Over the past 15 years, the Ethiopian government has designed and implemented policy programs and strategies to enhance its coordination and leadership capacities and to promote effective health sector outcomes. The country has repeatedly encountered calamities, both manmade and natural. In particular, its 17-year civil war (1974–1991) took a heavy toll in lives, destroyed social and physical infrastructure, and further aggravated the country’s socioeconomic problems. After the war, from the 1990s to the mid-2000s, the Ethiopian health landscape was discouraging, characterized by high maternal and child mortality, the expansion of HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome), and pervasive tuberculosis.
The aforementioned factors put pressure on the Ethiopian government to address the country’s health problems through different programs and policies. One fundamental approach was the use of comprehensive policy planning to bring concerned parties toward the same vision and results. In line with this approach, the government designed an innovative policy intervention, the Health Extension Program (HEP), in 2004 as an integral part of the second Health Sector Development Program (HSDP). This intervention was believed to build efficiency and effectiveness in terms of finance mobilization and utilization and to fill skill gaps and enhance accessibility, which were the main constraining factors in the execution of the first HSDP. However, the outcomes of the program in the first years of implementation were not as hoped; the program faced delivery challenges including inadequate stakeholder coordination and engagement and diffused leadership and commitment among the government and stakeholders. To address these problems, the government implemented various coordination leadership strategies to leverage the impact of overall involvement in the health sector.
While the aforementioned scenarios were taking place in Ethiopia’s health sector, the situation was changing in the global health structure. The international society began to sense the ineffectiveness of stakeholders’ health sector engagement in developing countries, which was characterized by fragmentation, volatility, proliferation of aid from development partners, and lack of ownership of the policy environment by the countries’ governments. This situation resulted in a divergence of focus and interests among the stakeholders in the sector emanating from the weakness of both the governments and their development partners. Therefore, coordinating the engagement of interested parties to enhance aid effectiveness and ownership has become the sector’s issue of the day.
In line with this focus, the One Plan, One Budget, and One Report approach brings all participants in the health sector to the same level of mutual accountability. This approach also aims to consolidate all commitment, efforts, and approaches of stakeholders on to one platform, where the plans, budgets, reports, and evaluation processes appear as one integrated package. In 2007, this approach was incorporated into the International Health Partnership (IHP) which was proclaimed in Paris. Its basic principles are (a) enhancing the ownership of aid in recipient countries, (b) aligning and harmonizing aid efforts concerning the health sector, and (c) realizing efficiency and mutual accountability to achieve strong and sustainable health systems in developing countries.
On the basis of the principles of the IHP, Ethiopia prepared its own country compact in 2008. Consequently, the Millennium Development Goals Performance Fund (MDG PF) was crafted as an instrument to bring the compact’s commitment into practice, starting with two donors who together contributed US$10 million to the fund. In 2009, to guide the administration of this fund, the first Joint Financial Agreement (JFA) was signed, containing the main responsibilities and duties of the government and donors. Both the number of participants in the fund and the amount contributed to it were far below what had been hoped for because of the leadership and coordination constraints of mobilization. Realizing this, the Ethiopian government launched overall efforts to enhance its coordination and reform efforts in political diplomacy, leadership, structural adjustment, and capacity building.
The coordination mechanisms practiced since 2009 have been tailored to the context of the country and are based on IHP principles and MDG PF structures. The overarching coordination mechanism has been led by the Joint Consultative Forum (JCF), which consists of ministers and heads of bilateral and multilateral development partners. It focuses on and discusses strategic issues every quarter. The JCF is technically supported by the Joint Core Coordinating Committee (JCCC), which includes experts from the Federal Ministry of Health (FMOH) and development partners (DPs) and focuses on planning, evaluation, and auditing and reporting systems. Without the JCF’s consent, no plan is approved and implemented in Ethiopia’s health sector. This coordination has helped to align the interests of different stakeholders and to enhance the effectiveness and efficiency (the value for money) of aid through improved allocation of money toward commonly identified gap areas, common administration, and mutual accountability. Furthermore, the Ethiopian government, being nourished with these flows of coordinated information and lessons, has transformed its internal process of business administration.
The DPs have also used their own coordination facility, the Health, Population, and Nutrition (HPN) Forum, since 2009. They set their own agenda, identify challenges, and discuss them in detail through this platform. “When we come to JCCC meetings, we sound as one voice reflecting the issues that are agreed on in the HPN consultations,” said a health expert from Irish Aid.1 The HPN Forum also invites and incorporates the interests and perspectives of civil society organizations (CSOs) that work with donors on specific health programs. This triangular coordination mechanism helps to consolidate and integrate the overall efforts in the health sector and align different interests.
Besides strengthening the coordination efforts, the Ethiopian government has focused on its planning process as a means of leveraging leadership and commitment. The planning system, which uses both top-down and bottom-up approaches, encompasses, includes, and accommodates the voices of all who are engaged with the health sector, enabling the government to play its leadership role. Having prepared these clear strategies, the government could use them to convince donors to join the network of the health sector fund. The country’s prime minister and leaders in the sector have geared all their efforts toward attaining the MDG goals, with strict leadership in the implementation of plans in mutually accountable bases, particularly since the third HSDP was enacted in 2008. “The Ethiopian government’s plans and strategies are so attractive that they are worthy of being financed by donors,” asserted one expert from the United Nations Population Fund (UNFPA).2 Because of these efforts, the JFA was revised in 2011, and the number of participants and their contribution amounts increased significantly, from 2 to 8 and from 10 million to 230 million, respectively.
In summary, the outcomes registered in the Ethiopian health sector over the past 15 years are impressive. The coordination, negotiation, transformation, implementation of strategic drafting processes, and, particularly, the bringing of stakeholders to a uniform level of concern and consensus have helped to fill the gaps in the sector efficiently and effectively by increasing the value for money spent on development. This process has greatly improved the sector’s overall results, particularly in HIV prevalence and maternal and child health, and the strength of the health system’s infrastructure.
- Operationalizing effective leadership and coordination systems for better health outcomes in Ethiopia
- Abebe, Engida
- Global Delivery Initiative; KDI School
Operationalizing effective leadership and coordination systems for better health outcomes in Ethiopia
Global Delivery Initiative; KDI School
|Series Title; No||Global Delivery Initiative|
|Subject||Social Development < Health|
|Holding||Global Delivery Initiative|