenditure, while increasing over time, is still too low (about 2 USD perperson/year), with wide variations across regions (Figure 14 and 15).TREND IN PER CAPITA PUBLIC EXPENDITURE ON HEALTH (IN ETB)(ETHIOPIA, 1994-98 EFY)201616.816.013.21211.311.9ETB8401994 1995 1996 1997 1998YEARFigure 14: Trend in per capita public expenditure on health over the last 5 years (Ethiopia FiscalYears 1994-98).Figure 14: Trend in per capita public expenditure on health over the last 5 years(Ethiopia Fiscal Years 1994-98).160DISTRIBUTION OF PER CAPITA PUBLIC EXPENDITUREON HEALTH (IN ETB) BY REGION(ETHIOPIA, 1997 AND 1998 EFY)1401201997100ETB806040199820National average in 19980TigrayAfarAmharaOromiaSomaliBenshangul/GumuzSNNPRGambellaREGIONHarariAddis AbabaDire DawaNationalFigure 15: Regional distribution of per capita public expenditure in the last two yearsFigure 15: Regional distribution of per capita public expenditure in the last two years (EthiopiaFiscal Years 1997-98). (Ethiopia Fiscal Years 1997-98).

4. Building the national health management information system (HMIS) in Ethiopia 555) ConclusionsHMIS reform is part of the efforts to orient the sector in such a way that ittruly becomes results-oriented and performance-based. The challenge is toimprove the quality of routinely collected data, to develop data analysis, andto find ways of translating the output of the information system into evidence-baseddecision-making. In this perspective, using inputs based onreadily available information (such as routine service and epidemiologic data),and combining data from different sources, have already proven to bevaluable for policy making, performance monitoring and epidemiologic surveillancepurposes. Such “bottom–up” approach focused on local priorities,integrated in the current health activities, and based on sustainable data collectionsystems, may ensure immediate and practical benefits in terms ofpublic health practice: developing a sustainable, comprehensive and multisourcehealth information system for decision support is a priority for HSDPIII in Ethiopia.

56 Sandro Accorsi, Nejmudin KedirBIANCA

Human resources Human forresources health (HRH) for health – nurses, (HRH) doctors, – nurses, pharmacists, doctors, pharmacists, community health community workers, health workers,5. Human resources for health (HRH): a crucial element for achieving international MDGs. 575. HUMAN RESOURCES FOR HEALTH (HRH):A CRUCIAL ELEMENT FOR ACHIEVINGINTERNATIONAL MDGs. NATURE OFTHE CRISIS IN ETHIOPIACarlo Resti, Yohannes Tadesse5. HUMAN RESOURCES 5. HUMAN RESOURCES FOR HEALTH FOR (HRH): HEALTH A CRUCIAL (HRH): AELEMENT CRUCIALFOR ELEMENT ACHIEVING FOR ACHIEVINGAt the UnitedINTERNATIONALNations INTERNATIONAL MillenniumMDGs. NATURE MDGs. SummitOFNATURE THEinCRISISSeptember OF THE IN ETHIOPIA CRISIS 2000, INworld ETHIOPIA leadersof both low- and high-income(Carlo Resti,countriesYohannes (Carlo Resti,committedTadesse) Yohannes Tadesse)themselves to combatingpoverty, hunger, disease, lack of basic education, environmental degradationand discrimination against women. Thus, eight Millennium DevelopmentGoals (MDGs) (www.un.org/millenniumgoals) were formulated, among them sixdirectly or indirectly related to health and to the health of the poor:At the United At Nations the United Millennium NationsSummit Millennium in September Summit in 2000, September world leaders 2000, world of both leaders low- and of both highincomecountries income committed countriesthemselves committed to themselves combating to poverty, combating hunger, poverty, disease, hunger, lack disease, of basiclack of basiclow- and high-education, environmental education, environmental degradation and degradation discrimination and discrimination against women. against Thus, women. eight Millennium Thus, eight MillenniumDevelopment Development Goals (MDGs) Goals (www.un.org/millenniumgoals) (MDGs) (www.un.org/millenniumgoals) were formulated, were among formulated, themamong six them sixdirectly or indirectly related or indirectly to health related and to the health health and of to thepoor:health of the poor:The Health-Related Millennium Development Goals (MDGs)The Health-Related The Health-Related Millennium Development Millennium Goals Development (MDGs) Goals (MDGs)Goal 1 Goal — 1—eradicating extreme poverty poverty and hunger. and hunger.Goal 4 — reducing child mortality.Goal 4—reducing child mortality.Goal 5 — improving maternal health.Goal 6 Goal — 5—improving combating maternal HIV/AIDS, health. malaria, and other diseases.Goal 7 — ensuring environmental sustainability (access to safe drinking water).Goal 6—combating HIV/AIDS, malaria, and other diseases.Goal 8 — developing a global partnership for development. (access to affordableGoal 7—ensuring essential environmental drugs). sustainability (access to safe drinking water).Goal 1—eradicating extreme poverty and hunger.Goal 4—reducing child mortality.Goal 5—improving maternal health.Goal 6—combating HIV/AIDS, malaria, and other diseases.Goal 7—ensuring environmental sustainability (access to safe drinking water).Goal 8—developingGoal a global 8—developing partnership a global for development. partnership (access for development. to affordable (access essential to affordable drugs). essential drugs).Source: United Nations Millennium Declaration, the United Nations MillenniumSummit 2000.Source: United Nations Source: Millennium United Nations Declaration, Millennium the United Declaration, Nations theMillennium United Nations Summit Millennium 2000. Summit 2000.For most priority diseases and major contributors to the global burden of disease,effective interventions, both preventive and curative, do exist. However, theaccess to the health system by poor is low. In Africa, a mere 1.3% of the world’sdisease burden.health workers struggle to combat fully 25% of the global disease burden.For most priority For most diseases priority and diseases major contributors and major contributors to the global to burden the global of disease, burden effective of disease, effectiveinterventions, interventions, both preventive both and preventive curative, and do exist. curative, However, do exist. theHowever, access to the health access system to the health by poor system by pooris low. In Africa, is low. a mere In Africa, 1.3% of a mere the world’s 1.3% of health the world’s workers health struggle workers to combat struggle fully to 25% combat of the fully global 25% of the globaldisease burden.

58 Carlo Resti, Yohannes TadesseHuman resources for health (HRH) – nurses, doctors, pharmacists, communityhealth workers, laboratory technicians, medical assistants, and manyothers – are at the core of health systems everywhere. Where there are HRHshortcomings, health systems will suffer, resulting in preventable death anddisease. Where HRH is in crisis, health systems will be in crisis.Such is the case in much of Sub-Saharan African countries (SSA). Hence,health workforce is said to be the glue of the health care delivery system.In every knowledge-based organization human resources act as a glue of the systemIn every knowledge-based organization human resources act as a glue of the system (adapted from JLI, 2004)(adapted from JLI, 2004)Human resources are also important from a budgetary perspective, typically accounting for 50 to 80percent of health sectors’ recurrent costs; formal and informal service remuneration are also animportant share of household expenditures on health. This entails that countries have the capacity toadvocate for, design, implement, monitor, and evaluate policies and practices to build sustainablehealth systems. At a time when the international community and SSA countries scale up interventionsto deal with the epidemics of tuberculosis, malaria, HIV-AIDS (GFATM and other various initiatives),the strengthening of the health workforce calls for immediate policy attention and action, as theworkforce situation all over the world and in Sub Saharan Africa is particularly critical:Human resources are also important from a budgetary perspective, typicallyaccounting for 50 to 80 percent of health sectors’ recurrent costs; formal andinformal service remuneration are also an important share of household expenditureson health. This entails that countries have the capacity to advocatefor, design, implement, monitor, and evaluate policies and practices tobuild sustainable health systems. At a time when the international communityand SSA countries scale up interventions to deal with the epidemics oftuberculosis, malaria, HIV-AIDS (GFATM and other various initiatives), thestrengthening of the health workforce calls for immediate policy attentionand action, as the workforce situation all over the world and in Sub SaharanAfrica is particularly critical:• Absolute numbers are inadequate, sometimes insufficient and decreasingbecause of the combined effects of brain-drain (out of the sector, out ofthe country) and HIV/AIDS; sometimes in excess for certain cadres, dueto poor training and employment regulation policies.• There are great imbalances: more doctors than nurses in certain countries,certain areas not covered (mental health, occupational health, publichealth, management), internal migrations with urban concentration, shiftAbsolute numbers are inadequate, sometimes insufficient and decreasing because of thecombined effects of brain-drain (out of the sector, out of the country) and HIV/AIDS;sometimes in excess for certain cadres, due to poor training and employment regulationpolicies.There are great imbalances: more doctors than nurses in certain countries, certain areasnot covered (mental health, occupational health, public health, management), internalmigrations with urban concentration, shift towards the private sectors’ greener pastures, gender

important share of household expenditures on health. This entails that countries have the capacity toadvocate for, design, implement, monitor, and evaluate policies and practices to build sustainablehealth systems. At a time when the international community and SSA countries scale up interventionsto deal with the epidemics of tuberculosis, malaria, HIV-AIDS (GFATM and other various initiatives),5. the Human strengthening resources for ofhealth the health (HRH): workforce a crucial element calls for for immediate achieving international policy attention MDGs. and action, 59 as theworkforce situation all over the world and in Sub Saharan Africa is particularly critical:Absolute numbers are inadequate, sometimes insufficient and decreasing because of thecombined effects of brain-drain (out of the sector, out of the country) and HIV/AIDS;sometimes in excess for certain cadres, due to poor training and employment regulationtowards the private sectors’ greener pastures, gender imbalances (management,specialists).policies.• Training is still mostly based on western models (even in Ethiopia and particularlyfor medical doctors) and not consistent with the needs of the region;imbalances quality is (management, extremely specialists). variable.• Staff work in poor conditions with incomplete access to essential drugsand consumables, poorly maintained equipment, little incentives, andpoor human resource management.• Country management. capacity to address these problems is limited.There are quite a lot of challenges related to human resources. Initiatives suchas the Millennium Development Goals, debt relief ear-marked to the healthand education sector, the Global Fund or the Global Alliance for Vaccinesand Immunization (GAVI) are not merely based on the scaling-up of healthrelated interventions but need adequate human resources to implementthem. HRH will also heavily influence absorptive capacities of supplementaryresources to health systems in low- and middle income countries. Thus,for any large scale effort to rapidly increase coverage of the population, anyfair management strategy functional for attracting and retaining HRH willbe a key to success. When comparing the need of health workers with the epidemiologicalcontext of a country, Ethiopia falls among the “low-density /high-mortality” countries.There are great imbalances: more doctors than nurses in certain countries, certain areasnot covered (mental health, occupational health, public health, management), internalmigrations with urban concentration, shift towards the private sectors’ greener pastures, genderTraining is still mostly based on western models (even in Ethiopia and particularly formedical doctors) and not consistent with the needs of the region; quality is extremely variable.Staff work in poor conditions with incomplete access to essential drugs andconsumables, poorly maintained equipment, little incentives, and poor human resource

Ethiopia falls among the “low-density / high-mortality” countries.60 Carlo Resti, Yohannes TadesseHuman Resources and health clustersHuman Resources and health clustersSource: WHO, 2004Source: WHO, 2004Challenges and constraints to the development of HRHBuilding up of the health workforce necessary to achieve internationalMDGs targets faces a number of constraints. The most important challengesfor a typical low-income country in Sub-Saharan Africa, as it is the case forEthiopia, are likely to include the following factors:• addressing the proportional representation of staff with a distinct socialand ethnic background in the workforce and addressing the issue of an appropriateskill mix of health personnel;• tackling geographical imbalances in the distribution of health sectorworkforce;• building qualitative and quantitative capacities of medical and paramedicaltraining institutions simplifying entry points in the educationalsystem and career ladder;• addressing the necessity to delegate some key skills (task shifting) tolower health cadres of workers to reach the grass root level in health servicesdelivery;• designing and implementing national HRH policies and ad hoc strategies;• carrying forward good governance for a conducive work environmentand a well conceived and balanced overall policy framework.Obviously, the size and the extent of these main constraints varies across differentlow- and middle income countries, but they will largely determine thepace of any effort to increase health service coverage of the population.

5. Human resources for health (HRH): a crucial element for achieving international MDGs. 61Representing minority groups in the workforce and setting the rightskill mixThe Millennium Declaration call for priority to be given to the poor. Oftenthese groups are under- or not at all represented in the health sector workforceand are not sufficiently taken onboard in establishing priority needs interms of health and acceptable and desirable social services.It has been reported that a major reason for extremely low access to healthservices and coverage of nomadic communities in different areas consists inlinguistic and cultural differences to the health personnel. Similar problemsare also described for minority groups such as the Rom people in EasternEurope or migrant laborers. Thus, it will be necessary to employ personnelwith a specific social, ethnic and cultural background for an effective and efficientdelivery of priority interventions to the poorest and most disadvantaged.In Ethiopia, for instance, health personnel from the highlands, normally havedifficulty in approaching and adapting themselves to pastoralist communitiessuch as those of “emerging regions” like Gambela, Afar, Somali, etc.“Skill mix” refers to the mix of posts, grades or occupation in an organization.It may also refer to the combinations of activities or skills needed foreach job within the organization. Setting the right “skill mix” for a definitecountry situation is a long process that should start with a task analysis. Thatis to know the tasks that different staff have to carry out at different level ofthe organization and the skills needed to perform them. The further step is,within the educational system, being able to plan, recruit, train and retainhealth personnel with the necessary bundle of skills. Especially for low- andmiddle income countries, there have been attempts to go beyond the traditionaldefinitions of skills defined by membership of a profession (medicine,nursing, midwifery and other health related professions). So, due to specificneeds, the range of health care workers has been widened to meet the serviceneeds. Some of them can enter the system after a very basic training in extremelybasic preventive and curative skills, while others receive enhancedtraining on specific key skills, such as generic nurses trained in emergency obstetricsor in primary surgery.Geographical imbalances (uneven distribution of health staff)The size and composition of the workforce will determine if priority interventionscan be delivered effectively and efficiently. Countries such as theUnited Kingdom, Ghana, Mauritania, Ethiopia or Zimbabwe report defi-

62 Carlo Resti, Yohannes Tadesseciencies of personal with specific skills (e.g. the UK reports huge shortages innurses). Scaling-up of interventions will require staffing of health serviceswith appropriate skill mixes. Regions with high HIV/AIDS prevalence arelikely to rely on other skill mix patterns than regions where acute respiratoryinfections in children or malaria are predominant. Thus, it will not beenough to develop and implement staffing norms across a country, but to allowfor variation based on cultural contexts and current and future epidemiologicalpatterns of priority diseases.As it is well known, organizational and management issues at the health sectorlevel can influence performance and productivity. Setting correct incentives inthe health sector will be of crucial importance for having the right skill mix atthe right place and for addressing geographical imbalances in the distributionof HRH and for establishing appropriate staffing patterns. For example, careerplans, salary levels, recruitment, appointment and retention procedures willstrongly affect where health workers practice and whether they will remain inthe health sector or in the hardship, remote areas of the country.Salary level is strongly linked with motivation and retention. In many countriessalaries of the governmental health sector workforce are low, in both absoluteand relative terms. Parallel activities, such as working during the morningshift for a public provider and in the afternoon for a private one is a commonstrategy to complement low salary levels. In order to retain health staffat the work place and in the health sector, it will be necessary to considersalary increases. As in many countries HRH absorb already an important partof sector budgets (often around 80%), a significant increase in the pay ofhealth sector workers may reveal difficult in terms of preferences and choicesto be given to salary expenditures and in terms of the economic and politicalfeasibility. The macroeconomic environment will also determine the publicsalary level.However, the experience of countries which have used monetary incentivesfor addressing motivation and imbalances in the geographical distribution ofhealth workers indicates that non-monetary incentives are as important.Other factors such as proximity to the family, continuous education, opportunitiesfor research and teaching also can influence an individual’s decisionwhere to work.Building up training capacityIn many countries, the scaling-up of priority interventions will require newpersonnel to be trained, especially general practitioners and nurses. Scaling-

5. Human resources for health (HRH): a crucial element for achieving international MDGs. 63up of priority interventions is likely to require significant investments intotraining capacities. Given the lead-time required to produce new healthworkers, such investments must occur in the early phases of scaling up, thereforeearly in the next decade (2006-2010).With regard to initial training, appropriately trained staff will require significantchanges in medical and nursing curricula, pedagogical methods, and inadmission criteria. The focus of medical training will need to shift from hospitalto primary care assignments and to substitutive and front-line healthcadres that can easily be deployed at household level closer to the community.Further, administration and management skills and/or the training of districtmanagers (in Ethiopia: Woreda Health Officers at District level and HealthOfficers at HC level) will require special attention.More generally, training approaches will need to tie into national health policiesand priorities and respond to required HRH skill patterns. Revising theeducational structure for health workers could increase access to educationalopportunities for all, and especially for women and for those from rural areas.Primaryleveleducation6-10 yearsSchoolingCommunityHealthAgents3 MonthsHealth ExtensionWorkers1 yearAssociated Nurse(key skills delegation)“substitute HW”UPGRADINGHealh Ass. &Juniors 1 yearSecondary level education3 yearsNurses and Medical Doctors3-6 yearsThe above flow chart shows an example of educational pathway. It resemblesthat one of Ethiopia, except for the not yet implemented training of a kindof Associated Nurse or “substitute health workers”, or any other form of “taskshifting”. These are health workers who have been trained for shorter periods(i.e. less than a generic nurse or a midwife) and required lower entry educationalqualifications to whom are delegated tasks and functions normally performedby more established health professionals with higher qualifications.To ensure equity of opportunity, it is recommended that a “multiple entrymultipleexit” educational framework is developed wherever possible, to en-

64 Carlo Resti, Yohannes Tadessesure that new cadres have access to continuing education opportunities andcan upgrade their skills and educational levels. Skill substitution or skill delegationis not but at an early discussion stage in Ethiopia, while there aresome experiences in other African countries.To face the challenge of shortage of HRH, the use of substitute health workersis quite common in Africa, but reviews and non anedoctal evidences arenot published.There are four main forms of substitution of health care workers in Africa,(D. Dovlo, 2004).Indirect substitution/task delegation (task shifting), i.e. substitution using an existingbut different professionAn example of this occurs when tasks carried out by physicians are taken upby nurses. Several examples of this type of substitution were found. InGhana, the “Life Saving Skills Training Project” trained midwives in rural areasto carry out delivery-related tasks normally undertaken by doctors. SouthAfrica (Choice on Termination of Pregnancy (CTOP) Act 1996) and Zambiahave changed their abortion laws and given new roles to nurses and midwives,including tasks normally restricted to physicians. White et al. (1987)report that in the Congo in the 1950s, nurses were trained to perform surgeryand in Malawi, Ghana, Tanzania and Zambia, nurse anesthetists providedanesthesia for surgical operations. These skill substitutions also enhancethe roles of these existing cadres and so are rather forms of task delegation.Informal substitution often occurred when nurses and other mid-level healthworkers in rural areas performed procedures normally disallowed by the regulations.Nurses in rural areas in Ghana, for example, delivered breech presentationsand performed episiotomies, even without additional training anddespite restrictions that these tasks be performed by physicians or underphysician supervision.Direct substitution: i.e. substituting an existing profession with new and differentcadresMany African countries have created country-specific cadres to carry outtasks that are internationally recognized as those of other professionals. Thisis a common form of substitution in Africa, where in most countries thesesubstitutes are no longer “new”, having been in place for over two decades.Examples include substitution for doctors using “clinical officers”, “medicalassistants”, “assistant medical officers” and “surgical or obstetric technicians”.

5. Human resources for health (HRH): a crucial element for achieving international MDGs. 65Two further subtypes are identified.• Partial substitutes, who carry out only limited and circumscribed tasks ofdoctors and refer other tasks to doctors. Medical assistants in Ghana andclinical officers in Zambia are examples of such substitutes.• True or full substitutes, who carry out significant segments of the scope ofpractice of doctors. Assistant medical officers in Tanzania and surgical/obstetrictechnicians (tecnicos de cirurg?a) in Mozambique independentlyperform surgery and are examples of this type of substitution.Intra-cadre skills delegation, i.e. delegating some specific, special tasks to lesstrainedcadres from the same professionTasks normally carried out by specialists are delegated to general practitionerswith or without additional training. The West Africa Post-GraduateMedical College determined a gap in certain specialties in the region – psychiatry,ophthalmology, ENT and anesthesia – and had provided 18-monthpractical diploma courses for general practice physicians to undertake enhancedroles in these specialties. General practice nurses have been used asoperating room nurses without the appropriate qualification.Task delegation, i.e. delegation of some non-technical tasks to relieve professionalsof unwarranted workloadClerical tasks in wards, such as administration of patient reports, can be delegatedto ward clerks working closely with nurses. The health sector in Ghanarecently authorized the creation of “health aides” aimed at relieving professionalnurses of the more menial tasks on wards, such as lifting or bedbathingpatients,A basic underlying factor in all substitutions is that the worker to whom thetasks are delegated is not trained to the same level or qualification as the cadrewho normally carries out these tasks. Laws or regulations should normallyformalize substitution, but it is also recognized that substantial informal skilldelegation exists because of unfilled needs in rural and remote areas.Good governance and overall policy frameworkThe scaling-up of priority interventions is intimately linked to ongoing reformsin the health sector. Decentralization, the promotion of private practice,new financing and payment schemes, hospital and/or pharmaceutical reformsare currently promoted in many countries as a means to improve performanceand outcomes of national health care systems. The development of

66 Carlo Resti, Yohannes TadesseHRH will need to tie in to these reforms. Thus, coherent and well-formulatednational HRH policies and strategies are required for giving direction onHRH development and on how HRH relate to health sector reform issues(e.g. decentralization, public-private mix), the scaling-up of priority interventions,poverty reduction strategies, and training methodology approaches.In many countries the development of coherent HRH planning approachesis of low priority and respective planning departments are badly equipped,both, technically and personnel-wise. Recently it was pointed out that evencountries such as Australia, France, Germany, Sweden and the UnitedKingdom have a partial approach to planning of the health sector workforceand that the relationships between different categories of health professionsis ignored. More specifically, nurse workforce requirements for addressingdisease patterns of the population are neglected.The socio-political and economic situation of a country will largely determinehuman resource constraints for achieving the MillenniumDevelopment Goals. Many factors will influence in an important waywhether and where health professionals will practice: e.g. political stability,priority accorded to social sectors, the overall policy framework, governance,and accountability.Emigration of medical professional illustrates this. Recruitment policies, immigrationlaws and regulations in better off countries induce whether thereis a demand for health professionals in high-income countries. On the otherhand, living conditions in a low-income country will determine whetherhealth staff is encouraged to leave the country. With various high-incomecountries such as the USA, UK, France having a high demand for health professionalstrained outside their country, there is a growing concern that theyabsorb large numbers of health staff from low- and middle income countries.For example, it is reported that the US is short of several hundred thousandnurses and that the high demand for medically trained staff is not likely to bereversed in the coming years. In contrary, for Africa it is estimated thataround 23.000 qualified academic professionals emigrate annually or forGhana it is estimated that over 50% of doctors having graduated are livingand practicing outside the country.Unless there is no possibility to address at the same time pull factors of migrationin high income countries and push factors in low-income countries,investments in medical and nursing training are likely to be jeopardized. Itwill be crucial to elaborate and implement well balanced and sound nationalretention strategies.

5. Human resources for health (HRH): a crucial element for achieving international MDGs. 67The Ethiopian context and the nature of the crisisEthiopia has an estimated population of above 76 million and is the secondmost populous country in Sub-Saharan Africa. 85% of the population is ruraland earns its living from rain-fed subsistence agriculture which constitutesabout 42 % of GDP. The country is one of the poorest in the world with percapita income not exceeding 100 USD and about 44% of the populationlives below the poverty line. The population has been growing at a rate of 2,8% per year. Life expectancy is approximately 54 years for both sexes.Ethiopia’s poverty strategy, the guiding strategic framework for the five-yearperiod 2006-2010, is the PASDEP (Plan for Accelerated and SustainedDevelopment to End Poverty). The PASDEP carries forward importantstrategic directions related to human development, rural development, foodsecurity, and capacity-building. The document is also focusing on growth inthe coming five-year period – with a particular emphasis on greater commercializationof agriculture and the private sector - and a scaling-up of efforts toachieve the Millennium Development Goals.Up to now there is no formally endorsed HRH strategy at central level, buta “health sector human resource development framework (2006-2010)” as theonly reference guideline. Some of the Regional Health Bureaux in Ethiopiahave started to implement in autonomy some management strategies to curbthe migration of health professionals, especially medical doctors. The manifestationsof the crisis in Ethiopia are particularly acute. In 2006 a HRH nationalObservatory has been established to develop soon a comprehensivestrategy.Quantitative Shortage of All Forms of Health WorkersEthiopia is considered to have one of the lowest ratios of doctors to populationin the world. In particular, with the recent expansion of health facilitiesacross the country, severe shortages of health workers for staffing them havebeen witnessed. Furthermore, the threshold density below which high coverage(80%) of essential interventions, (including those necessary to meetMDGs) is estimated at 2.3 health workers per 1,000 people 1 , the definitionof Health workers being all people primarily engaged in actions with the primaryintent of enhancing health. However, with a total workforce of 45,8591 WHO. The world health report 2006: Working together for health. 2006. WHO,Geneva.

68 Carlo Resti, Yohannes Tadesse(including Health Extension Workers) for 73,044,000, there were only 0.53health workers per 1,000 population in Ethiopia at the end of 1997 EC.Figure 1 below also shows availability of human resources for health of variouscategories during the past six years. (excluding the new HEWs cadre).Figure 1 - HRH availability over six years in EthiopiaFigure 1 - HRH availability over six years in EthiopiaNo. per 1000 pop.0.6MD0.50.40.30.20.1MD+ HONursesPharma + tech.HAMD+HO+Nurses+HAHA + NursesAll HW (excluding HEWs)01992 1993 1994 1995 1996 1997Year (EC)Shortages have been more acute in some particular categories of workers that include: surgeons,Shortages obstetricians, have pharmacists been more and midwives. acute in Even some though particular the nurses-to-population categories ratio of has workers become more thatfavorable recently, this is partly due to the inclusion of “junior’ cadres of workers in this categoryinclude: surgeons, obstetricians, pharmacists and midwives. Even though the2 .There is also a critical shortage of midwife nurses, a category that is particularly crucial in view of thenurses-to-population need for addressing the excessively ratio has high become maternal more mortality favorable ratio in the recently, country. Two this of the is partly largestregions (Oromia and SNNP), for instance, had less than one midwife per100,000 people duringdue to the inclusion of “junior’ cadres of workers in this category 2 1997.. There isStaffing for health management and planning tasks has also been equally challenging with thealso decentralization a critical shortage of the health of management midwife system nurses, to thea level category of Woredas. that The is situation particularly of staffing crucialforthe senior positions at the level of the Federal Ministry of Health is also optimal. Currently,considerablein viewproportionsof the needof theseforpositionsaddressingare vacant.theEvenexcessivelythe few positionshighthatmaternalare filled aremortalityeither ratio by in relatively the country. less qualified Two or by of personnel the largest that are regions seconded (Oromia through bilateral and and SNNP), multilateral forstaffedpartner organizations.instance, The majorhad reasons less for than such quantitative one midwife shortages per100,000 may be economic people and fiscal during difficulties 1997. as well asStaffing demandsfor outpacing health supply. management In most casesand production planning could not tasks keep has pacealso with been demands equally due topopulation growth. As shown in the table 1, there has been a significant increase in the number ofchallenging health officers with and nurses the decentralization starting 1994 EC due of to the accelerated health expansion management of training system activities. totheHowever,level oftheWoredas. overall population/personnelThe situationratioofhasstaffingdecreasedforonlythemarginally.seniorInpositionsaddition to theatfactthethat the baseline ratios were excessively high, the rapid population growth and the problems of attritionlevel make of the the efforts Federal of reducing Ministry these ratios of quite Health challenging. is also optimal. Currently, considerableproportions of these positions are vacant. Even the few positions thatThe other reasons for quantitative shortage are the increased shift in demand for modern medical care(from previous reliance mostly in indigenous medical care) as well as due to new and emergingare pathologies. filled are Instaffed addition, either with theby growth relatively of health less technologies, qualified the need or by forpersonnel health human that resources arealso rises as the health sector is highly labor intensive. Training orientations towards more expensiveseconded through bilateral and multilateral partner organizations.and less cost-effective types of health personnel relative to affordability and relative to disease burdenThe also major exacerbate reasons the shortage for of such health quantitative human resources. shortages may be economic and fiscaldifficulties as well as demands outpacing supply. In most cases produc-2 The World Bank. Ethiopia A Country Status Report on Health and Poverty (DraftReport). March 2005. Draft Report No.28963-ET.2 The World Bank. Ethiopia A Country Status Report on Health and Poverty (Draft Report). March 2005. Draft ReportNo.28963-ET.

5. Human resources for health (HRH): a crucial element for achieving international MDGs. 69tion could not keep pace with demands due to population growth. As shownin the table 1, there has been a significant increase in the number of healthofficers and nurses starting 1994 EC due to accelerated expansion of trainingactivities. However, the overall population/personnel ratio has decreased onlymarginally. In addition to the fact that the baseline ratios were excessivelyhigh, the rapid population growth and the problems of attrition make the effortsof reducing these ratios quite challenging.The other reasons for quantitative shortage are the increased shift in demandfor modern medical care (from previous reliance mostly in indigenous medicalcare) as well as due to new and emerging pathologies. In addition, withthe growth of health technologies, the need for health human resources alsorises as the health sector is highly labor intensive. Training orientations towardsmore expensive and less cost-effective types of health personnel relativeto affordability and relative to disease burden also exacerbate the shortage ofhealth human resources.Table 1 - Trends in Magnitude of Graduates of Selected Categories 3Year (EC) Physicians Health Nurses Pharmacists HealthOfficersExtensionWorkersGrad. Grad. Grad. Grad Grad1990 140 83 1129 1741991 136 79 1416 1561992 152 157 1399 1201993 128 181 2164 961994 152 183 1562 861995 182 181 1465 851996 193 249 2374 57 2,7371997 309 333 4536 70 7,0903 MOH. Health and health related indicators. Various issues (1995 – 2006), Planning andProgramming Department, Addis Ababa.

70 Carlo Resti, Yohannes TadesseUrban-Rural Imbalance in DistributionCurrently, the government does not seem to have a proper and consistentmechanism for ensuring the deployment of graduates in places where they arerequired. Most of the available health workers (especially the higher levelones) tend to concentrate in the few major urban areas, Addis Ababa havingthe largest concentration.Table 2 - Percentage Distribution of Professional Categoryby Place of Residence 4Professional categoryPlace of residenceUrban RuralTotal in numberPhysicians 88 12 1,480Nurse 83 17 862Midwives 96 4 643Dentists 76 24 6,705Pharmacists 70 30 686Physiotherapist 76 24 107Laboratory 73 27 408Radiographer 59 49 171Environmental and public Health 100 0 11Other technician and cadres 100 0 60HEP workers 12 88 6,264Others 40 60 7,160Gender Balance of Health WorkersAnother noteworthy issue in the magnitude and distribution of theEthiopian health work force is the fact that it is highly male dominated, especiallyin view of the preponderance of maternal and child health conditionswithin the major health problems. For instance, in 1997, only 11% of physicians,15% of health officers and 48% of nurses were females.4 MOH & WHO. Progress Report on the 2005 Human Resource for Health Assessmentin Ethiopia. 2006. Human Resources Department, MOH, Addis Ababa.

5. Human resources for health (HRH): a crucial element for achieving international MDGs. 71Problems in Training Curricula and InstitutionsThe expectations of the curricula in terms of skills and knowledge to be acquiredby most of the mid-level trainees, as well as those of health officers,seem to be too ambitious, in view of the currently available levels of trainingresources as well as the durations allotted for the respective programs. For instance,even though about 1,005 health officers have been trained during theperiod of 1990 to 1997 EC, there are concerns on whether these graduatesare really equipped with the required competence, particularly in terms ofskills for handling emergency obstetric care. Graduate health officers are inprinciple expected to have acquired knowledge and skills for performing proceduressuch as caesarean section, appendectomy and emergency laparatomy.However, this has been hardly seen to be practical even for graduate physicians,let alone for health officers. Considering these limitations, serious attentionshould be given to the context in which the MOH has recently initiatedan accelerated the HO training within selected hospitals with the objectiveof staffing the PHCUs that are under construction within theAccelerated Expansion of Primary Health Coverage.The magnitude of practical sessions allocated during training seems to be inadequatefor acquisition of the required levels of practical skills by traineessuch as health officers. The fact that the MOH has limited roles in influencingcurriculum development and the process of training of higher level healthprofessionals may have contributed to such deficiencies.Private sector training activities have contributed to the huge increase in thenumber of junior level paramedics within the last few years. However, thereseem to be concerns on the quality of training at some private institutions.In addition, increase in the presence of the health workforce in rural areas hasnot been observed yet proportional to the magnitude of private sector graduates.Furthermore, most of the new private training institutions lack the capacityto fulfill the required equipment, transport facilities, teaching aids andreference materials for their respective standards.Problems Related to Administration, Management and MotivationEven though the country’s health policy includes a strategic component onhuman resources development, there are no clear mission statements orguidelines that help operationalize the HRD statements in the policy by relevantstakeholders. The conditions of its implementations of these statementsat various levels are not yet clearly articulated. Furthermore, the governmentdid not yet lay any mechanism for realizing its stated strategy of coordination

72 Carlo Resti, Yohannes Tadessewith service needs and objective realities in terms of the training of high levelprofessionals. In particular, there is a serious problem in terms of the deploymentof physicians within the public sector, especially to rural areas.Practice regulation is almost non-existent, particularly for those within theprivate sector.Attrition and Brain Drain due to migration abroadThe problem of brain drain in African countries is multi-dimensional. Onesuggested typology of this problem is to see it as “soft” and “hard” braindrain 5 . Loss of knowledge due to unavailability of health research results tohealth practitioners in Africa because many African researchers prefer to publishin northern journals can be considered as “soft brain drain”, while physicalmovement of health personnel from developing countries to northerncountries can be counted as “hard brain drain”.Among the “push” factors contributing to brain drain are: low salaries andbenefits, fear of occupational infections where HIV/AIDS and other infectiousdiseases are rife, lack of well equipped physical infrastructure, drugs, suppliesand good health management system, inadequate research possibilitiesand lack of opportunity to keep up-to-date with information in their field.In addition to the factors that are pushing health professionals out of thecountry, conditions in and practices of high-income countries (“pull” factors)encourage them and contribute to their ability to work abroad.Brain drain is a relatively recent phenomenon in the Ethiopian health sectorworkforce. Prior to 1974, Ethiopia’s skilled professionals neither emigratednor decided to stay on in the countries of their training in search of betterworking conditions and for fear of political persecutions. With the advent ofan increasing number of push factors, however, this trend has changed overthe past couple of decades. About 50% of Ethiopians who went abroad andcompleted their studies did not return home during the past 10-15 years. Forinstance, between 1980 and 1991 only 5,777 students out of a total of22,700 returned home 6 .5 Muula A. Is there any solution to the “Brain Drain” of health professionals and knowledgefrom Africa? Croat Med J 2005 46(1): 21-29.6 Mengesha Y and Kebede Y. Brain Drain. In Berhane Y, Haile Mariam D, Kloos H. TheEpidemiology and Ecology of Health and Diseases in Ethiopia. SHAMA Books andEthiopian Public Health Association, Addis Ababa, Ethiopia (1 st edition 2006).

5. Human resources for health (HRH): a crucial element for achieving international MDGs. 73Table 3 – Brain Drain of Health Professionals (Mengesha and Kebede, 2006)Year Institution Field Persons Non- % lossof Study leaving returnees1968/69- MOH Medical 2013 423 211995/96 and AAU sciences1980 - 2001 AAU MF All disciplines 121 85 70Attrition due to migration out of public sectorPharmacists and druggists seem to have been proportionally more affected byinternal migration from public to private sector. There is a huge shortage ofpharmacists in the public sector institutions. For instance, from a total ofabout 500 pharmacists, only 24% were working in the public sector. Eventhough there are attempts to replace pharmacy technicians in places that usedto be staffed by pharmacists, even the number of technicians within the publicsector is not still adequate with the result that nurses, health assistants aswell as other junior staff are getting assigned in these positions.Health workers who migrated internally continue to serve the country’s population,even though those with higher socio-economic status and usually urbanresidents. On the other hand, there also seem to be inefficiencies due toinappropriate and underutilization of highly trained health workers by theprivate sector institutions as well as vertical health programs.As shown in table 4, there seems to be an increasing trend in the attrition ofphysicians from the public sector.Table 4 – Trends in the Proportion of Physicians within the Public sectorYear Total number of Number of physicians Attrition per yearregistered physicians working with MOH1997 1,634 1,483 151 (10.2%)1998 1,743 1,415 328 (23.2%)1999 1,617 1,283 334 (26.0%)2000 1,434 1,263 171 (13.5%)2001 1,424 1,366 58 (4.2%)2002 2,374 1,888 486 (20.4%)2003 2,663 2,032 631 (23.7%)2005 2,063 1,527 536 (26%)

74 Carlo Resti, Yohannes TadesseVery Poor Motivation due to low level of remunerationEven though public sector salaries weighted against GDP for physicians inthe Ethiopian are said to be relatively higher when compared to other sub-Saharan African countries 7 , their actual magnitude is very low. In addition tothe very high salary gradient between the public and private/NGO sectors locally,salary levels are excessively low for physicians and nurses who have somedegree of access to the international labor market.In terms of salary gradient, it is interesting to note the huge and demoralizinggaps in payment scales between government hired workers and those secondedby other agencies who, otherwise, are assigned on exactly the same taskwith exactly the same qualification and experience. Such payment gaps wouldeven be incredibly large when a dimension of citizenship difference is addedbetween the personnel involved.Very Poor Motivation due to non-conducive working conditionsIn addition to low levels of remuneration, lack of conducive working conditionsare the major reasons given by health workers, especially physicians, forbeing reluctant to work in public, particularly rural health institutions. Theseconditions include: availability of basic equipment, drugs and supplies, accessto resources for updating oneself, fair opportunities for continuing educationand professional freedom. The other major complaint among those workingout of the major urban centers is lack of provisions for housing as well as scarcityof suitable educational facilities for children and close family members.Other types of poor working conditions that may lead to brain drain include:infrequently supervised facilities and limited career structure for personnel.Health Worker Morale and Professional EnvironmentA recent survey and experimental study to assess the development of intrinsicmotivation on a sample of newly graduating physicians and nurses inEthiopia has shown the majority of student physician and nurses as being intrinsicallymotivated 8 . One of the questions asked in this survey was designed7 The World Bank. Ethiopia A Country Status Report on Health and Poverty (DraftReport). March 2005. Draft Report No.28963-ET.8 Barr A, Lindelow M, Garcia-Montavio J and Serneels P. Intrinsic motivation on the developmentfrontline: Do they exist? Do they endure? 2005. Economic & Social ResearchCouncil (ESRC) Global Poverty Research Group.

5. Human resources for health (HRH): a crucial element for achieving international MDGs. 75Very Poor Motivation due to non-conducive working conditionsIn addition to low levels of remuneration, lack of conducive working conditions are the major reasonsto given assess by health why workers, the students especially had physicians, chosen forto being pursue reluctant a career to work in public, the health particularly sector. ruralhealth institutions. These conditions include: availability of basic equipment, drugs and supplies, accessThe to resources frequencies for updating with oneself, which fairthey opportunities gave the for continuing five most education common and professional answer, freedom. someother The other answer, majoror complaint reported among no those special working reason out offor the their major urban career centers choice is lack are ofpresent-ed Other in Figure types of 2. poor As working shown conditions in the that figure, may lead desire to brain to help drain people, include: infrequently an indication supervised ofprovisionsfor housing as well as scarcity of suitable educational facilities for children and close family members.intrinsic facilities and motivation, limited careerwas structure a response for personnel. given by over 64% of the sample.Health Worker Morale and Professional EnvironmentA recent survey and experimental Figure 2 study - Reasons to assess for the Choosing development Professionintrinsic motivation on a sampleof newly graduating physicians and nurses (Barr inA Ethiopia et al., has 2005) shown the majority of student physician andnurses as being intrinsically motivated 8 . One of the questions asked in this survey was designed toassess why the students had chosen to pursue a career in the health sector. The frequencies with whichthey gave the five most common answer, some other answer, or reported no special reason for theircareer choice are presented in Figure 2. As shown in the figure, desire to help people, an indication ofintrinsic motivation, was a response given by over 64% of the sample.Figure 2 - Reasons for Choosing Profession(Barr A et al., 2005)100This particular study has also shown evidence that intrinsic motivations are50socially rather than individually determined and, therefore, may change asthe social contexts 0 of the individuals change and may be eroded by exposureto an environment To help in which peopleunproductive Tobehavior get job is endemic. This impliesthat even though For most goodphysicians payment and nurses Assigned graduate by government with high degree of intrinsicmotivation,Traditionintegrityof myand familycommitmentOther reasonto “serve people”, such altruisticbehaviors require good working conditions as well as conducive profes-No Special reasonsional environment to endure.This particular study has also shown evidence that intrinsic motivations are socially rather thanIn addition to good working conditions, social and professional environmentsmay beare eroded important by exposure in to sustaining an environment health in which workers’ unproductive intrinsic behavior motivation, is endemic. a fact Thisindividually determined and, therefore, may change as the social contexts of the individuals change andimplies that even though most physicians and nurses graduate with high degree of intrinsic motivation,that integrity signals and commitment the importance to “serve people”, of professionalizing such altruistic behaviors the require health good sector working environment.as wellOn as conducive the other professional hand, environment unless such to endure. intrinsic motivations are sustained andconditionsIn addition to good working conditions, social and professional environments are important inthe sustaining problems health in workers’ personnel intrinsicmanagement motivation, a fact are thatproperly signals the addressed, importance of they professionalizing can endangeradaptive and counterproductive behaviors.the health sector environment. On the other hand, unless such intrinsic motivations are sustained andthe problems in personnel management are properly addressed, they can endanger adaptive andA counterproductive World Bank behaviors. assessment of health worker performance in Ethiopia, basedA World Bank assessment of health worker performance in Ethiopia, based on data from focus groupondiscussions,data fromhas attemptedfocus groupto outlinediscussions,both the naturehasofattemptedperformance problems,to outlineas wellbothas thethepossiblenatureof performance problems, as well as the possible structural reasons forthese 8 Barr A, Lindelow M, Garcia-Montavio J and Serneels P. Intrinsic motivation on the developmentproblems as they relate to human resource policies 9 frontline: Do theyexist? Do they endure? 2005. Economic & Social Research Council (ESRC) Global Poverty. Research Among Group. the per-9 Lindelow M, Semeels P and Lemma T. The Performance of Health Workers in Ethiopia:Results from Qualitative Research. World Bank Policy Research Working Paper 3558,April 2005.

76 Carlo Resti, Yohannes Tadesseformance problems identified in this study were: absenteeism and shirking,salary augmenting practices (moonlighting) pilfering drugs and materials, informalhealth care provision, illicit charging, corruption malingering as wellas poor handling of patients. These problems are ascribed to causes that arerooted in the ongoing transition from a command-and-control health sector,to a more pluralistic system, and the failure of government policies to keeppace with the transition toward a mixed model of service delivery.Furthermore, weak accountability mechanisms and the erosion of professionalnorms in the health sector as well as the impact of HIV/AIDS are consideredto exacerbate these situations. Nevertheless, according to this particularstudy, there is still a relatively high work ethic among health workers inEthiopia, and the rate of absenteeism among physicians has been consideredto be low compared to those of other countries.Effects of disease conditionsThe current crisis in human resources situation in Ethiopia, as in other developingcountries, is an old problem exacerbated by fresh forces taking onnew forms. This is because the HIV/AIDS pandemic has added a “triplethreat” – generating huge work burdens, directly impacting on the lives ofhealth workers through personal or family illness, death, and stressing workerswho have become terminal care providers rather than healers.Therefore, the condition of HIV/AIDS has exacerbated the HRH crisisthrough various dimensions. First, it has increased the workload and skill demandson health workers. As health institutions are being overwhelmed byAIDS patients, massive expansion of work requires increased magnitude ofstaff as well as high burden on available workers. As has been reported elsewhere,in the current initiation and expansion of Global Fund supported activities(to combat HIV/AIDS, malaria and tuberculosis) the primary bottleneckshave been in terms of high level staff to undertake planning, managementas well as actual implementation 10 11 . The problem of availing highlytrained staff has emanated both from the scarcity of such workers in the10 Van Damme W, Kober K and Laga M. The real challenges for scaling up ART in sub-Saharan Africa. Editorial Note. AIDS (Editorial Note) 2006; 20:653 – 656.11 Banteyirga H, Kidanu A, Bennet S and Stillman K. The system-wide effect of the GlobalFund in Ethiopia: Baseline study report. 2005. Miz-Hassab Research Center, Partners forHealth Reform-plus and Abt. Associates Inc. Addis Ababa.

5. Human resources for health (HRH): a crucial element for achieving international MDGs. 77country as well as from fears within government for employing people withhigher salaries from GF funds. The reasons for such reluctance include: thatthese higher salaries might create high turnover and migration of workersfrom the public sector, and that the higher salaries set through the GF fundsmay not eventually be sustainable.HIV/AIDS also affect health workers who get ill and die of the disease.Health workers have also to cope with the psychosocial stress of offering palliativecare to increasing numbers of dying patients along with caring for theirown sick family and relatives. There is also the issue of fears of risk by healthworkers in caring for the sick in facilities where the basic equipment and suppliesfor such undertaking are usually lacking 12 .ConclusionsIn summary, there are many mutually connected and interrelated challengesfor typical low-income countries in sub-Saharan Africa or Central Asia foraddressing HRH related issues in the context of scaling-up priority interventionstowards the Millennium Development Goals.Essential elements of successful improvement of HRH problems consist inthe elaboration and implementation of strategies that fit into health sector reformsand the political and macroeconomic context. Efforts to improveHRH should consider available human and financial resources, be in linewith government administrative policies and should promote consultativepolicy-making processes and ownership at country level.Definitely the health-related Millennium Development Goals cannot bereached without significant improvements in human resources for health.The health sector in Ethiopia has so far formulated its strategy for achievingits health policy objectives. The sector program is now implementing the HS-DP III five year plan. According to this program, the focus in the short termin human resources development is to be on training and upgrading offrontline (HEWs), low level and mid-level health workers that will staffprimary health care facilities. In addition, training of high level professionalsis also to continue along coordination with needs of the health service anda realistic assessment of requirements for such skills and the real economiccontext of the country.12 Mebratu A. Emerging challenges of HIV/AIDS care to health institutions in AddisAbaba. MPH Thesis, School of Graduate Studies, Addis Ababa University 2000.

78 Carlo Resti, Yohannes TadesseThe realization of the above policy objectives can be witnessed from the emphasisgiven to expanding health center team training programs in the country.During the past eight years alone, these programs have been initiatedwithin about six public institutions of higher learning. In addition, the hugeinvestment being made in the “Accelerated Expansion of Primary HealthCare Coverage (2005 – 2009)” is also in line with these objectives. This proposalrequires the construction and equipping of 3,118 health centers and12,249 health posts, with related human resources scaling up costs.However, the country is still in need of a separate comprehensive HRD policywith detailed strategies in terms of implementation at various levels as avital and indispensable roadmap in addressing the HRH problems of thecountry.In view of all the problems related to human resources for health, the MOHrecently organized a new department for human resources and launched theNational HRH Observatory in April 2006 that will have among others themain task to develop a sound HRH strategy with national guidelines for theRegions.To support these important undertakings, donors must cooperate withGovernment to ensure that health workers have safe working conditions, adequatecompensation, the capacity to help their patients, and the support ofa sound management system. On the other hand, wealthy nations must stopactively recruiting health professionals from developing countries, except aspart of an agreement with those countries, which should allow for recruitmentto benefit both the source and destination countries.Donors should also provide the World Health Organization the support it requiresto vastly scale up its technical assistance in the area of human resourcesfor health by supporting a network of technical advisors, training institutions,sharing information on human resources to enable evidence-based policy-making,and building local human resource planning and managementcapacity.

5. Human resources for health (HRH): a crucial element for achieving international MDGs. 79References• Background paper on the status of Human Resources for Health in Ethiopia,FMOH, July 2006.• Banteyirga H, Kidanu A, Bennet S and Stillman K. The system-wide effect of theGlobal Fund in Ethiopia: Baseline study report. 2005. Miz-Hassab Research Center,Partners for Health Reform-plus and Abt. Associates Inc. Addis Ababa.• Barr A, Lindelow M, Garcia-Montavio J and Serneels P. Intrinsic motivation on thedevelopment frontline: Do they exist? Do they endure? 2005. Economic & SocialResearch Council (ESRC) Global Poverty Research Group.• Buchan J, Dovlo D, International Recruitment of Health Workers to the UK: AReport for DFID (2004).• Dovlo D, Using mid-level cadres as substitutes for internationally mobile healthprofessionals in Africa. A desk review. Human Resources for Health 2004, 2:7.• Hongoro C, Normand C, Health Workers: Building and Motivating the Workforce.Diseases Control Priorities in Developing Countries 1309-1332, DCP 2 nd edition,2006.• Joint Learning Initiative (JLI), Human Resources for Health: Overcoming the Crisis(2004), http://www.globalhealthtrust.org/Report.html.• Lindelow M, Semeels P and Lemma T. The Performance of Health Workers inEthiopia: Results from Qualitative Research. World Bank Policy Research WorkingPaper 3558, April 2005.• Mebratu A. Emerging challenges of HIV/AIDS care to health institutions in AddisAbaba. MPH Thesis, School of Graduate Studies, Addis Ababa University 2000.• Mengesha Y and Kebede Y. Brain Drain. In Berhane Y, Haile Mariam D, Kloos H. TheEpidemiology and Ecology of Health and Diseases in Ethiopia. SHAMA Books andEthiopian Public Health Association, Addis Ababa, Ethiopia (1 st edition 2006).• MOH & WHO. Progress Report on the 2005 Human Resource for HealthAssessment in Ethiopia. 2006. Human Resources Department, MOH, Addis Ababa.• MOH. Health and health related indicators. Various issues (1995 – 2006), Planningand Programming Department, Addis Ababa.• Monga V, Ndhlovu M: Midwives’ role in management of elective abortion and postabortioncare. Zambian country report. Paper at the conference “Expanding Access;Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective AbortionCare” South Africa 2–6 December 2001• Muula A. Is there any solution to the “Brain Drain” of health professionals andknowledge from Africa? Croat Med J 2005 46(1): 21 – 29.• Norad, Human Resources for Health Consultation, Oslo, 24-25 February 2005(http://www.Norad.no/)• STOP-TB, UNAIDS, Progress Report on the Global Response to HIV-AIDSEpidemic 2003,• UN Millennium Project, Investing in Development: A Practical Plan to Achieve theMillennium Development Goals, New York, 2005• Van Damme W, Kober K and Laga M. The real challenges for scaling up ART in sub-Saharan Africa. Editorial Note. AIDS (Editorial Note) 2006; 20:653 – 656.

80 Carlo Resti, Yohannes Tadesse• White SM, Thorpe RG, Maine D: Emergency obstetric surgery performed by nursesin Zaire. Lancet 1987, 2:612-613.• WHO, World Health Report 2005, Make Every Mother and Child Count, Geneva,2005.• WHO. The world health report 2006: Working together for health. 2006. WHO,Geneva.• World Bank, Improving Health, Nutrition and Population: Outcomes in SubSaharan Africa, Washington, 2004.• World Bank, World Development Report 2004, Making Services Work for the Poor,Washington, 2004;• World Bank. Ethiopia A Country Status Report on Health and Poverty (DraftReport). March 2005. Draft Report No.28963-ET.

6. Using indicators to measure the pharmaceutical sector in Ethiopia 816. USING INDICATORS TO MEASURETHE PHARMACEUTICAL SECTOR IN ETHIOPIAAndrea Gardellin, Abraham Gebre GiorgisHealth is a fundamental human right. Access to health care, which includes accessto essential medicines, is a prerequisite for realising that right. Essentialmedicines play a crucial role in many aspects of health care. If available, affordable,of good quality and properly used, medicines can offer a simple, cost-effectiveanswer to many health problems. In many countries medicine costs accountfor a large share of the total health budget. Despite the obvious medicaland economic importance of medicines there are still widespread problems withlack of access, poor quality, irrational use and waste. In many settings essentialmedicines are not used to their full potential.WHO. How to Develop and Implement a National Drug Policy; 2001.WHO Medicines Bookshelf 2004This article gives the results of the international assessment of indicators conductedbetween 2002 and 2004 (1), compared with various surveys and assessmentsdone in Ethiopia during the same period 2002-2003 (2, 3, 4).WHO pharmaceutical indicatorsThe Word Health Assembly (WHA) 54.11 Word Health Organization(WHO) medicines strategy acknowledged the four main objectives ofWHO’s medicines strategy, namely, to frame and implement policy; to ensureaccess; to ensure quality, safety and efficacy; and to promote rational useof medicines. To monitor the progress of efforts to improve the global medicinessituation, WHO has developed a system of indicators that measure importantaspects of a country’s pharmaceutical situation. Indicators measurethe existence and performance of key national pharmaceutical structures andprocesses and key outcomes of these structures and processes in the areas ofaccess, product quality and rational use.1. National Medicines PolicyIn 1975, the World Health Assembly in resolution WHA28.66 requestedWHO to develop means to assist Member States in formulating nationaldrug policies. Thus, WHO recommends that countries consider formulating,

82 Andrea Gardellin, Abraham Gebre Giorgisimplementing and monitoring a national medicines policy (NMP) as a “commitmentto a goal and a guide for action” to define a framework for settingand monitoring medium to long-term objectives in the pharmaceutical sector.The functions and strategies of each component of the policy should bebrought together in an implementation plan. Most countries, especially lowincomecountries, do have an NMP and implementation plan and most ofthe NMPs have been updated within the past 10 years. More countries hadan official NMP in 2003 than in 1999.1.1 Why is this important?The NMP should encompass:• ensuring equitable availability and affordability of essential medicines;• ensuring that all medicines are safe, efficacious and of high quality; and• promoting rational use of medicines by health care professionals and consumers.By attaining these objectives, countries can reduce morbidity and mortality,decrease the incidence of catastrophic illness that can increase impoverishment,and prevent large-scale losses to health and economic systems. It is recommended∞ promoting that an rational NMP implementation use of medicines by plan health will carecover professionals a period and of 3–5consumers.years. NMPs require regular review to evaluate whether objectives have beenachieved. By attaining Standardized these objectives, indicators countries can of reduce the morbidity pharmaceutical and mortality, situation decrease allowthe incidence of catastrophic illness that can increase impoverishment, and preventcountries to monitor and evaluate the impact of implementing an NMP.large-scale losses to health and economic systems. It is recommended that an NMPimplementation plan will cover a period of 3–5 years. NMPs require regular review toevaluate whether objectives have been achieved. Standardized indicators of the1.2 What pharmaceutical is the current situation situation?allow countries to monitor and evaluate the impact ofimplementing an NMP.Figure 1 illustrates which countries have either an official or a draft NMP,1.2 What is the current situation?and whether policy has been updated within the past 10 years.Figure 1 illustrates which countries have either an official or a draft NMP, andwhether the policy has been updated within the past 10 years.Figure 1. Global status of national medicines policies (NMPs)Figure 1. Global status of national medicines policies (NMPs)Table 1. Status of national medicines policies (NMPs) in 2003

6. Using indicators to measure the pharmaceutical sector in Ethiopia 83Table 1. Status of national medicines policies (NMPs) in 2003Table 1. Status of national medicines policies (NMPs) in 2003∞∞∞The majority of countries have an NMP and implementation plan integrated with the health• The majority of countries have an NMP and implementation plan integratedwithplan.Low-income countriesthe health plan.particularly well on these indicators.The • majority Low-income of NMPs countries haveperform been updated particularly within the well past on these 10 years. indicators.• The majority of NMPs have been updated within the past 10 years.1.3 In EthiopiaThe pharmaceutical sector in Ethiopia is guided by a National Drug Policy(NDP), which was developed in 1993 G.C in line with the National HealthPolicy (1). There is no specific NDP implementation plan that set responsibilities,budget and timeline although some elements of the NDP are incorporatedin the Health Sector Development Programme (HSDP) of the country.The sector is regulated by the “Drug Administration and Control ProclamationNo. 176/199, which was promulgated on 29 June 1999 G.C. This proclamationhas superceded the former regulation called “Pharmacy Regulation No.288/ 1964”, which formed the legal basis for official establishment of drugregulation in Ethiopia. “The Pharmacy and Laboratory Department” was thefirst drug regulatory body established under the Ministry of Health by thePharmacy Regulation No. 288/ 1964. The department performed drug regulatoryactivities as well as the registration of pharmacy personnel. Followingthe passage of proclamation No 176/ 1999, the pharmacy department wastransformed to an independent drug control authority named “DrugAdministration and control Authority (DACA)” which became operational onSeptember 2001 G.C.

84 Andrea Gardellin, Abraham Gebre Giorgis2. Legislation and Regulation2.1 Why is this important?A legislative framework is required to implement and enforce policies regulatingthe pharmaceutical sector. Laws and regulations create a legal basis forthe control of activities in the public and private pharmaceutical sectors, includingadministrative measures and sanctions in response to violations.Areas covered include the roles and responsibilities of the drug regulatory authority;market approval and registration of medicines; regulation of premiseswhere medicines can be handled; and the qualifications, rights, and responsibilitiesof drug manufacturers, importers, exporters, distributors, prescribesand dispensers. Other key regulatory issues include implementationof policies on generic products to ensure the availability and use of lowerpricedmedicines, and monitoring of adverse drug reactions (ADRs) to productson the market. The regulatory authority must ensure that only safe, effective,high quality medicines are produced, marketed, prescribed and dispensedto protect and promote public health.2.2 What is the current situation?Table 2. Presence of key pharmaceutical sector legislation∞∞The majority of countries have established a drug regulatory agency.Countries • The majority at all income of countries levelshave report established the presence a drug of regulatory extensive agency. legal and regulatoryframeworks • Countries covering at all all income aspects levels of the report pharmaceutical the presence sector. of extensive legal and regulatoryframeworks covering all aspects of the pharmaceutical sector.Table 3. Legislation and regulation on registration of medicines

∞ The majority of countries have established a drug regulatory agency.∞ Countries at all income levels report the presence of extensive legal and regulatoryframeworks covering all aspects of the pharmaceutical sector.6. Using indicators to measure the pharmaceutical sector in Ethiopia 85Table 3. Legislation and regulation on registration of medicinesTable 3. Legislation and regulation on registration of medicines∞ • The The median median number number of drugs of drugs marketed marketed increases increases with with country country income income level. level.∞ • The The requirement requirement for for marketing marketing authorization authorization was was supported supported by by written written guidelines forregistrationguidelinesinforoverregistrationthree quartersin overof countries.three quarters of countries.∞ Low-income countries were more likely to require use of the WHO Certification Scheme on• Low-income countries were more likely to require use of the WHOthe Quality of Pharmaceutical Products Moving in International Commerce.Certification Scheme on the Quality of Pharmaceutical Products Moving in∞ The availability of information about drug registration on the Internet increasesInternational Commerce.dramatically with country income level.• The availability of information about drug registration on the Internet increases4. Site dramatically inspection with of country establishments income level. as requirement of Table licensingTable 4. Site inspection of establishments as requirement of licensing∞∞Most • Most countries countries inspect inspect importers, importers, manufacturers, manufacturers, distributors distributors and pharmacies. and pharmacies.is somewhat less frequent in low-income countries.Site inspection• Site inspection is somewhat less frequent in low-income countries.Table 5. Monitoring of adverse drug reactions (ADRs)

∞∞Most countries inspect importers, manufacturers, distributors and pharmacies.Site inspection is somewhat less frequent in low-income countries.86 Andrea Gardellin, Abraham Gebre GiorgisTable 5. Monitoring of adverse drug reactions (ADRs)Table 5. Monitoring of adverse drug reactions (ADRs)∞∞Most countries inspect importers, manufacturers, distributors and pharmacies.Site inspection is somewhat less frequent in low-income countries.Table 5. Monitoring of adverse drug reactions (ADRs)∞Few • low-income Few low-income countries countries monitor monitor ADRs, ADRs, and the and median the median number number of ADR of ADR reports reportsin thesecountries isinverytheselow.countries is very low.2.3 In EthiopiaRegarding2.3 IntheEthiopiapresence of the following legislation and regulation: pharmaceuticalsector legislation, Regarding the legislation presence and of the regulation following on legislation registration and medicines, regulation: site pharmaceuticalinspection∞ Few low-income countries monitor ADRs, and the median number of ADR reports in theseof establishments countriessector as is requirement legislation,very low.legislation of licensing, monitoring regulation of on adverse registration drug medicines,and legislation site inspection prescribing of establishments and substitution as requirement of generic of licensing, medicines monitor-in publicreactions(ADRs)and private ing of sectors adverse in drug Ethiopia, reactions the(ADRs) drug authority and legislation (Drug Administration prescribing and substitutionControlAuthority 2.3 – InDACA) Ethiopiaof generic has elaborated medicines standard, in public directives and private and sectors guidelines in Ethiopia, for most the of theactivitiesRegardingdrug related authority withthe presence(Drug the sector.of the following legislation and regulation: pharmaceuticalsector legislation, legislation Administration and regulation and on registration Control Authority medicines, – site DACA) inspection hasThe following elaborated documents standard, are directives available and also guidelines in the web for site most (www.daca.gov.et)of establishments as requirement of licensing, monitoring of of adverse the activities drug reactions related(ADRs) with the and sector. legislation prescribing and substitution of generic medicines in publicof the DACA: Policies, Legislation Regulation, Standards, Directives andguidelines, and private List ofsectors drugsin and Ethiopia, formularies, the drug Treatment authority (Drug guidelines, Administration other and documents Control andThe following documents are available also in the web site (www.daca.gov.et)Bulletins Authority – DACA) has elaborated standard, directives and guidelines for most of theof activities the DACA: related Policies, with the Legislation sector. and Regulation, Standards, Directives andguidelines, The Table following 6. Some List documents of indicators drugs are and available of formularies, thealso pharmaceutical in the Treatment web site (www.daca.gov.et)guidelines, sector in Ethiopia other documentsof theand DACA: Bulletins Policies, Legislation and Regulation, Standards, Directives andguidelines, List of drugs and formularies, Treatment guidelines, other documents andIndicator descriptionResultBulletinsEstimated total value of drug imports (CIF), 2003/20041.1 billion ETBTotal number of drug Importers and/or wholesalers,126Table2003/20046. 6. Some indicators of the pharmaceutical sectorin in EthiopiaTotal number of drug Manufacturing firms in the13:Indicator descriptionResultCountry, 2003/2004Estimated total value of drug imports (CIF), 2003/20041.1 billion ETBTotal number of drug Importers and/or wholesalers, 9 Drug Manufacturers, 126 1 Syringes2003/2004Manufacture, 2 Bandage and GauzeTotal number of drug Manufacturing firms in the manufactures, 1Hard 13: Gelatine capsule shellCountry, 2003/2004manufacture9 Drug Manufacturers, 1 SyringesManufacture, 2 Bandage and Gauzemanufactures, 1Hard Gelatine capsule shellmanufacture

6. Using indicators to measure the pharmaceutical sector in Ethiopia 87Total Number of Drug Retail Outlets (Pharmacies, Drug3238Shops and Rural Drug Vendors), 2003/2004Number of Registered Drug Products, 2003/20044000 (400 chemical entities)No of drug product tested by the quality control376laboratory during the past Fiscal Year, 2004/2005Percentage of drugs/batches that failed quality controltests, out of the total number of drugs/batches tested pastFiscal Year, 2004/2005 11.2%Adverse drug reactions (ADRs) cases reported last26Fiscal year 2003/2004Ethiopia does not export medicines and the importation market share is 80-85% of theEthiopiatotal. Onlydoes15-20%notofexportthe marketmedicinesneeds isandlocallythe importationproduced. Themarketfactoriessharethemselvesis 80-85% do not of the meettotal. Good Only Manufactory 15-20% Practice of the market (GMP) needs requirements. is locally Theproduced. computerized Thefactories registration themselves system of medicines do not meet is available Good butManufactory not fully utilized. Practice (GMP) requirements.The authorityThe has acomputerized web site even ifregistrationnot well updated.system of medicines is availablebut not fully utilized. 3. Quality Control of PharmaceuticalsThe authority has a web site even if not well updated.Why is this important?Quality control is important to ensure that patients receive medicines that are safe andeffective. Quality control extends beyond testing whether medicinal products contain3. Quality Control of Pharmaceuticalsthe right ingredients in the correct amount, to ensuring that they are properly storedand have not passed the expiry date. The latter measure is intended to ensure that, atthe final distribution point, patients are getting high quality and efficacious drugs.Why is this important?Prevailing conditions of high temperature and high humidity; common storageQualityproblems,controlsuch asis importantstorage ontotheensurefloor; lackthat patientsof systematicreceivearrangementmedicinesofthatstock;aresafe presence and effective. of dust and Quality pests; inadequate control extends protection beyond from testing direct sunlight; whether and medicinal lack ofproducts provision contain of temperature the right monitoring ingredients chartsin and the facilities correct to amount, monitor room to ensuring temperature thattheycan leadare properlyto degradationstoredof drugs.and have not passed the expiry date. The latter measure3.2 is What intended is the current to ensure situation? that, at the final distribution point, patients are gettinghigh quality and efficacious drugs. Prevailing conditions of high temperatureand high Table humidity; 7. Productcommon samples collected storage for problems, regulatory such purposes as storage on thefloor; lack of systematic arrangement of stock; presence of dust and pests; inadequateprotection from direct sunlight; and lack of provision of temperaturemonitoring charts and facilities to monitor room temperature can leadto degradation of drugs.∞Low-income countries tend to collect fewer samples and of those that were tested, theyreport higher rates of products failing testing.Table 8. Presence of expired medicines in health facilities and warehouses

presence of dust and pests; inadequate protection from direct sunlight; and lack ofprovision of temperature monitoring charts and facilities to monitor room temperaturecan lead to degradation of drugs.88 Andrea Gardellin, Abraham Gebre Giorgis3.2 What is the current situation?3.2 What is the current situation?Table 7. Product samples collected for regulatory purposesTable 7. Product samples collected for regulatory purposes∞• Low-income countries tend to collect fewer samples and of those that wereLow-income tested, they countries report tend higher torates collect of products fewer samples failing and testing. of those that were tested, theyreport higher rates of products failing testing.Table 8. Presence of expired medicines in health facilities and warehousesTable 8. Presence of expired medicines in health facilities and warehouses∞ None of the survey teams that conducted Level II surveys of health facilities found expiredproducts present at health facilities or warehouses among the 20 key medicines selected.• None of the survey teams that conducted Level II surveys of health facilitiesFigure ∞ None 2. found of Storage theexpired survey and teams products handling that present conducted conditions at health Levelfacilities in II surveys public or of health warehouses facilities among found and the expiredproducts 20 key present medicines at health selected. facilities warehouses or among the 20 key medicines selected.Figure 2. 2. Storage and handling conditions conditions in public inhealth public facilities health and facilities warehouses andwarehouses• Stock-keeping and handling of medicines in pharmacy stock areas in public∞ Stock-keeping health facilities and handling were of generally medicines satisfactory. in pharmacy stock areas in public health facilitieswere• generally Storage satisfactory. conditions in warehouses tended to be better than in pharmacy stock∞ Storageareas conditions in public in health warehouses facilities. tended to be better than in pharmacy stock areas inpublic health facilities.Figure ∞ Stock-keeping 3. Storage and handling of medicines conditions in pharmacy in publicstock pharmacies areas in public by country health facilitieswere generally satisfactory.∞ Storage conditions in warehouses tended to be better than in pharmacy stock areas inpublic health facilities.

∞ Stock-keeping and handling of medicines in pharmacy stock areas in public health facilitieswere generally satisfactory.6. Using∞ Storageindicatorsconditionsto measureinthewarehousespharmaceuticaltendedsectorto beinbetterEthiopiathan in pharmacy stock areas in89public health facilities.Figure 3. Storage and handling conditions in public pharmacies by countryFigure 3. Storage and handling conditions in public pharmacies by countryFigure 4. Storage and handling conditions in public warehouses by countryFigure 4. Storage and handling conditions in public warehouses by country∞ Storage and handling scores were consistently high in most countries.• ∞ Storage Six of eleven and handling low-income scores countries were consistently and eight of high ninein middle-income most countries. countries had• Six warehouse of eleven storage low-income and handling countries scoresand over eight 80% of of the nine maximum. middle-income countrieshad warehouse storage and handling scores over 80% of the maximum.3.3 In EthiopiaCounterfeit and sub-standard medicines exist in the market in Ethiopia and there is a“black-market” in operation. The drug authority (DACA) has approached this taskwith 3.3 In strategic Ethiopia development plans for laboratory and inspectorate development.DACA Counterfeit in Ethiopia and sub-standard have one Drug medicines Quality exist Control in the and market Toxicology in Ethiopia Laboratory andDepartment. there is a “black-market” The main function in operation. of the department The drug is to authority ensure quality, (DACA) safety has and approachedthis task with strategic development plans for laboratory and in-efficacy of drugs, medical supplies, pesticides, cosmetics and their raw and packagingmaterials through laboratory based quality testing before and after marketing.spectorate development.Tests DACA are performed in Ethiopia according have to one international Drug Quality standard officially Control accepted and Toxicology by DACA:BP, Laboratory USP, IP and Department. other in-house The validated main function methods of of analysis. the department is to ensureThe quality, major safety responsibilities and efficacy of theof department drugs, medical are: supplies, pesticides, cosmeticsand their ∞ raw Drug and quality packaging analysis: physicochemical materials through drug quality laboratory analysis and based microbiological quality testingbefore and after marketing.drugquality testing∞ Cosmetic analyses, condom quality testing, vaccine quality testingTests are ∞ performed Pesticide: quality according analysis, residue to international analyses standard officially accepted by∞ Toxicological tests: pesticide exposure tests, acute toxicological analysis, toxicologicalDACA: BP,screeningUSP,test,IP andveterinaryotherdrugin-house residue analysesvalidated methods of analysis.The Laboratory has four divisions namely:∞ Physicochemical laboratory division∞ Toxicology laboratory division∞ Pharmaceutical Microbiology laboratory division

90 Andrea Gardellin, Abraham Gebre GiorgisThe major responsibilities of the department are:• Drug quality analysis: physicochemical drug quality analysis and microbiologicaldrug quality testing• Cosmetic analyses, condom quality testing, vaccine quality testing• Pesticide: quality analysis, residue analyses• Toxicological tests: pesticide exposure tests, acute toxicological analysis, toxicologicalscreening test, veterinary drug residue analysesThe Laboratory has four divisions namely:• Physicochemical laboratory division• Toxicology laboratory division• Pharmaceutical Microbiology laboratory division• Pesticide laboratory divisionThe Laboratory is staffed with: Pharmacists, Veterinarians, Chemists,Biologists, Agro chemists, Pharmacy Technicians and Administrative Staff.In the 1998 EFY (2004/2005 G.C.), the department has tested 376 newdrugs sample with a failure rate of 11.2% of the sample tested. The laboratoryis supported by different international donors: WHO, USAID, GlobalFund and Italian Cooperation.Regarding the expired drugs and the storage and handling conditions in thepublic health facilities in Ethiopia, a recent assessment (2) conducted in thecountry by the WHO and the Federal Ministry of Health showed the followingresults:Table 9. Summary of national indicators on qualityIndicatorsPHCFsMeanMedianPercentage of expired drugs 8.24 0Storage condition rate (on a scale of 0-11 scores) 5.98 64. Access to essential medicines4. Access to essential medicines4.1 Why is this important?Essential medicines save lives, reduce suffering, and improve the functioning and4.1 Why is this important?well-being of people who have access to them. On the population level, access toEssential affordablemedicines and appropriately save lives, used reduce high-quality suffering, medicines and improve boosts productivity the functioning andand economic well-being output. of people who have access to them. On the population level,access Many factors affordable determineand access appropriately to essential medicines. used high-quality Access can vary medicines between boosts urbanand rural areas because of problems with health system development. Pharmacies,productivity and economic output.medicines distributors, health facilities, and public and private health providers areusually concentrated in cities and regional centres.The retail prices of essential drugs can vary widely. Reliance on distribution ofmedicines in the private sector often means that essential medicines are too expensivefor poor patients to afford.

Essential medicines save lives, reduce suffering, and improve the functioning andwell-being of people who have access to them. On the population level, access toaffordable and appropriately used high-quality medicines boosts productivity andeconomic 6. Using output. indicators to measure the pharmaceutical sector in Ethiopia 91Many factors determine access to essential medicines. Access can vary between urbanand ruralManyareasfactorsbecausedetermineof problemsaccess towithessentialhealthmedicines.system development.Access can varyPharmacies,betweenurban and rural areas because of problems with health system develop-medicines distributors, health facilities, and public and private health providers areusually concentrated in cities and regional centres.The ment. retail prices Pharmacies, of essential medicines drugs distributors, can vary health widely. facilities, Reliance and on public distribution and ofmedicines private in health the private providers sector are often usually means concentrated that essential in cities medicines and regional are too centres.patients to afford.expensivefor poorThe retail prices of essential drugs can vary widely. Reliance on distribution4.2 What of medicines is the current in the private situation? sector often means that essential medicines are tooexpensive for poor patients to afford.4.2 What is the current situation?Table 10: Estimated percentage of population with access to essential medicinesTable 10: Estimated by WHO percentage region of population and country with income access to level essential medicinesby WHO region and country income level∞• 72% of of countrieswith < 50% 50% access accessare arein inthe thelow-income low-incomecategory, category, and andoverover half arehalf in Africa. are in Africa.∞• Eight out of of 10 10 countries with with very very high high access access are inare Europe in Europe and theand Americas. theAmericas.4.3 In EthiopiaIn Ethiopia the accessibility of essential drugs is showed in the following tablewhich is part of the assessment made by WHO and FMoH in 2003 as mentionedabove (2).

IndicatorsPublic Health Care Facilities4.3 In EthiopiaIn Ethiopia the accessibility of essential drugs is showed Mean in the following tableMedianwhichPercentage 92 Andrea Gardellin, Abraham Gebre Giorgisis part availability of the assessment made by WHO and FMoH in 69.83 2003 as mentioned above (2). 75Affordability (adult) 135% 141Affordability (children) TableTable11.11.SummarySummaryofofNationalNational IndicatorsIndicators 67.69%ononaccessaccess 71.5Average stock out duration (days) 99.22 91Percentage of prescribing Indicators drugs dispensed Public 85.48Health Care Facilities 94MeanMedianPercentage availability 69.83 75Affordability (adult) 135% 1414.3.1 Availability of essential drugsThe table Affordability 11 above (children) shows that the national average 67.69% availability of essential 71.5 drugs wasAverage stock out duration (days) 99.22 9170% in PHCFs. The availability in PHCFs is lower than the ideal value (100%) and itPercentage of prescribing drugs dispensed 85.48 94is also lower than the private sector (Figure 5) with significant mean variation(P

Comparison of affordability (both for adult and child) between the public and theprivate sectors (Figure 8) in Ethiopia shows that the treatment costs are moreaffordable in the public sector then the private sector.6. Using indicators to measure the pharmaceutical sector in Ethiopia 93Figure 6. Proportion of prescribed medicines dispensed in public facilities bycountryFigure 6. Proportion of prescribed medicines dispensed in public facilities by countryIn the above study (2) the three levels of health care facilities were also compared(Figure 7), and the figures were 82.9%, 81.3% and 86.7% in hospitals, health centresand health stations, respectively.In In the the above above study study (2) (2) the the three three levels levels of health of health care care facilities facilities were were also compared also compared7), (Figure and the 7), figures and the were figures 82.9%, were 81.3% 82.9%, and 86.7% 81.3% in and hospitals, 86.7% health in hospitals, centres(Figureand health centres stations, and respectively. health stations, respectively.Figure 7. Extent of dispensing of prescribed drugs by level of PHCFsFigure 7. Extent of dispensing of prescribed drugs by level of PHCFsFigure 7. Extent of dispensing of prescribed drugs by level of PHCFs4.3.4 4.3.4 Affordability Affordability of essential of essential drugs drugsThe Table 11 above shows that the national average for affordability of treatmentcost was 135% for adult and 67.7% for children. Formally the afford-The Table 11 above shows that the national average for affordability of treatment costwas 4.3.4 135% Affordability for adult and of essential 67.7% for drugs children. Formally the affordability is expressed as“the ratio ability of is the expressed cost treating as “the ratio moderate of the cost pneumonia treating moderate to the lowest pneumonia dailyto salary the ofunskilled The lowest Table government daily 11 above salary shows workers”. of unskilled that the Therefore government national average more workers”. high for affordability Therefore is the percentage, of more treatment high minor cost is theis theaffordability. was percentage, 135% for adult minor andis 67.7% the affordability. for children. Formally the affordability is expressed as“the ratio of the cost treating moderate pneumonia to the lowest daily salary ofunskilled government workers”. Therefore more high is the percentage, minor is theFigure 8.affordability.Figure Affordability 8. of of essential drugs in inpublic public and and private private sectors sectorsFigure 8. Affordability of essential drugs in public and private sectors

94 Andrea Gardellin, Abraham Gebre GiorgisComparison of affordability (both for adult and child) between the public and theprivate sectors (Figure 8) in Ethiopia shows that the treatment costs are moreaffordable Comparison in the public of affordability sector then (both the private for adult sector. and child) between the publicand the private sectors (Figure 8) in Ethiopia shows that the treatment costsThe same are more situation affordable is found in in the others public developing sector then countries. the private sector.The same situation is found in others developing countries.Figure 9. Affordability of pneumonia treatment for children and adultsFigure 9. Affordability of pneumonia treatment for children and adults5. Rational use of medicines5. Rational use of medicines5.1 Why 5.1 isWhy this important? is this important?Rational Rational use ofuse medicines of medicines means means that that “patients “patients receive receive medications appropriate appropriateto their clinical needs, in doses that meet their own individual require-totheir clinical needs, in doses that meet their own individual requirements, for anadequate period of time, and at the lowest cost to them and their community”.Overuse, ments, under for use an and adequate misuse period of medicines of time, and mayat lead the to lowest unnecessary cost to them suffering and anddeath, their and waste community”. of scarceOveruse, resources. under use and misuse of medicines may lead tounnecessary suffering and death, and waste of scarce resources.Many Many factors factors influence influence use use of medicines, of and and countries need to implementvar-ious strategies to improve rational use. Some policies, strategies and interven-variousstrategies to improve rational use. Some policies, strategies and interventions found tobe of value include: creating a mandated multidisciplinary national body to coordinatepolicies tions on found medicine to be of use; value standard include: treatment creating a mandated guidelines multidisciplinary (STGs) for common nationalusing body essential to coordinate medicines policies lists on medicine (EMLs) to use; guide standard procurement treatment and guide-training;conditions;establishing lines (STGs) drug and for common therapeutics conditions; committees using to essential coordinate medicines medicines lists (EMLs) management toin hospitals; guide procurement implementing and problem-based training; establishing pharmacotherapy drug and therapeutics training in undergraduatecommitteesto coordinate medicines management in hospitals; implementing prob-curricula; mandating continuing in-service medical education as a licensurerequirement; establishing effective supervision in health systems; using audit andfeedback lem-based to inform pharmacotherapy clinicians training and facilities in undergraduate about their curricula; practice; mandating developingindependent continuing sources in-service of information medical education about medicines as a licensure for requirement; providers and establishingeffective perversesupervision financial in incentives health systems; to overuse using audit medicines; and feedback establishing to inform andconsumers;avoidingclinicians and facilities about their practice; developing independent sources ofinformation about medicines for providers and consumers; avoiding perversefinancial incentives to overuse medicines; establishing and enforcing a soundregulatory framework; and guaranteeing sufficient government expenditure toensure availability of medicines and retain well-trained staff.

6. Using indicators to measure the pharmaceutical sector in Ethiopia 95Essential medicines lists, treatment guidelines, formularies5.2 Why is this important?The essential medicines concept is the basis for rational use of medicines.Ideally, countries develop and routinely update EMLs and drug formulariesthat meet the needs of their population according to a number of criteria, includingdisease patterns, patient characteristics, treatment recommendationsformulated in STGs, and level of care provided. Using an EML makes managementof medicines easier in all respects: procurement, storage and distributionare easier with fewer items, and prescribing and dispensing are morestraightforward for health professionals if they have to know about fewermedicines. A national EML should be based upon national STGs.Together an EML and STGs help to ensure rational drug use. STGs shouldbe developed for each level of care, based on prevalent clinical conditions andthe skills of prescribers practicing at that level. The STGs consist of systematicallydeveloped statements to help prescribers make decisions about appropriatetreatments for specific clinical conditions, providing a benchmark forsatisfactory diagnosis and treatment. Adherence to the recommendations inSTGs should be reinforced by prescription audit and feedback.A formulary can be an important source of evidence-based information aboutmedicines but it is important that it is consistent with STGs and the EML ifall three strategies are to achieve the maximum overall effect.5.3 What is the current situation?Figure 10. Countries withessential medicines lists(EMLs) updated within lastfive years

96 Andrea Gardellin, Abraham Gebre GiorgisTable 12. Status of essential medicines lists (EMLs), standard treatment guidelines(STGs) and national medicines formularies• Almost all low- and middle-income countries have an EML, and most limit∞ Almost all low- and middle-income countries have an EML, and most limit procurement tomedicinesprocurementon thetolist.medicines on the list.∞ The • The number number of of medicines medicines included included on on EMLs tends to toincrease increasewith withincreasingincreasing countryincome. country income.∞ Only • Only a few a few countries countries reported reported that that public public or private or private sector sector insurance reimbursement reimbursementto the EML. was linked to the EML.waslinked∞ Standard • Standard treatment treatment guidelines are are available for for primary health carein inoverover 70% ofcountries. 70% of countries.∞ National • National formularies formularies exist exist in over in over two thirds two thirds of countries, of countries, and over and half over ofhalf low-ofand middleincomelow- countries and middle-income limit the formulary countries to limit medicines the formulary on the EML. to medicines on theEML.Key policies and regulations to promote rational useKey policies and regulations to promote rational use5.4 Why is this important?The role of a drug and therapeutics committee (DTC) is to ensure the safe and5.4 Why is this important?effective use of medicines in a health facility or the area under its jurisdiction. TheDTCThe must role have of a clear drug objectives, and therapeutics a firm mandate, committee the (DTC) support is to ofensure senior the hospital safe staff,transparency, and effective wide use representation, of medicines in technical a health competence, facility or the a multidisciplinary area under its jurisdiction.The resources DTC must to implement have clear its objectives, decisions. a firm mandate, the supportapproachand sufficient ofOver-the-counter (OTC) sale of antibiotics is a concern worldwide. This can be due tolack of enforcement of regulations or lack of information on the part of consumersabout the potential negative impacts of antibiotic misuse. Irrational use of antibiotics

6. Using indicators to measure the pharmaceutical sector in Ethiopia 97senior hospital staff, transparency, wide representation, technical competence,a multidisciplinary approach and sufficient resources to implement itsdecisions.Over-the-counter (OTC) sale of antibiotics is a concern worldwide. This canbe due to lack of enforcement of regulations or lack of information on thepart of consumers about the potential negative impacts of antibiotic misuse.Irrational use of antibiotics contributes to increased antimicrobial resistance,rendering essential antibiotics ineffective and requiring the use of newer,more expensive antibiotics for treating bacterial illnesses. The result of unnecessaryand ineffective use of antibiotics is an increase in avoidable morbidityand mortality.Given the known impact of advertising and promotion of medicines on bothprescribing Given the known behaviour impact and of patient advertising demand, promotion it is essential of medicines to regulate on both andmonitor prescribing medicines behaviourpromotion and patientto demand, ensure itthat is essential it remains to regulate ethical. and All promotionalmedicines claims promotion should to be ensure reliable, thataccurate, it remainstruthful, ethical. All informative, promotionalbalanced, claims should up-monitorbe reliable, accurate, truthful, informative, balanced, up-to-date, and capable ofto-date, substantiation and capable and in good of substantiation taste. and in good taste.5.5 What is is the the current current situation? situation?Table 13. National policies concerning drug and therapeutics committees (DTCs)Table 13. National policies concerning drug and therapeutics committees (DTCs)and antimicrobial resistance (AMR)and antimicrobial resistance (AMR)• ∞Nearly two thirds of of countries report report that DTCs that DTCs are a mandated are a mandated element inelement their national intheir medicines national policy. medicines policy.∞ High-income countries were much more likely to have a national AMR strategy, a national• High-income task force to countries implement were the strategy much more and alikely national to have reference a national laboratory AMR tostrat-egy, surveillance. a national task force to implement the strategy and a national referenceconductlaboratory to conduct surveillance.Table 14. Establishment of drug and therapeutics committees

∞ Nearly two thirds of countries report that DTCs are a mandated element in their nationalmedicines policy.∞ High-income countries were much more likely to have a national AMR strategy, a nationaltask force to implement the strategy and a national reference laboratory to conduct98 surveillance.Andrea Gardellin, Abraham Gebre GiorgisTableTable 14.14.EstablishmentEstablishmentofofdrugdrugandandtherapeuticstherapeuticscommitteescommitteesEducation and information about rational useEducation and information about rational use5.6 Why is this important?Rational use of medicines depends on the knowledge, attitudes and behaviours of5.6 prescribers Why is this and important?patients. Training in rational pharmacotherapy, linked to STGs andRational EMLs, can use help of medicines establish good depends prescribing on the habits knowledge, and should attitudes be part and of behavioursthe basiccurriculaof prescribersof medical,andnursingpatients.and pharmacyTrainingstudents.in rationalIn-servicepharmacotherapy,education allowshealth workers to keep up to date with changes in pharmacotherapy, to becomelinked familiar to with STGs policies, and EMLs, to sharecan experiences help establish and learn good fromprescribing discussion with habits theirandpeers.should In some be part countries, of the continuing basic curricula education of medical, is a licensure nursing requirement and pharmacy for students.professionals. In-service education allows health workers to keep up to date withhealthchanges in pharmacotherapy, to become familiar with policies, to share experiencesand learn from discussion with their peers. In some countries, continuingeducation is a licensure requirement for health professionals.Patient demand and popular media are important drivers of medicines use.Without sufficient and accurate knowledge about the risks and benefits of usingmedicines, consumers can have unrealistic expectations. Countriesshould consider a range of strategies to better inform consumers about appropriateuse of medicines.Frequently, advertising by pharmaceutical companies is the only source ofeasily available information on medicines. Unbiased consumer informationon use of medicines is much needed in the form of public education campaignsor through independent information centres. Targeted public educationshould take into account the cultural beliefs and social factors that influenceuse of medicines.Health facilities where medicines are dispensed should also provide adequateinformation through verbal information and adequate labelling. Both prescriptionand non-prescription medicines should have labels that are accurate,legible and easily understood.

independent information centres. Targeted public education should take into accountHealth the cultural facilities beliefswhere and social medicines factors that are influence dispensed use should of medicines. also provide adequateinformation through verbal information and adequate labelling. Both prescription and6. non-prescription Health Using indicators facilitiesto medicines where measure the medicines should pharmaceutical have are labels dispensed sector in that Ethiopia are should accurate, also legible provideand adequate easily 99understood. information through verbal information and adequate labelling. Both prescription andnon-prescription medicines should have labels that are accurate, legible and easily5.7 understood. What is is the the current current situation? situation?5.7 What Tableis 15. theObligatory current situation? continuing education on medicines for health careTable 15. Obligatory continuing educationproviderson medicines for health care providersTable 15. Obligatory continuing education on medicines for health careproviders• ∞The likelihood of requiring mandatory continuing education for health for health professionals professionalsincreases with increases countrywith income. country income.∞ The likelihood of requiring mandatory continuing education for health professionalsTable increases 16. Public with country education income. campaigns on rational medicines use topicsTable 16. Public education campaigns on rational medicines use topicsTable 16. Public education campaigns on rational medicines use topics∞ The likelihood of public education about antibiotic use and misuse increases with countryincome level.• ∞Injection The likelihooduse isofmore publicoften educationthe focus aboutofabout antibioticpublic educationantibiotic use and use misusein lowandincreasesand middle-incomemisuse increases with countrycountries.with income country level. income level.∞ Injection use is more often the focus of public education in low- and middle-income• Injection use is more often the focus of public education in low- and middleincomecountries.countries. Figure 12. Prescribing of antibiotics and injectionsFigure 12. Prescribing of antibiotics and injectionsFigure 12. Prescribing of antibiotics and injections∞• The percentage of of patients prescribed prescribed antibiotics antibiotics is high in is all high countries. in all countries.∞• Prescribing of of injections is still is still very high very in high low-income low-income countries. countries.Figure 13. Medicines labelling and patient knowledge about use

∞ The percentage of patients prescribed antibiotics is high in all countries.∞ Prescribing ∞ The percentage of injections of patients is still prescribed very highantibiotics in low-income is high incountries.all countries.∞ Prescribing of injections is still very high in low-income countries.100 Andrea Gardellin, Abraham Gebre GiorgisFigure 13. Medicines labelling and patient knowledge about useFigure Figure 13. 13. Medicines Medicines labelling and andpatient knowledge knowledge about about use use• ∞The adequacy of of labelling of prescription of items items varied varied widely between widely countries. between countries.Four outof oflabelling five patients of prescription knew how to take items their varied medicines widelywhen between interviewed countries. immediately∞ The∞adequacy∞ Four• Fourout afterof out the five medicines of fivepatientspatients were knew dispensed. knewhowhowto taketo taketheirtheirmedicinesmedicineswhenwheninterviewedinterviewedimmediatelyafter the medicines were dispensed.immediately after the medicines were dispensed.Table 17. Quality of treatment of diarrhoea and acute respiratory infectionsTable 17. Quality of treatment of diarrhoea (ARIs) and acute respiratory infections(ARIs)Table 17. Quality of treatment of diarrhoea and acute respiratory infections (ARIs)∞∞∞∞ Oral rehydration solution (ORS) is commonly used to treat paediatric diarrhoea and firstlineantibiotics are usually given to treat paediatric pneumonia in low- and middle-incomecountries.Oral∞rehydrationThe use of antidiarrhoealssolution (ORS)or antispasmodicsis commonlyforusedtreatingto treatdiarrhoeapaediatricin childrendiarrhoeais low.and firstlineantibiotics are usually given to treat paediatric pneumonia in low- and middle-income• ∞ Oral There rehydration was a high solution rate of prescribing (ORS) is antibiotics commonly forused acuteto respiratory treat paediatric infections, diarrhoeaand first-line antibiotics are usually given to treat paediatric pneumo-most ofwhich will not respond to antibiotics.countries.The use nia of in antidiarrhoeals low- and middle-income or antispasmodics countries. for treating diarrhoea in children is low.There • The wasuse a high of antidiarrhoeals rate of prescribing or antispasmodics antibiotics for for acute treating respiratory diarrhoea infections, chil-willis not low. respond to antibiotics.most ofwhichdren• There was a high rate of prescribing antibiotics for acute respiratory infections,most of which will not respond to antibiotics.

6. Using indicators to measure the pharmaceutical sector in Ethiopia 101Figure 14. Average number of medicines per prescription in public healthfacilitiesFigure 14. Average number of medicines per prescription in public health facilities• ∞The number of medicines prescribed per per episode episode of outpatient of care care was 2–3 was for 2–3mostfor countries. most countries.5.8 In EthiopiaOnly in January 2004 the Ethiopian Drug Administration and Control Authority(DACA) 5.8 In Ethiopia has published a completed set of Standard Treatment Guidelines (STG) fordifferent Only in level January of health 2004 care the facilities, Ethiopian hospitals, Drug health Administration centres and health and Control stations(the Ministry of Health has prepared STG for six types of most common andAuthority (DACA) has published a completed set of Standard Treatmentimportant diseases). In the same period (January 2004) a set of national formulariesbased Guidelines on the (STG) List of Drugs for different for Ethiopia level (LIDE of health July 2002 care edition) facilities, have hospitals, been published healthby centres DACA. and health stations (the Ministry of Health has prepared STG for sixtypes of most common and important diseases). In the same period (JanuaryThe concept of essential drugs in Ethiopia is part of the basic curricula of pharmacists2004) a set of national formularies based on List of Drugs for Ethiopiaand pharmacy technicians. Public education on rational use of drugs is being given byDACA (LIDE through July 2002 the mass edition) media. have There been is published no mandated by continuing DACA. education programfor The health concept professionals, essential except drugs thatin pharmacy Ethiopia and is medical part of associations the basic curricula occasionally oforganize pharmacists continuing and pharmacy education programs technicians. for their Public members. education on rational use ofdrugs is being given by DACA through the mass media. There is no mandatedcontinuing and rarely education in the Health program Centres, for health without professionals, coordination except among that themphar-andThe Drug and Therapeutic Committee are established only in few Hospitals in thecountryDACA macy and at central medical level. associations DACA has established occasionally a Drug organize Information continuing Centreeducationbut is notwell programs developed for their and needs members. to better evaluated. Very recently (2006) a task force forthe antimicrobial resistance strategy has been established at national level but notThe Drug and Therapeutic Committee are established only in few Hospitalsreference laboratory has been organised.in the country and rarely in the Health Centres, without coordination amongIn them and following DACA table at some central of level. the important DACA indicators has established related a with Drug theInformationrational druguse Centre in Ethiopia but is are not showed: well developed and needs to be better evaluated. Very recently(2006) a task force for the antimicrobial resistance strategy has beenTable 18. Summary of national indicators on rational drug use in PrimaryHealth Care Facilities (PHCFs)established at national level but not reference laboratory has been organised.In the following Indicators table some of the important Therapy indicators related Mean with the Median rationaldrug use in Ethiopia areTreatment of diarrhoea (watery, non Percentage of ORS use 81.87 90showed:bloody) in childrenPercentage of antibiotic use 49.63 50Percentage of anti-diarrhoea and/or 2.55 0

102 Andrea Gardellin, Abraham Gebre GiorgisTableTable18. Summary18. Summaryof nationalof nationalindicatorsindicatorson rationalon rationaldrugdruguseusein Primaryin PrimaryHealthCare Facilities (PHCFs)Health Care Facilities (PHCFs)Indicators Therapy Mean MedianTreatment of diarrhoea (watery, non Percentage of ORS use 81.87 90bloody) in childrenPercentage of antibiotic use 49.63 50Percentage of anti-diarrhoea and/or 2.55 0antispasmodic drugs useTreatment of non-pneumonia ARTI Percentage of antibiotic use 60.69 70Treatment of mild/moderate pneumonia Percentage of use of any of the first line 54.1 50antibiotics (procaine penicillin inj.,Amoxicillin, Cotrimoxazole)Percentage of use of more than one 2.36 0antibioticAverage number of drugs per encounter 1.99 1.97Percentage of antibiotic(s) per encounter 58 57Percentage of injection(s) per encounter 26.98 23Percentage of drugs adequately labelled 42.66 46Percentage of patient with adequate knowledge 67.36 70Percentage availability of STG 39 0Percentage availability of regional or facility EDL in the facility

6. Using indicators to measure the pharmaceutical sector in Ethiopia 103commonly assessed by checking whether the chosen tracer diseases had beentreated according to the treatment schedules recommended in the STGs.For this purpose, three disease conditions, namely, diarrhoeal disease in children(watery, non-bloody), non-pneumonia Acute Respiratory TractInfection (ARTI) and mild/moderate pneumonia have been chosen. The recommendedtreatments are: ORS for watery, non-bloody diarrhea; non - use ofantibiotic for non-pneumonia ARTI and use of any of the first line antibiotics forMild/Moderate pneumonia (Procaine Penicillin, Amoxicillin or Cotrimoxazole).The national average for percentage of ORS use is 81.9% and it is close tothe ideal value of 100%.The national average for percentage of antibiotic use in health facilities is49.6% . This is a bad practice since the norm is not to use any antibiotic inwatery, non-bloody diarrhoea.The national average for percentage of this mode of treatment in healthfacilities is 2.6% and this is not very far from the ideal value of zero use.The national average percentage use of antibiotic is 60.7% and this is a significantdeviation from the STGs.The national average percentage use of any of the first line antibiotics is54.1% with a minimum of 0% and maximum of 100% showing a widerange of 100. The practice is unsatisfactory as compared with the recommendationsin the STG.At the national level, the percentage of use of more than one antibiotic inthe treatment of mild/moderate pneumonia is 2.4% with a maximum of30% and minimum of 0%. The results show a very good overall complianceto STG and needs to be maintained, if not improved.

104 Andrea Gardellin, Abraham Gebre GiorgisReferences:1. Most of the figures are tables are from: WHO-Harvard Medical School and HarvardPilgrim Health. Using indicators to measure country pharmaceutical situations. 20062. FMoH-WHO. Assessment of the Pharmaceutical Sector in Ethiopia. Addis Ababa, October2003.3. HCF Secretariat, FMoH. National Baseline Study on Drug Supply and Use in Ethiopia.Addis Ababa, September 2002.4. Ethiopia HSDP II. Report of the final evaluation of HSDP II 31 January – 6 March 2006Volume 1 & 2 2002/03 to 2004/05 (EFY 1995-1997). Addis Ababa May 1, 2006.

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 1057. HIV AND SKIN: AN OPERATIONAL RESEARCH (O.R.)IN TIGRAY REGION, ETHIOPIA(Tigray Regional Health Bureau)(TMA, Tigray Medical Association)(IISMAS onlus - International Institute of Medical,Anthropological and Social Science)(S. Gallicano Dermatological Institute-Rome)(Italian Cooperation- HSDP)As for most Developing Countries, basic health services in Ethiopia are notavailable particularly to the large part of the population living in rural areas.Limited availability of qualified staff, poor diagnostic capability, scarcity ofequipment and medicines is a common situation in the country. These shortcomingsare even more dramatically evident at peripheral level where a minimumhealth service package is still not yet available to the population.Moreover, the problem is worsened and aggravated by the escalatingHIV/AIDS epidemic and its consequences. Ethiopia has the third largestnumber of people living with HIV in the world after South Africa andNigeria. Modelled data suggested a rise in prevalence of HIV in rural areas(2003: 2.6%) and in all Ethiopia (2003: 4.4%), but a stable or decliningprevalence in Addis Ababa (2003: 14.6%) and other urban areas (2003:11.8%). Modelled HIV incidence, inferred from prevalence changes, showeda slowly rising trend in Addis Ababa (2003: 2.0%), other urban areas (2003:1.7%) and rural Ethiopia (2003: 0.46%). The total burden of HIV/AIDS isexpected also to rise substantially due to population growth. Tigray is particularlyvulnerable to HIV/AIDS due to additional factors such as the socialdisorganization and population displacement related to the protracted armedstruggle, the Ethio-Eritrean war, recurrent famines and drought, rapid urbanizationand the huge number of female headed households in both the ruraland urban areas. The prevalence of HIV/AIDS in Tigray in 2005 is estimatedto be 4.7% and the epidemic appears to be intensifying. The skin is probablythe organ most commonly affected in patients with HIV. The range ofskin diseases in patients who are HIV-positive is broad, encompassing bothHIV and non-HIV related dermatoses. The immune status of the patient, reflectedin the CD4 T-cell count and viral load, is an important parametersince there is often a strong correlation between the CD4 count and the presenceof particular HIV-associated rashes. Correlation of skin diseases and

106 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDPHIV disease staging has long been recognized and used to guide medicalmanagement in resource-limited settings. Sexually transmitted infections(STIs), once called venereal diseases, are among the most common infectiousdiseases in Africa. Though extensive studies have not been conducted so far,more and more knowledge is being acquired nowadays. For example in theUnited States more than 20 STIs have now been identified, and they affectmore than 13 million men and women in that country every year.Understanding the basic facts about STIs and related manifestations – theways in which they are spread, their common symptoms, and how they canbe treated – is the first step toward prevention. STIs affect men and womenof all backgrounds and economic levels and they are most prevalent amongteenagers and young adults. The incidence of STIs and other possible skinand systemic condition is rising in the world, partly because in the last fewdecades young people have become more sexually active and have multiplesex partners during their lives, potentially becoming at higher risk to developSTIs. Most of the time, STIs cause no symptoms, particularly in women evenif manifestations on the skin are common. When and if symptoms develop,they may be confused with those of other diseases not transmitted throughsexual contact. When diagnosed and treated early, many STIs can be curedeffectively but nowadays some infections have become resistant to the drugsused to treat them and now require newer types of antibiotics. Experts believethat having STIs other than AIDS increases one’s risk for becoming infectedwith the HIV. STIs and related skin conditions cause physical and emotionalsuffering to millions and are costly to individuals and to society as a whole.Knowledge of STIs can be very important in reducing the incidence andcomplications of sexually transmitted diseases.This operational research aims at addressing the skin conditions in rural communitiesas an entry point to Public health at low cost approach with betteraccessibility (see in Annex 1). This program intends to employ a basic strategyof easy diagnosis, treatment and referral skin condition through the simpleuse of eyes by health workers at peripheral levels in Tigray. TheOperational Research (OR) scheme therefore deals with the establishment ofa basic health service to address the emerging skin diseases related toHIV/AIDS and to other systemic illnesses in Tigray region. Specific objectivesare the establishment of a database on dermatological diseases and STIsrelated with systemic conditions and the early detection of systemic illnessesthrough the skin manifestations.This OR aims to improve the diagnostic and therapeutic capacity on HIV

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 107and STIs of health facilities in three selected study-weredas of Tigray andcompare the impact of the interventions in three control-weredas. Both theintervention and control weredas have been purposefully selected andmatched for the following criteria: climate and altitude, population size,number of health institution and health personnel, urbanity. In addition, theintervention and control weredas have been set apart to avoid contamination.The Italian Cooperation in Ethiopia is the prominent fund givers for theproject. The IISMAS Onlus-San Gallicano Dermatological Institute in Rometogether with the TMA and the Tigray Health Bureau are the implementingagencies. The project duration is two years from October 2005 to October2007.The methodology of intervention includes training of health workers (HealthOfficers, nurses and laboratory technicians) on skin diseases and STIs relatedwith systemic conditions, provision of low cost and sustainable laboratoryreagents and equipments, provision of basic medical supplies for the treatmentof skin diseases and STI, supportive supervision, data collection andanalysis. Base line cross sectional survey have been collected from the interventionand control weredas on knowledge and skill of health workers onskin diseases and STIs related with systemic conditions, health facility’s infrastructure,services and supplies. Ongoing report from the intervention andcontrol weredas will be collected on a structured data collection format andanalyzed at the time of initial survey, interim period and conclusion of the research.The intervention and control groups will be compared for impact usingoutcome measures such as knowledge and skill of health workers, numberof patients with STIs, skin diseases related with systemic conditions treated,cured and referred at the health facilities.During the first phase of the project we collected data on the top ten diseasesburdens, the health workers’ skills and the health furniture’s availability in thestudy and control weredas. After the training courses were conducted therewas the need to carry out monitoring and supervision of the performance ofthe Health Workers in the facilities where they work.In the three study weredas we’ve already registered some expected outcomesof the research such as an increased access to the health facilities in the interventionareas and the early detection of the commonest communicable disease.The data collected at the Italian Dermatological Centre show that halfof the patients with evocative skin lesions and/or STIs tested for HIV waspositive. The most common skin problems we observed in HIV positive patientswere infections including viral, fungal, mycobacterial and bacterial,

108 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDPwith cutaneous atypical and spread manifestations. Pruritus was one of themost common symptoms encountered in patients with HIV. In the latestages of HIV infection with a low CD4 count we observed the combinationof the above mentioned skin infections especially viral like molluscum contagiosumand superficial mycosis, whereas we didn’t observe Kaposi’s sarcoma,reported as common manifestation of advances HIV infection stages. Inthe early stage, with a relatively high CD4 count, we observed muco-cutaneousdisorders like herpes zoster and vaginal candidiasis. These results indicatethat all patients with these skin conditions should be counselled and testedfor HIV infection.Moreover, through the support-supervision of health facilities, the interviewof the health workers and a workshop held at the end of the first year inMekele we will have other expected outcomes and data from the study areas.This also give the opportunity to organize with the health workers a series ofsensitization campaigns at village level in order to promote early diagnosisand prevention of many common skin diseases and STI.This operational research represents an attempt to improve the implementationcapacity of the health system and the health status of people in theTigray region through the access to new services like dermatology and theprevention of communicable diseases such as HIV/AIDS. Hence, the dermatologistshave a central role in the detection of these conditions and in thetraining of the local health staff.

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 109References:1. Rigopoulos D, Paparizos V., Katsambas A., Cutaneous markers of HIV infection, ClinDermatol, 2004; 22:487-982. Kreuter A, Schugt I, Hartmann M, Rasokat H, Altmeyer P, Brockmeyer NH.,Dermatological diseases and signs of HIV infection., Eur J Med Res. 2002 Feb21;7(2):57-623. Wolday D, Messele T, Prevalent infectious diseases in patients with HIV/AIDS inEthiopia, Ethiop Med J. 2003 Apr;41(2):189-203.4. Holmes CB, Losina E, Walensky RP, Yazdanpanah Y, Freedberg KA. Review of humanimmunodeficiency virus type 1-related opportunistic infections in sub-Saharan Africa.Clin Infect Dis. 2003 Mar 1;36(5):652-62. Epub 2003 Feb 17.5. Hotez P, Remme J, Buss P, Alleyne G, Morel C, Breman J. Combating tropical infectiousdiseases: report of the diseases control priorities in Developing Countries project.Clin Infect Dis 2004;38:871-86. http://www.who.int/hac/crises/eth/background/Ethiopia_Aug06.pdf7. Tigray Regional Health Bureau HMIS. Tigray Health Bureau Profile 1997 EthiopianCalendar (2005 Gregorian Calendar)8. W Hladik, I Shabbir, A Jelaludin, A Woldu, M Tsehaynesh, W Tadesse. HIV/AIDS inEthiopia: where is the epidemic heading? Sex Transm Infect 2006;82(Suppl I):i32–i35.doi: 10.1136/sti.2005.0165929. Singh F, Rudikoff D. HIV-associated pruritus: etiology and management. Am J ClinDermatol 2003;4(3):177-8810. Mbuagbaw J, Eyong I, Alemnji G, Mpoudi N, Same-Ekobo A. Patterns of skin manifestationsand their relationships with CD4 counts among HIV/AIDS patients inCameroon. Int J Derm 2006, 45, 280–28411. Figueroa JI, Fuller LC, Abraha A, Hay RJ. Dermatology in southwestern Ethiopia: rationalefor a community approach. Int J Dermatol 1998;37:752-8.

110 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDPANNEX 1PROJECT DOCUMENTOPERATIONAL RESEARCH FORIMPROVEMENT OF THE BASIC HEALTHSERVICES THROUGH BETTERKNOWLEDGE OF DERMATOLOGICAL ANDSEXUALLY TRANSMITTED DISEASES ANDTHEIR POSSIBLE CONNECTION WITHUNDERLYING SYSTEMIC CONDITIONS INTIGRAY REGION

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 111ACRONIMSAIDSCBRCHCHWDPT 3DOTSEBMECGDPGISGFRGPSHCHEPHFHIVHMISHPHSDPHWICMOHNGONIAIDPAPPCPHCPHCUPHCRHBTRHBZHDSTDSTIsSWAPTBTFRTOTTT 2 +UTIVHCWCTZCTAcquired Immune Deficiency SyndromeCrude Birth RateCommunity HealthCommunity Health WorkersDiphtheria Pertussis Tetanus (three doses)Directly Observed TherapiesEvidence Based MedicineEthiopian CalendarGross Domestic ProductGeographical Information SystemGeneral Fertility RateGlobal Positioning SystemHealth CentreHealth Extension PackageHealth FacilityHuman Immune Deficiency VirusHealth Management Information SystemHealth PostHealth Sector Development ProgramHealth WorkerItalian CooperationMinistry of HealthNon Governmental OrganizationThe National Institute of Allergy and Infectious DiseasesProgram Action PlanPersonal ComputerPrimary Health CarePrimary Health Care UnitPrimary Health CareRegional Health BureauTigray Regional Health BureauZonal Health DepartmentSexually Transmitted DiseasesSexually Transmitted InfectionsSector Wide ApproachTuberculosisTotal Fertility RateTraining of TrainersTetanus Toxoid Vaccination (two or more doses)Urinary Tract InfectionsVillage Health CommitteeWoreda Coordinating TeamZonal Coordinating Team

112 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDPSummaryAs in most developing countries, basic health services in Ethiopia are notavailable particularly to the large segment of the population living in rural areas.A shortage of qualified staff, poor diagnostic capability, scarcity of equipmentand medicines, etc. is a common situation in the country. The per capitaexpenditure for health is about 5US$ per year, 2/3 of which are “out ofpocket” by the patient. These shortcomings are even more dramatically evidentat peripheral level where a minimum health service package is still notyet available to the population. Moreover the problem is worsened and aggravatedby the escalating HIV/AIDS epidemic and its consequences.This OPERATIONAL RESEARCH scheme therefore deals with the improvementof basic health services in order to address the emerging skin diseasesrelated to HIV/AIDS and to other systemic illnesses in Tigray Region.This endeavour aims at improving the capacity of health professionals andhealth workers at 1 st and 2° level (Health Post and Health Centre) throughtraining and surveys on skin conditions in the research localities. Capacitybuilding together with basic survey strategy is believed to improve the diagnosticand curative capabilities of those health workers, as well as their orientationin case referral abilities. The survey findings will provide a useful databasefor future improvement on the skills of the health workers and on theservice provided to the community.The Italian Cooperation (IC) in Ethiopia through its “Contribution to HS-DP” programme is the prominent fund giver for this project, whereas theTigray Regional Health Bureau (RHB) is the institutional counterpart andthe ultimate beneficiary. The IISMAS Onlus (Istituto Internazionale ScienzeMediche Antropologiche Sociali) - Istituto San Gallicano in Rome, togetherwith the Tigray Medical Association (TMA) will be the two scientific partnersand implementing agencies. The project duration is two years fromOctober 2005 to September 2007.1. Background informationEthiopia is located in the horn of Africa and it is one of the largest countriesin Africa, extending over an area of about 1.112.000 square kilometers.Ethiopia is the second most populous country in sub-Saharan Africa afterNigeria with an estimated total population of approximately 71.1 million accordingto the projection of the 1994 population and housing census, of

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 113which more than 60 million (85%) live in rural areas. The sex ratio (male tofemale) is approximately 1:1 with slight prevalence of females.The annual population growth rate is 2.7%. The percentage of populationaged 60+ is 4.6%.Administratively, Ethiopia is divided into 9 regional states and 2 administrativecouncils and further subdivided into zones and weredas. The country isa land of great topographical diversity of high rigged mountain, flat toppedplateaus, deep gorges, incised river valleys and rolling plains which are responsiblefor tropical, sub-tropical and temperate climatic conditions. Thisenvironmental mosaic marked the diversity of plant and animal life. Thecountry is a land not only of highly varied landscape, and hence flora andfauna, but also of a multiplicity of ethnic groupings with complex cultural diversity.Furthermore, the existing archaeological evidence suggests thatEthiopia is one of the few countries considered to be the cradles for the evolutionof mankind, a fact that is also a testimony to the great antiquity anddiversity of cultural values. This cultural diversity is the result of a long processof interaction and contact among the people in the country and withthat elsewhere, mainly across the red sea. It is believed that this interaction ofpeoples was primarily responsible for the introduction of written languagebeginning from the era of the ancient Axumite kingdom.Unfortunately, recurrent droughts that often lead by epidemics of cholera, typhus,dysentery, the current HIV/AIDS epidemics and the opportunistic infections,poverty of the majority of the population as embodied by malnutrition,illiteracy, and neglected surroundings have always favoured the propagationand dissemination of diseases, migration, family breakage and streetlife etc. in the country. In this desolation the rural community is the conspicuousvulnerable groups. Ethiopia has extremely poor health status relative toother low-income countries (largely attributable to potentially preventableinfectious diseases and nutritional deficiencies) and a high rate of populationgrowth. Widespread poverty along with general low income levels of the vastmajority of the population, low education levels (especially among women),inadequate access to clean water and sanitation facilities, and poor access tohealth services have also contributed to the burden of ill health.The low level of economic development places severe strains on the healthsector, and increases the importance of good health at the same time. Thehealth sector is called upon to provide greater services for persons in poorhealth, but with little resources. At the same time, economic conditions ofthe country can be improved by improving the productivity of its population.

114 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDPImproved nutrition and health status of individuals translates into increasedproductivity and economic gains.The health status of Ethiopians is among the lowest in the world. Accordingto 2003 health and health related indicator of the FMOH the crude deathrate is estimated to be 12.6 per thousand populations. Life expectancy atbirth (LEB) of males and females is 53.4 and 55.4 years respectively. The infantmortality rate (IMR) is estimated at 96.9 per thousand live births whilethe < 5 mortality rate is 140 deaths per 1000. The maternal mortality rate(MMR) is estimated at 871 per 100,000 live births.Ethiopia’s burden of disease is dominated by peri-natal and maternal conditionsand by acute respiratory infection, followed by malaria, nutritional deficiency,diarrhoea and AIDS. Indeed, the top ten causes of mortality accountfor 59.6 percent of all deaths. Diseases that affect children under the age of5 years (ARI, diarrhoea, nutritional deficiencies and measles) account for 33percent of deaths. When peri-natal and maternal conditions are added, thehealth problems of mothers and children combined account for 50 percentof all deaths.The overall level of potential health service coverage is estimated to be approximately64 percent. Coverage estimates for individual health programs arevery low. Currently, health services for a population of some 71.1 millionpeople comprise 126 hospitals, 519 health centers, 1797 health stations and2899 health posts.2. Operational research for improvement of the basic healthservices through better knowledge on dermatological andsexually transmitted diseases and possible underlying systemicconditionsAs it is acknowledged, operational research offers significant gains on healthservice delivery and outcome at relatively low cost, and in a timeframe of fewyears. In this context, we mean operational research rooted in local experiencespecifically aiming at developing the capacity of health workers workingat a grass root level in Tigray region. The aim of this project is to develop theknowledge and skill of the health workers to diagnose, treat and refer cases ofSTIs, skin conditions and possible underlying systemic consequences.Hopefully the research will help to bring about better standard and interven-

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 115tions that result in improved policy making, better design and implementationof health systems, and more efficient methods of service delivery.Sexually transmitted infections (STIs), once called venereal diseases, areamong the most common infectious diseases in Africa. Though extensivestudies have not been conducted so far, more and more knowledge is beingacquired nowadays. For example in the United States more than 20 STIs havenow been identified, and they affect more than 13 million men and womenin that country every year. The annual total cost of STIs diagnosis and treatmentin the United States is estimated to be well in excess of $10 billion.Understanding the basic facts about STIs and related manifestations – theways in which they are spread, their common symptoms, and how they canbe treated – is the first step toward prevention. The National Institute ofAllergy and Infectious Diseases (NIAID), a part of the National Institutes ofHealth, has prepared a series of fact sheets about STIs to provide this importantinformation. Research investigators supported by NIAID are looking forbetter methods of diagnosis and more effective treatments, as well as for vaccinesand topical microbicides to prevent STIs. It is important to understandkey points as follows about all STDs today:• STIs affect men and women of all backgrounds and economic levels.They are most prevalent among teenagers and young adults. Nearlytwo-thirds of all STIs occur in people younger than 25 years of age.• The incidence of STIs and other possible skin and systemic conditionis rising, partly because in the last few decades young people have becomemore sexually active and have multiple sex partners during theirlives, potentially becoming at higher risk to develop STIs.• Most of the time, STIs cause no symptoms, particularly in women.When and if symptoms develop, they may be confused with those ofother diseases not transmitted through sexual contact. Manifestationson the skin are however more common. Even when an STI causes nosymptoms a person who is infected may be able to pass on the diseaseto a sexual partner.• When diagnosed and treated early, many STIs can be cured effectively.Some infections have become resistant to the drugs used to treat themand now require newer types of antibiotics. Experts believe that havingSTIs other than AIDS increases one’s risk for becoming infected withthe HIV.• STIs and related skin conditions cause physical and emotional sufferingto millions and are costly to individuals and to society as a whole.

116 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDP• Health professionals and each individual have responsibilities to learnmore about STIs and then make choices about how to minimize therisk of acquiring these diseases and spreading them to others.Knowledge of STIs, as well as honesty and openness with sex partnersand with one’s doctor, can be very important in reducing the incidenceand complications of sexually transmitted diseases.3. Rationale for the proposed interventionSkin as an extensive organ covers the entire body part and its disorders are oftenthe first manifestations of several diseases potentially involving all the internalorgans. Some skin signs/symptoms strongly suggest the presence ofsome infectious or neo-plastic diseases and sometimes the relation betweencutaneous signs/symptoms and related disease is as marked as to indicate withextremely precision the diagnosis of underlying illnesses to the health (workers)professionals. This is evident in the case of HIV and HCV infections,where the presence of some kind of dermatoses strengthens the suspect of viralaetiology. Skin disorders occur at the same time in 64% to 90% of all patientsinfected with HIV.Fortunately enough the appearance are visible to our sights and mostly it is amatter of using only our sight sense to get an impression and to diagnose thediseases. In general, this operational research aims at addressing the skinconditions in rural communities as an entry point to Public health atlow cost approach with better accessibility. This program intends to employa basic strategy of easy diagnosis, treatment and referral skin conditionthrough the simple use of EYES by health workers at peripheral levels inTigray Region.A possible improvement of the situation in such context of extremely reducedavailable resources could be attained by increasing the know-how and clinicalskills of the peripheral health workers in the sectors not requiring specificdiagnostic aids. On this regard the relevance for dermatological and venerealpathologies is evident: for them, indeed, no other tool is required but apair of good eyes.

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 1174. Objective of the projectGeneral objectiveThe general objective of the present project is to promote improvement ofthe health service offered to the Ethiopian population through strengtheningof the diagnostic and healing capabilities of the dermatological and venerealpathologies as such and moreover, as above explained, of general systemic andinfectious pathologies (HIV infection included) in rural community ofTigray Regional State.Specific objectives1. To improve the diagnosis and management skill of peripheral health workerson common skin condition related to HIV/AIDS and to other systemicinfections2. To establish a simple database on skin conditions in the project area for futurepublic health service strengthening and improvement of the communityhealth status.5. Project siteThe Tigray Regional StateTigray is the northernmost national regional state of Ethiopia and is locatedbetween latitude 12 o and 15 o north. The region is divided into north-westernand southern lowlands (700-1500 meters above sea level) and centralhighlands (1500-3000 meters above sea level). The region covers 54-572.6square kilometres. Tigray is bounded on the north by Eritrea, on the southby Amhara Regional State, on the east by the Afar Regional State, and on theWest by Sudan.As per the projection of the 1994 Population and housing census the populationof Tigray is estimated at 4.11 million of which 51% are females, andgrowth rate is estimated at 3% per year.Eighty-five percent of the population is rural and engaged in subsistence agriculture.Large population movements have occurred since 1991 GC withpermanent resettlement of refugees, settlement of demobilized soldiers inlowland areas of economic development, and seasonal migrations from highlandsto lowlands for labour on large-scale agricultural development projects.Tigray’s agriculture is based on plough cultivation of mainly cereal crops and

118 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDPuntil recently depended almost entirely on rainfall. The main rainy season isfrom May to September, with most rains falling in June and July. In southeasternTigray additional rains full during January and February, providingsufficient moisture for a second harvest. Mean annual temperature is 18 o c.The region’s socio-economic and health problems are immense and highly interrelated.As development without healthy people is unthinkable, the healthsector is considered as integral target of development by the regional government.Since 1991 GC there has been upgrading of general health services throughrehabilitation and construction of health facilities, training and deploymentof health personnel, and expansion of primary health care. As a significantproportion of the population still lives beyond catchment’s areas of even peripheralhealth institutions, community-based volunteer health workers continueto play an important part in delivery of primary health care services.Communicable diseases and nutritional problems are major health problemsof the region and account for the majority of all health problems. Malaria,Tuberculosis, ARI (acute respiratory tract infection), diarrhoeal diseases andHIV/AIDS are among the top disease burdens. These diseases are preventablethrough approaches such as supply of adequate and safe water, control ofvectors, expanding vaccination and educating the people to bring behaviouralchanges.The pandemic of HIV/AIDS is spreading at an alarming rate. The numberof HIV carriers in the towns of Tigray is estimated to be 33,949-37, 12.

The pandemic of HIV/AIDS is spreading at an alarming rate. The number of HIV carriers in the7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 119towns of Tigray is estimated to be 33,949-37, 12.Health service delivery in Tigray Regional StateHealth service delivery in Tigray Regional StateTable Table 1. Health 1. Health Professionals Professionals and and Health Health facilities in in Tigray Regional stateSerial Health Professionals Number Health Facilities NumberThe no. pandemic of HIV/AIDS is spreading at an alarming rate. The number of HIV carriers in thetowns 1 of Tigray General is estimated practitioners to be 33,949-37, 61 12. Hospitals 12 Govt. + 3privatehospitalsHealth service delivery in Tigray Regional State2 Health officers/field 19 Clinic 166 Govt + 15Table 1. surgeons Health Professionals and Health facilities in Tigray Regional state private clinics3 Laboratory2 Health Posts 164Serial Health Professionals Number Health Facilities Numberno. Technologists(BSc)14 General Senior practitioners &Junior lab. 61 181 Hospitals Total 12 Govt. + 354 3 Govttechniciansprivate +38 private5 Senior &Junior 1344 Pharmacy hospitals 162 Health Clinical officers/field Nurses 19 Clinic 166 Govt + 15surgeonsprivate clinics6 Senior &Junior Health 1026 Drug store 313 Laboratory2 Health Posts 164Technologists(BSc)Assistances47 Senior Primary &Junior health workers lab. 181 124 Total Rural drug vendor 354 Govt 2238 technicians Community health 2,588+38 private5 Senior agents &Junior 1344 Pharmacy 169 Clinical Rural Nurses health agents 1,5356 Senior &Junior Health 1026 Drug store 3110 FLHW (this includesAssistances7 Primary PHWs, healthCHAs workers and 124 7070 Rural drug vendor 2238 Community TBAs) health 2,588agents9 Rural health agents 1,535Table 2:-Main health service and programs coverage in the Region as compared to the10 FLHW (this includesPHWs, national CHAs coverage. and 7070TBAs)Program coverage in % of populationTable 2:-Main health service and programs coverage in the RegionTable 2:-Main Potential health Health service and programs coverage in the Region as compared to theas compared to the national coverage.national coverage.coverage

120 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDPTable 3:-Currently existing health service facilitiesand population ratio in Tigray RegionTable 3:-Currently existing health service facilities and population ratio in Tigray RegionHealth Facility Number Per PopulationHospital12 Govt1:274.2043 PrivatesHealth Centre 32 1:128.533Clinic166 Govt1: 22.72415 privateHealth Posts 164 1: 25.079Table Table 4:-Number of health of health workers workers by category by category and and population ratio ratio in Tigray.in Tigray.Category of health worker No. Regional RatioGeneral practitioners 61 1:67.427Specialists 31 1:132.679Health Officers 57 1:72.157Senior &Junior Clinical nurses 1344 1:3.060Health Assistants 893 1:4.6056. Methodology for conducting the operational research6. METHODOLOGY FOR CONDUCTING THE OPERATIONAL RESEARCHParticipatory training techniqueParticipatory training techniqueA participatory, learner centered and task oriented training methodology willA participatory, learner centered and task oriented training methodology will be employedbe employed throughout the training since the health workers are expected todo throughout the actual the and training required since task the health after the workers training are expected in their to respective do the actual health and center.the In training addition, in their they respective are expected health to center. teach In the addition, CHWs they so are as to expected expand to the teach serv-the CHWs so asice to to expand the community. the service to Different the community. methods Different of teaching methods such of as teaching the short such lecture, as the short lecture,demonstration, case case presentation, presentation, group group discussion discussion etc. will etc. be will utilized.be utilized.required task afterVarious teaching aids shall also be in use to facilitate the learning process.Various teaching aids shall also be in use to facilitate the learning process.The survey methodologyThe methodology survey methodologyhas been planned to first give participants an overview ofthe current status of Dermatological and STIs infections, diagnostic andThe methodology has been planned to first give participants an overview of the current status ofDermatological and STIs infections, diagnostic and treatment methods that could be used in lowincome countries, together with didactic needs for health workers.

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 121treatment methods that could be used in low income countries, together withdidactic needs for health workers.The target groups, trainers and the main topics to be covered during thecourses will be described in the chapters 6.4 and 6.5.This is a brief summary of a model of intervention that could be used in theeducational courses for the health workers and in the process of evaluation ofpatients with suspected STIs and other dermatological diseases in Tigray region:The suspect cases are identified based on clinical symptoms especially if thesymptoms have a history of more than 4 weeks. These suspects are then referredto the laboratory’s room where the collection of the complete clinicalhistory is coordinated. During this first visit the biological samples are collectedfor evaluation:a) the general situation of the principal hematological parameters in the firstday;b) the type of some skin lesions eventually presented; a second specimenwhich is collected when the patient present specific types of coutaneouslesions related to other diseases; this process requires two clinic visits tocollect all the necessary specimens.c) if needs arises and upon agreement with the RHBs, specimen obtainedfrom biopsies of particularly complex cases could be evaluated in Italy(San Gallicano Institute) and the histological diagnosis will be send backin Ethiopia in the next 2-3 weeks, for eventual treatment;d) Patients who return for their results and are found to be positive are immediatelystarted treatment. If there is no response to treatment the patientmay have to be evaluated again. Patients who are negative on the allspecimens are evaluated and observed by the Italian or Ethiopic expertphysicians again and they will be eventually treated.Steps following Dermatological and STIs diagnosis:1. Maintain patient confidentiality at all times.2. Reassure employees with the diseases that treatment is effective.3. Immediately notify the case to the local health authority officer.4. The patients can return to the laboratory once fit enough and no longerinfectious (normally after the first few weeks of treatment). The patientsshould not be discharged with an active disease.5. Collaborate in case management with the local health authority officer, forexample by arranging the best therapeutic opportunity in the workplace,monitoring and follow-up.

122 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDP6. Collaborate with the local health authority officer in contact tracing andevaluating the risk to Dermatological and STIs infections transmission inthat particular workplace.In some cases a range of measures will be recommended, including directlyobserved treatments (DOT).The DOT promote adherence and treatment. Other measures include placingthe patient at the centre of the control activities; ensuring confidentiality andconsideration of patients’ needs; organizing the socio-sanitary services so thatthe patient can receive treatment as close as possible to his/her home, or in theworkplace; considering incentives; identifying potential problems in advance;keeping accurate address records; and taking action towards defaulters.Directly observed treatment is a key part of promoting adherence to treatment.It helps to prevent inconsistent, partial, or incorrect treatment, therebyincreasing the likelihood of successful treatment outcome and reducingthe risk of the emergence of drug resistance. It involves direct observation ofthe patients while taking their drugs every day during the initial phase of thetreatment.The system of recording and reporting results under the DOT strategy hasthree essential components:• registering all patients with a new diagnosis of Dermatological and STIsinfections;• recording their standard treatment outcome;• reporting of results to the local health authority office.Early Diagnosis and PreventionAfter the training courses have been conducted there will be the need to carryout monitoring and supervision of the performance of the Health Workersin the facilities where they work. This will also give the opportunity to organizewith them a series of sensitization campaigns at village level in order to promoteearly diagnosis and prevention of many common skin diseases and STI.Expected outcomesThrough the above areas of intervention an attempt to improve the healthstatus of the people of the Tigray region will be ascertained.The implementation capacity of the health system and health personnel ofthe region will be improved.People will have access to new services like dermatology, and prevention ofthe commonest communicable diseases.

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 123Target groupNurses of different category (Senior Clinical nurses, public health nurses,junior clinical and public health nurses and health assistants) currently workingat the health center level will participate in the training.Health centers (the exact number is to be identified considering the numberof the health workers involved) will be randomly selected from weredas inTigray region (also the number of weredas is to be identified considering thenumber of people living in each region). The candidates Health workers willthen be selected from each health center according to the criteria mentionedabove. After the training, the activities performed by the trained healthworkers and the impact on the service after the training will be comparedwith the health workers working in non selected wereda. That means, theuntrained health workers/ non selected health centers will be used as controlgroups. Survey tools (information gathering tools) having the pertinent variablesto the study will be prepared by experts and by the people involved inthe training. The data obtained from the comparison is useful to get factbased information on the impact of the project and for future developmentat wider level.TrainersThe training is given by experts who have vast and long years experience inthe field from Italy, and by local experts working with the TMA or in theRHB.ResearchThe trainers involved in the project will be also responsible for the middletermand final evaluation of the findings, and for the reporting to the RHBand to the Project Management Unit of the Italian Contribution to HSDP(PMU-HSDP). Any concrete result emerging from this research will beshared with the federal Ministry of Health as an input to the national program(HSDP).Topics to be covered Program 11) Principles of the Evidence Base Medicine (EBM)

124 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDP Program 2Prevention and Therapy of infectious and food born diseases.1) Basic guidelines of cleanliness (CHW)• Cleanliness and problems that come from lack of cleanliness• Personal cleanliness (or Hygiene) and Public cleanliness (or Sanitation)• Cleanliness in eating and drinking• How to protect the children’s health2) Worms and other Intestinal Parasites (CHW)• Roundworm (Ascaris)• Pinworm, Threadworm, Seatworm (Enterobius)• Whipworm (Trichuris, Trichocephalus)• Hookworm• Tapeworm• Trichinosis• Amebiasis• Giardia• Blood flukes (Schistosomiasis, Bilharzia)3) Vaccinations (Immunizations)• Vaccinations (immunizations) – simple, sure protection• When, why, where, how and who will be vaccinated4) STD and HIV/AIDS• Epidemiology• Signs and symptoms• Therapy• Primary and secondary prevention5) Malaria• Epidemiology• Signs and symptoms• Therapy• Primary and secondary prevention6) Tuberculosis• Epidemiology• Signs and symptoms• Therapy• Primary and secondary prevention7) Human African TrypanosomiasisHuman African trypanosomiasis, commonly known as sleeping sick ness,which had been virtually eliminated from Africa during the 1960s, has come

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 125back as a disease of major public health importance. It is caused by two differentspecies of trypanosomes, namely Trypanosoma brucei gambiense in Westand Central Africa, and Trypanosoma brucei rhodesiense in East Africa. T. b.gambiense has a chronic and protracted course, and may last several yearswhereas T. b. rhodesiense is acute and can cause death in a matter of weeks ormonths. Both types of sleeping sickness are fatal if left untreated. Sleepingsickness is found uniquely in sub-Saharan Africa.Trypanosomes are able to evade the immune system of the host because oftheir enormous potential for antigenic variation (over 1000 variants). It isvery difficult to treat, particularly after it has crossed the blood-brain barrier.The medicines themselves are often in short supply, difficult to administer,and can be fatal. It has been estimated that between 3 and 5% of those treatedin the last stage of illness die from the treatment itself. In addition, resistanceto currently used drugs is a serious problem. There is a clear need fornew drugs, as well as better access to currently used ones.• Background of disease• Transmission• Surveillance• History• Epidemiology and description of the data• Signs and symptoms• Therapy• Primary and secondary prevention8) Viral diseases related to skin conditions• Epidemiology• Signs and symptoms• Therapy• Primary and secondary prevention9) Bacterial Diseases related to skin conditions• Epidemiology• Signs and symptoms• Therapy• Primary and secondary prevention Program 3Guidelines for maternal, child and reproductive health.1) Menstrual period2) Menopause

126 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDP3) Pregnancy and pregnancy related problems4) Prenatal care and postnatal care5) Newborn babies care6) Newborn illnesses7) Complications from abortion and miscarriage8) Counselling and family planning (reproductive health)9) Female Genital Mutilation10) Children health and sicknesses. Program 4Diagnosis and therapy of the most common diseases.1) Definitions of the main clinical signs and symptoms2) How to examine a sick person3) STD and HIV/AIDS4) Human African Trypanosomiasis5) Malaria6) Parasitic Diseases7) Diarrhoea and Dysentery8) Tuberculosis9) Dengue and other hemorrhagic diseases10) Infectious Diseases11) Skin diseases and other skin symptoms related to systemic diseases12) Other diseases and sicknesses that are often confused7. Fund agencies and project sustainabilityProject SustainabilityThe sustainability of the intervention will be sought through the regional authoritysupport; accountability and ownership of the project by the localhealth authorities; building of institutional and management capacities; involvementand participation of the local communities.Funding AgencyItalian Cooperation (IC)The General Directorate of the Italian Cooperation for Development is theofficial cooperation of the Italian Government, Ministry of Foreign Affairs,for Developing Countries. The sectors where the IC is involved in Ethiopia

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 127are: Commercial Enterprise, Agriculture, Infrastructure, Education andHealth. In the health sector Italy is contributing to the HSDP at 3 levels;Federal MOH, DACA and 4 Regional Health Bureaus: Oromiya, Afar,Somali and Tigray.The Italian Cooperation with the MOH, have selected 4 of the 7 componentsof the HSDP in which to focus its support: Human Resources, HMIS,Health Service Delivery & Quality of Care and Pharmaceutical services. TheItalian intervention follows the “Sector Wide Approach” (SWAP) with aTechnical assistance support.Furthermore, other contribution of the Italian Government in the health sectorare for the HIV/AIDS initiatives and in the Global Fund to fight Malaria,Tuberculosis and HIV/AIDS, for which Italy is one of the major donors.The Italian Cooperation is directly accountable in funding the project.However, both the international and the national the implementing agenciescan supplement funds for supporting activities when ever necessary.8. Implementing agenciesRegional health bureauTigray Regional Health Bureau is the direct beneficiary and will utilize theexperience and the services of the partner institutions IISMAS and TMA tocarry out the activities included in this research.IISMAS Onlus (Istituto Internazionale Scienze Mediche AntropologicheSociali); Istituto San Gallicano – ROMEIISMAS is an Italian Non Governmental Organization (NGO), active in thefield of the medical research and anthropological and social sciences, operatingin numerous projects for the poor population of Africa, Latin Americaand South-East Asia.In Italy IISMAS promotes the prevention, diagnosis and treatment of the diseasesthat affect the disadvantaged people living in the biggest metropolis.In Ethiopia IISMAS has collaborated with the NGO Hansenians’ Ethiopianand Eritrean Welfare Organization (H.E.W.O.) for the realization of socialhealthservices helping the person suffering from Leprosy and otherDermatological Diseases, Tuberculosis and AIDS. Moreover IISMAS has organizedand conducted the first three editions of the International Congresson Dermatology and Infectious Diseases at Mekele, Quihà and Axum.

128 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDPIn India IISMAS collaborates with NGO Shukrodaya Animation Centre fora plan about the promotion of the health in the poorest groups of the populationliving in the city of Mysore.In collaboration with the University of Buenos Aires IISMAS promotes andsupports a programme of formative exchange for the doctors working in thefield of the international dermatology.THE DEPARTMENT OF MEDICINE OF MIGRATION ATSAN GALLICANO HOSPITAL, ROMEConsidering the importance of the phenomenon of immigration, since 1stJanuary 1985 a Department of Preventive Medicine of Migration has beenoperating at San Gallicano Hospital. For years the Department has representedthe only public referral point not only for assistance and treatment, but alsofor medical, epidemiological, social and anthropologic research concerningimmigrant, nomadic and homeless populations.Prof. Aldo Morrone MD, a Roman physician who specialised in dermatologyand venereology at the University of Rome, was appointed Director of theDepartment. Since then, the service has greatly expanded with a staff of 14physicians, 4 social assistants, 1 administrative co-ordinator, 6 registerednurses, and many other collaborators: physicians with various specialities,psychologists, epidemiologists, sociologists and statisticians.Since the opening of the Department, the service is open to all citizens,Italians and foreigners, in Italy. The services are particularly addressed to regular,illegal and clandestine immigrants, homeless, gypsies and those havinghealth problems but without a health insurance card.At present, between 150-200 people receive assistance every day. As soon asa patient arrives, they receive a first stage evaluation by a team composed ofa doctor, usually an internist, a nurse and a cultural mediator. They registerthe patient directly and, where necessary, establish the STP document. A furtherexamination and advice can be requested on dermatology, allergology,oncology, plastic surgery, internal diseases, infectious diseases, neurology,tropical diseases, sexology, STDs and AIDS. Recently a service of odontostomatologyhas been added.The general structure of the hospital activities is the following:Department of Clinical Dermatology10 normal beds and 10 day hospital bedsDepartment of Inflammatory Dermatology and Allergology10 normal beds and 10 day hospital beds

7. HIV and skin: an operational research (O.R.) in Tigray region, Ethiopia 129Department of Sexually Transmitted DiseasesDepartment of Preventive Medicine of Migration, Tourism and TropicalDermatologyMigration’s Medicine and Minor Surgical ProceduresDepartment of Oncological DermatologyOncological Dermatology SurgeryEpi-luminescence SurgeryDepartment of Plastic and Reconstructive Surgery 18 normal beds and4 day hospital bedsDepartment of AnaesthesiaDepartment of Radiology and Image DiagnosticsDepartment of Non Invasive DiagnosticsDepartment of Clinical Pathology and MicrobiologyDepartment and Laboratory of PorphyriaPorphyria SurgeryDepartment of Microscopical and Ultra structural DiagnosticsResearch LaboratoriesLaboratory of Cutaneous FisiopatholgyLaboratory of Ultra structureLaboratory of Cellular and Molecular BiologyLaboratory of Dermatological ImmunologyTMA (Tigray Medical Association)The TIGRAY MEDICAL ASSOCIATION was established in February2005 in Mekele town having as its members forty five physicians practicingin the region be it in governmental institutions, private practice or NGO. Itis a non profit professional association with the following objectives:iImproving the health and wellbeing of our people through scientific,evidence based medical practice, research, training and managementii To uphold the integrity and dignity of the profession by ensuring quality,ethics and professionalism of the highest degreeiii To stand for rights and privileges of the professionalThe association is legally registered at the Bureau of Justice of TigrayRegional Government.

130 Tigray RHB; T.M.A.; IISMAN onlus; Italian Cooperation - HSDP9. SCHEDULEScheduleTable 8:- Planned Activities for the two years duration 2005-2007Table 8:- Planned Activities for the two years duration 2005-2007ACTIVITIES First Year Second YearEstablishment of dermatology and STIs centres x XImproving access to modern health informationand management system (Computers, printers,and other informatics equipment)I II III IV I II III IVx x x XSending distance education materials: CDs,Video Cassette, Books x X XSupport of logistics and drugs fordermatological and other STIs diseasesBaseline survey in selected woredasx X x x x x x XTraining (short-term and long-term courses) x X x X X x xSending expatriate professionals on temporarybasis (off PMU budget)Support-Supervision of Health Facilities andOrganisation of campaigns for communitysensitization and participationxX X xx x x xConducting conferences (regional & national) X XEvaluation of the short and long term courses X XFinal analysis and reporting (periodic and final) x x xX(Final)10. PROJECT BUDGET FOR TWO YEARS10. Project budget for two yearsFINANCIAL PLANFINANCIAL PLANBudget line (Euro) 1 st Year 2 nd Year TotalLocal staff 2.040 2.040 4.080Transports 2.500 2.500 5.000Equipment and drugs 20.000 10.000 30.000Baseline survey 2.000 0 2.000Training (including training material) 3.000 4.000 7.000Support Supervision 1.920 3.000 4.920Office equipment, furniture and running costs 4.000 2.000 6.000(stationary, telephone, fax, etc.)Analysis and reporting 0 1.000 1.000TOTAL 35.460 24.540 60.000

8. Operational research in tigray region 1318. OPERATIONAL RESEARCH IN TIGRAY REGION:REPORT OF THE FIRST YEAR OF ACTIVITIES 2005-2006Margherita Terranova, Valeska Padovese, Aldo MorroneOperational Research on “Correlation between Dermatologic andSystemic Diseases in Tigray Region”Report of the first year of activity(October 2005 - October 2006)1. IntroductionThanks to the initiative called “Italian Contribution to the Health SectorDevelopment Program (HSDP)”, the Italian Embassy in Addis Abeba, fromSeptember 2002 is supporting developing of “Operational Researches” inEthiopia. The Regional Health Bureau of the National Regional State ofTigray (RHB) and the Italian Embassy, have decided that part of the fundswill be utilized for funding an Operational Research (OR) on correlation betweendermatologic and systemic disease in Tigray Region.In order to properly carry out this project, the Tigray RHB (TRHB) is supportedby two of the following organizations:• IISMAS (International Institute of Medical, Anthropological and SocialScience) an Italian organization with extensive international experience indermatology, working in Mekele at Ayder Hospital.• TMA (Tigray Medical Association) which the physicians association forthe Tigray Region.The general objective of the present project is to promote the improvementof the health service offered to the Ethiopian population through thestrengthening of the diagnostic and healing capabilities of the dermatologicaland venereal pathologies as well as general systemic and infectious diseases(HIV included) in rural community of Tigray Regional State.The activity of the research, which started in October 2005, has come to theend of the first year of work.In the following pages of this document, there are reported all the activitiesand the results of this first year of research.

132 Margherita Terranova, Valeska Padovese, Aldo Morrone2. Specified objectivesAs described in the Project Proposal (PP), the specific objectives of the researchare:• To train health workers (nurses, lab technicians, health officers) on dermatologicaldiseases, STI and systemic illnesses with skin manifestations• To improve the diagnostic capacity of laboratories in health facilities ofthree weredas.• To improve therapeutic capacity of health facilities in three weredas.• To improve documentation and record keeping system of health facilitiesin three weredas.• To conduct supportive supervision in the above health facilities.• Early detections of systemic illnesses through the skin manifestations• To compare the impact of the above interventions with health facilities inthree control weredas.This objectives will be the result of our OR to be reached according to the scheduledactivities during the two years duration of the proposal. Specified objectivesof the project were planned in different aim rely on quarter of 2 years startingfrom October 2005 until the end of the work foreseen for September 2007. Inthe following table (Tab.1) this Program Action Plan (PAP) is reported.Tab.1 Planned chronogram by quarter for two years project duration

8. Operational research in tigray region 1333. ResultsDuring the one-year activity, the bases for all the established purpose of theOR were realized.The following objectives of the PP were reached and details as well as relatedmethodology are described in the issue 4:• Improved diagnostic and therapeutic capacity of health facilities in threeweredas was permitted performing training course of 12 health workers(nurses, lab technicians, health officers), working in the local HC, on dermatologicaldiseases, STI and systemic illnesses with skin manifestations.• Documentation and record keeping system on health facilities in threeweredas about data of dermatological cases were started thanks to distributionof a card for the “Report of Medical History”. The Health Workersof the intervention weredas have been instructed during the practicumtraining on how to collect data. The card’s copies have been distributed tothe Health Centres at the end of the training and again after first supervision.• Supportive supervision in the selected health facilities was conducted duringthe months of July and August.• Data analysis regarding baseline survey of selected weredas compared withcontrol weredas was performed. It represents the base for next evaluationabout the impact of the interventions in the selected weredas comparedwith control weredas.4. Carried out activities, methology and meansAccording to the PAP, The Italian Dermatological Center (IDC), placed inAyder Hospital in Mekele, was established as Dermatology and STIs centerrepresenting the base for the training activities as well as the referral center inMekele for complex clinical cases.The Project Management Unit (PMU) of the “Italian contribution to HS-DP” during this year has provided purchasing (in local suppliers of AddisAbeba and Mekele), of medical equipment, instruments and drugs for clinicaland laboratory activities of the IDC and the three weredas study. Thecomplete list of medical supplies and the related costs are reported on the issue4.1 and 4.3.For logistic and administrative duty of research activities, a local office has

134 Margherita Terranova, Valeska Padovese, Aldo Morronebeen provided by TRHB. The office has been equipped according to theneeds of the research and the planned costs established on the project budgetreported on the Memorandum Of Understanding (MOU) for the project(see issue 4.3).A logistic officer was employed for the activities of the research in Mekele. Heworked in the local office provided by TRHB with the function of logisticcoordinator and accountant.The Project Coordinator (provided by IISMAS) and TMA had periodicalmeetings with TMA to establish the research methodology (see in Annex 1).Six woredas were included in this operational research, three interventionsand other three in the control group. The interventional and control weredaswere purposefully selected and matched for the following criteria:• Climate and altitude• Population size• Number of health institution, health personnel and their mix• UrbanityIn addition, the intervention and control weredas were set apart to avoid contamination.Thus the intervention weredas, Abi Adi, Hagere Selam andHauzien are from the central and the eastern zones while the control weredas,Hintalo Wajarat, Alamata and Samre Saharti, are all from the southern zone(see the map in Annex 2).After the project activity sites, we selected four Medical Doctors of TMA tobe involved in the research’s activities. In order to develop the right methodologyand models for integrated human sustainable healthcare and to explainthe project activities, the training on “Dermatology and Sexually TransmittedDiseases and their correlation with systemic diseases” has been addressed tothe TMA’s Medical Doctors selected for the research’s activities . A shortcourse training has been held in Mekele on 4th–7th April 2006 by the ProjectCoordinator-specialist in Dermatology and Venereology, and by anEpidemiology expert of the TMA. The trainees were the four MedicalDoctors involved in the OR. The objective of the course was the improvementof the MDs’ knowledge and skill concerning skin diseases and STIs relatedto systemic conditions (particularly HIV/AIDS). Different methods ofteaching, such as the short lecture, demonstration, case presentation in theIDC, group discussion were utilized. Didactic materials as a CD-Rom and aprint version of a Dermatology Atlas has been given to the participants.To analyze the skills on current health care practice of the health workers inthe selected weredas and identify their training needs were prepared an assess-

8. Operational research in tigray region 135ment checklist based on the direct observation of the nurse and PrimaryHealth Worker (PHW) performance by regional experts (the MedicalDoctors involved in the research) and expatriate consultants (the ProjectCoordinator).The Primary Health Care (PHC) service quality checklist rates knowledge andskill concerning:1. Primary Health Care• Health education• Antenatal care• Safe delivery• Postnatal care• Family planning• Breast feeding• Growth monitoring/nutrition education• Child immunization• Acute respiratory infection• Diarrhoeal disease control/oral re-hydration therapy2. Sexually Transmitted Infections3. Skin diseases related with systemic conditionsThis checklist is intended for use in the observation of the Health Centreswhich are delivered by health care service providers. It was expected thatproviders have different levels of training and expertise and have varied accessto resources such as clinical, diagnostic and treatment services. PHC managerscan use the checklist as a supervision tool to determine whether servicesare delivered according to established norms and to plan the intervention.The PHC service quantity checklist rates:• the availability of equipment and drug supplies for OR activities• the availability of HIV rapid test (Determine, Unigold, Capillus) andthe presence of a counsellor and a VCT (Voluntary Counselling andTest) service• the availability of laboratory supplies such as a microscope, chemicalreagents (KOH, kit for Gram, Methilene Blue etc.) in the HealthCentre’s laboratory• Report about the health facilities, skills and available furniture in eachwereda

138 Margherita Terranova, Valeska Padovese, Aldo MorroneCoordinator to collect all this data. The Health Workers of the interventionweredas have been instructed during the practicum training on how to collectdata. The card’s copies have been distributed to the Health Centres at theend of the training (see a copy in Annex 4).During the months of July and August, the Project Coordinator with the 4medical doctors of TMA went back to the weredas study, for a total of 9 days,to evaluate the work carried out from the HW that received the trainingcourse. They were directly observed and the PHC service checklist were completed.The project coordinator and the medical doctors were present duringout-patient activity and the professionalism was appreciate as good. Skill onDermatology resulted to have improved especially for all that concerned diagnosis,management and treatment of the commonest skin diseases. The cardsfor the “Report of Medical History”, previously distributed at the end of thetraining course, were filled in a variable number of 16-52 for each trainedHW. Not all the cards were completely filled in all their parts. Moreover, somemistakes observed in the management and in the treatment of some skin diseases,were directly discussed with the HW and recorded to be considered andfocused in the next training course. The total number of patients referred tothe IDC in Mekele from the HC of the weredas was of 11 patients. One hundrednew copies of the card for “Report of Medical History” were distributedto each wereda. During the supervision emerged the necessity of an handbookfor practical management of the most common skin diseases, completed withtreatment chapters. This handbook will be distributed during the workshopthat will take place in Mekele during next months.From discussion with the trained health personnel and laboratory techniciansduring the supervision, emerged the necessity of other laboratory supplies(like KOH solution for fungal investigations) and drugs for daily activities;part of them have been already bought and distributed. For example, duringsupervision emerged data for scabies epidemic on the weredas study wherespecific drugs were not available. To limit the spreading of this epidemic, duringthe first week of October, 232 tubes of scabicide treatment (sulphur ointment)were distributed for each wereda study and other 700 will be given tothe Health Centres (HC) with the next supervision. The information regardingthe emerging epidemic of scabies was immediately communicated to theTRHB.About drugs previously distributed in the weredas, a complete account of theamount used for patients until first supervision, has been recorded as showedin Annex 7. In the respective pharmacy of each HC, were still present most

8. Operational research in tigray region 139of the drugs received by the OR, proving low use and low rate of the free distributionof the drugs related to the out-patient activity in the 3 weredas. Forthis reason, the importance of the drugs prescription as well as the regimentof free distribution were discussed and reaffirmed to improve the service forthe patients flow to the HC. Thanks to the supervision, practical and technicalproblems have been noted, recorded and successive measures were providedor are yet to be provided.4.1 Equipment and drugs suppliedAccording to the planned costs established, the PMU in Addis Abeba providedpurchasing and the delivery to the IDC in Mekele of the medical instrumentsreported in Annex 5. All the equipment was received and tested in theIDC and was utilized for the daily activity of the laboratory.PMU has also provided the purchase of the drugs for the pharmacy of theIDC and weredas study , as reported in Annex 6 and Annex 7. The purchasingwas done in Mekele and, when not possible, in Addis Abeba; the distributionto the HC of the weredas was done by the TRHB PharmacyDepartment.4.2 Human resourcesThe choice of humane resource involved in the research was object of somechange and up to now it is going to be modified.At the beginning, we selected the Medical Doctors to be involved in the researchactivities. The availability of Medical Doctors in Tigray is very littleand often they work as medical directors in zonal hospitals without the supportof expert health professionals. For these reasons, we choose the doctorswho are working in the selected sites and for the scarcity of human resourceswe reduced the number of the Medical Doctors to 4 instead of the 6 previouslyforeseen. Presently, completed the first supervision, 2 of the MedicalDoctors of TMA involved in the research, are going to mouver out of Tigray(in Addis Abeba) to start a course of specialization.Moreover, 5 over 12 of the trained health workers are waiting for result of examinationto accede to further course of medical studies. If it occurs, it willlead to the change of personnel and further training courses will be necessaryto provide continuity of the dermatological service in the selected weredas.A Logistic Coordinator was employed at the real beginning of the project butafter 3 months he resigned for personal problems. We started immediately tointerview other candidates for the vacancy of secretary and logistic coordina-

140 Margherita Terranova, Valeska Padovese, Aldo Morronetor but the local people skilled and with the required quality for this job werevery few. In the end we were able to find a Logistic Coordinator and in accordancewith the project’s partners and the beneficiary we decided to employonly one person with the function of logistic coordinator and accountant.4.3 Financial resourcesThe expenses related to the Italian Contribution to Health SectorDevelopment Program for the first year of activity is the following:Tab 2. Planned and actual Expenses until 3 October 2006.5. External conditionsOne year of activity was carried out with care and attention from all the partners,but data concerned 9 months because operative phase of the researchwas started in January 2006.Other conditions responsible of the delay of the planned activities are relatedto some external circumstances occurred during this year of activity. Thechange of the logistic officer and the transfer of the Italian DermatologicalCentre (IDC) from Quihà to Mekele are examples.Moreover, during the months of July and August, one epidemic in Humero’s

8. Operational research in tigray region 141zone made not possible for the cars to go back to the weredas for supervisionfor many weeks.During the first supervision, it was not possible to meet all the involved HW,due to personal problems, training courses and their moving to Humero’sarea for the emergency.The transferring to Addis Abeba of two of the Medical Doctors of TMA involvedin the research as well as the continuation of medical studies for someof the trained HW, as described before, could influence next months’ activity.Probably, further training courses will be necessary to provide continuityof the dermatological service in the selected weredas. The availability ofMedical Doctors in Tigray is very little and often they work as medical directorsin zonal hospitals without the support of expert health professionals. Forthis reason, we are planning to continue the OR with only two MedicalDoctors.6. Conclusion and operative plan for next semesterDuring one-year activity, the bases for all the established activity of the ORwere realized. Preliminary data were collected, analyzed, and training of theinvolved HW was done and clinical capacity was supervised for the first time.Drugs and laboratory supplies were provided and distributed to the IDC andthe selected woredas.During next month (November 2006), a second supervision is planned. Theresult of the all activities and the data emerged from the comparison of thebaseline and two supervisions will be communicated and discussed in theworkshop that is going to be organized next December in Mekele. The participantsto the workshop will be the Health Workers from the study woredasand the workshop’s duration will be 5 days.We are already working on the selection of the iconographic material to preparea Dermatology and STIs atlas, complete with therapy chapters, to distributeto the Health Workers of the selected woredas during the workshop.According to the consume, other drugs will be provide from PMU and distributedaccording to the needs in the three woredas study by the TRHBPharmacy Department.Regarding the Italian contribution to the Operational Research, we are planningto spend 39.450 Euro.We are sure that improved collaboration of the partners will permit to com-

142 Margherita Terranova, Valeska Padovese, Aldo Morroneplete all the activities of this OR, to promote improvement of the health serviceoffered to the Ethiopian population.through the strengthening of the diagnostic and healing capabilities of thedermatological and venereal pathologies as well as general systemic and infectiousdiseases (HIV included) in the rural community of Tigray RegionalState.7. AnnexsAnnex 1RESEARCH METHODOLOGY1. Introduction2. Objectives:2.1. General: This is an operational research which aims at improving thediagnostic and therapeutic capacity of health facilities in certainweredas of Tigray which may eventually be scaled up to involve thewhole region and beyond. In addition it aims at establishment of adatabase on dermatological diseases, STI and systemic illnesses withcutaneous manifestations.2.2. Specific objectives2.2.1. To train health workers (nurses, lab technicians, health officers)on dermatological diseases, STI and systemic illnesseswith skin manifestations2.2.2. To improve the diagnostic capacity of laboratories in health facilitiesof three woredas.2.2.3. To improve therapeutic capacity of health facilities in threeworedas.2.2.4. To improve documentation and record keeping system ofhealth facilities in three woredas.2.2.5. To conduct supportive supervision in the above health facilities.2.2.6. Early detections of systemic illnesses through the skin manifestations2.2.7. To compare the impact of the above interventions with healthfacilities in three control woredas.

8. Operational research in tigray region 1433. Materials and Methods3.1. Study areaSix woredas will be included in this operational research, three interventionand three in the control group. The interventional and control woredas willbe purposefully selected and matched for the following criteria:• Climate and altitude• Population size• Number of health institution, health personnel and their mix• UrbanityIn addition the intervention and control woredas will be set apart to avoidcontamination. Thus the intervention woredas, Abi Adi, Hagere Selam andHauzien are from the central and the eastern zones while the control woredas(are all from the southern zone.3.2. The intervention3.2.1. Training of health workers (Health officers, nurses and labtechnicians) on skin diseases, STI and systemic diseases withskin manifestation.3.2.2. Provision of low cost and sustainable laboratory reagents andequipments3.2.3. Provision of basic medical supplies for the treatment of skindiseases and STI3.2.4. Supportive supervision3.2.5. Establishment of referral system to a center for dermatologicaldiseases, IISMAS- Italian Dermatological Hospital in Mekellè3.2.6. Health education to improve hygiene of communities andhealth service seeking behavior for dermatological diseases.3.3. Data collection and analysis3.3.1. Base line cross sectional survey will be collected from the interventionand control woredas on• Knowledge and skill of health workers on Dermatological,venereal and systemic diseases with skin manifestations• Health facility’s infrastructure, services and supplies• Documentation and record keeping on Dermatological andvenereal diseases and systemic diseases with skin manifestations.Ongoing report from the intervention and control woredaswill be collected on a structured data collection format. The

144 Margherita Terranova, Valeska Padovese, Aldo Morronedata such collected will be analyzed at the time of initial survey,interim period and conclusion of the research. The interventionand control groups will be compared for impactusing the following outcome measures:-• Knowledge and skill of health workers• Number of patients with STI, skin diseases and systemicdiseases with skin manifestations treated at the health facilities• Number of patients cured• Number of patients referredAnnex 2Map of Tigray Region and selected woreda for Operational Research. In redthe three woreda intervention, in yellow the three wareda control

8. Operational research in tigray region 145Annex 3DATA ANALISIS OF BASELINE SURVAYOF BOTH STUDY AND CONTROL WEREDASTable 1: Percentage of correctly answered or done selected activities of primary health careservices care services in both study and control wereda groups.(All figures are in percent correctly answered or done to the total numberof observations made under the activity.)Safe delivery and postnatal care were part of the questionnaire but no singledelivery was observed during the field visit in all the weredas. So they are excludedfrom analysis.As can be seen from table 1, the EPI service quality is excellent in all the supervisedweredas.Information regarding STIs (sexually transmitted infections) was collectedonly from two Weredas, one from the study and the other from controlweredas (Abi-Adi and Alamata). The following Table shows the performanceof the two weredas in those activities.Table 2: Performance of two weredas in STI patient evaluation and treatment.

146 Margherita Terranova, Valeska Padovese, Aldo MorroneNext, health professionals were observed while assessing and managing caseswith skin diseases and observers (supervisors) were filling checklists.Questions on cases of leprosy, protozoal infections and skin tumors were notfilled in all weredas as these cases were not seen during the evaluation period.Cases with pruritic skin diseases and bacterial, fungal and viral skin infectionswere seen in all the weredas and the following table shows the performanceof each. Knowledge of health workers pertaining to pruritic skin disease wasassessed using questions like “what are some common causes of itching? howdo you treat scabies? how do you treat eczema? how do you treat allergic dermatitissuch as urticaria?”. This questions include keys to evaluate base ofitching knowledge.Table 3: Quality of service in relation to skin diseases related with systemic conditions.We can conclude that the performance of all the weredas in both the studyand control groups is comparable. All the weredas performed well in primaryhealth care but poorly in STI and skin disease.

8. Operational research in tigray region 147Annex 4OPERATIONAL RESEARCH ON CORRELATIONBETWEEN DERMATOLOGIC AND SYSTEMICDISEASES IN TIGRAY REGIONTHE PHYSICAL EXAMINATION OF THE SKINExamine each regionInspect and palpate• Colour normal cyanosis pallor erythema• Moisture moist dry oily• Temperature normal cool warm• Texture smooth rough• Mobility - the ease with which a foldof skin can be moved mobile fixedDecreased in edema• Turgor - the speedwith which the normal slowly very slowly• fold returns into place

148 Margherita Terranova, Valeska Padovese, Aldo MorroneDecreased in dehydratation-Examination techniques--Possible findings-• Anatomic location generalized localized• Grouping or arrangement linear clustered dermatomal• TypePrimary: macula, papule, vesicle, bulla, nodule, pustule, whealSecondary: ulcer scale crust erosion scar lichenification atrophyTHE PHYSICAL EXAMINATION OF THE HAIRInspect and palpate the hair• Quantity sparse normal• Distribution normal patchy or total alopecia• Texture fine coarse• Presence of patches and scaling with infectedhairs brittle and break up just above the scalp yes no

8. Operational research in tigray region 149THE PHYSICAL EXAMINATION OF THE NAILSInspect and palpate the fingernails and toenails• Colour normal cyanosis yellow brown white• Shape normal clubbing spoon nails• Any lesions no yes pitting onycholysis subungueal hyperkeratosis yellowish- brown spots under the nail plate (oil spots)THE PHYSICAL EXAMINATIONOF THE MUCOUS MEMBRANESORAL CAVITYInspect and palpate• Lips normal cyanosis hypopigmentation cheilitis plaques• Buccal mucosa normal lesions (describe…)• Gums normal gingivitis• Tongue, including normal• papillae glossitis• any lesions no yes (describe…)MALE GENITALIAThe penisInspect the• Developement of the penis and the skinand hair at its base normal lice• Prepuce normal phimosis• Glans normal balanitis chancre herpes warts cancer• Urethral meatus normal hypospadias discharge of urethritisPalpate• Any visible lesions (with gloves) no yes(describe: chancre, cancer…)• The shaft normal urethral stricture or cancer

150 Margherita Terranova, Valeska Padovese, Aldo MorroneThe scrotum and its contentsInspect the• Contours of scrotum normal hernia hydrocele cryptorchidism• Skin of scrotum normal rashes angiokeratomi cystsPalpate each• Testis normal orchitis• Epididymis normal epididymitis cystFEMALE GENITALIAInspect the• Labia normal inflammation FGM*• Clitoris normal FGM*• Urethral orifice normal urethral caruncle• Introitus normal vaginal dischargePalpate for enlargement normal Bartholin’s gland infectionor tenderness of Bartholin’s glands(*Female Genital Mutilations)NOTES:

8. Operational research in tigray region 151CLINICAL DIAGNOSISLABORATORY FINDINGS (Microscopic examination, Bloodexamination, HIV test etc.)TREATMENT (drug’s name, dose, topical and/or systemic and duration oftreatment)

152 Margherita Terranova, Valeska Padovese, Aldo MorroneAnnex 5LABORATORY EQUIPMENT AND SUPPLIESACQUIRED FOR THE IDC IN MEKELE

8. Operational research in tigray region 153Annex 6DRUGS AND MEDICAL SUPPLIESCHEK LIST DISTRIBUTED IN THE IDC

154 Margherita Terranova, Valeska Padovese, Aldo MorroneACRONYMS