Ethiopia

Last Updated: May 5, 2011

Senior Program Officer:

Diana Kizza, MSc

• Program Activities
• Health Sector Architecture
• Health Financing
• Budgeting
• Budget Flows and Reporting
• Budget Performance
• Parliamentary Notes
• Immunization Performance Indicators
• Disease Burden
• Useful Links

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Program Activities:

• September 2008: Program Officer Diana Kizza and Dr. Michael McQuestion held introductory visits with Ministry of Health and GAVI partner agency counterparts.
• July 2009: P.I. Ciro de Quadros and Program Officer Diana Kizza met with the First Lady and parliamentarians in Addis.
• September 2009: Director Mike McQuestion conferred with Ethiopian parliamentarians during an African Parliamentary Union conference on health financing, held in Addis.
• October 2009: Mike McQuestion and Diana Kizza organized first parliamentary briefing in Addis.
• March 2010: Senior Program Officer Diana Kizza attended the AMMRIRA health resource mobilization workshop hosted by the WHO on resource mobilization for Ethiopia’s measles elimination campaign in Addis Ababa.
• February 2011: Kizza and McQuestion met with ministers of health and finance and conferred with external partner counterparts in Addis.

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Health Sector Architecture:

• The health infrastructure consists of about 15,000 health posts (kebeles), 819 district health offices (woredas), 98 health zones and 11 health regional bureaus. There is an EPI focal point in each health region. (Sources: (a) Fed. Ministry of Health, Annual Performance Report HSD-III 2009-09; (b) National presentation, African Regional Immunization Conference, Harare 2009.)
• In 2008-09, the Ministry of Health was extensively reorganized. A series of core civil service and Business Process Re-engineering reforms were implemented. An annual bottom-up (Woreda) planning process and a new Health Management Information System were introduced. Each health program was placed in one of three Directorates: Agrarian, Urban and Pastoralists.
• Ethiopia is not a SWAp country.
• Ethiopia is a fully inaugurated IHP+ country. A country compact was signed in August 2008. Read more here.
• As of 2009, seven external partners were pooling funds in the MDG Performance Fund.
• A Central Joint Steering Committee, with government and external partners represented, coordinates health sector planning. An Inter-Agency Coordinating Committee coordinates national and external immunization system inputs. The ICC met five times during 2007.
• The Government began decentralizing health services in 1994. With decentralization, line ministries no longer directly control sectoral activities at operational levels. Donors are thus allocating less aid directly to sectoral bodies. A number of health donors directly fund selected regions and weredas, bypassing the federal budgetary structures.
• Chronic staff vacancies limit health sector performance, particularly at wereda level.

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Health Financing:

• In 2008-09, health accounted for 10% of the government budget. (Source: Fed. Ministry of Health, Annual Performance Report HSD-III 2009-09.)
• In 2007, Ethiopia spent US$30 per capita on health. Health accounted for 10% of recurrent government expenditures. (Source: Countdown to 2015 Report, 2010)
• In 2008, Ethiopia received US$158.0m in Official Development Assistance for health, down from US$380.8m in 2007. (Source: OECD Creditor Reporting System)
• Annual federal block grants are sent to nine regional councils. The latter allocate funds across sectors and transfer the funds to over 600 wereda councils. In 2005, block grants to regions accounted for about 38% of government expenditures.
• Since 2002 a Development Assistance Group has coordinated all external aid to the country. One of its aims is to increase the proportion of aid that is in the form of direct budget support and in compliance with sectoral programs and policies (programmatic versus project support).
• Since 2005, Ethiopia has used a unique aid management tool, the Protection of Basic Services (PBS) modality, to increase budget oversight and transparency. The PBS modality ensures that direct budget support from external partners earmarked for certain health commodities, capacity building and service delivery at sub-national levels is used only for those purposes.
• Highly Indebted Poor Countries (HIPC) / Multilateral Debt Relief (MDR) Initiatives: Ethiopia began receiving HIPC debt relief credits in November 2001. As of mid-2009, the country had received credits totaling US$3.35b (of a total commitment of $6.62b). As per the Sustainable Development and Poverty Reduction Program (PRSP), the government has used these savings to invest more in poverty-reducing programs, including PHC delivery (from $733.4m in 2001 to $2.5b in 2007). This is more than a three-fold increase in poverty-reduction spending. Source: IDA/IMF. HIPC and MDRI- Status of Implementation: September 15, 2009.
• Immunization Financing
  
  • In 2007, US$54.8m were spent on immunization, of which the Government provided $3m (6%). Most external immunization funding is off-budget.
  • According to the 2006-2010 cMYP, $17m were spent in 2004 specifically on the routine EPI program ($6 per infant born that year). Adding in shared health services expenditures to support EPI increases this to $24.0m ($9 per infant). The government financed $805,721 of the specific routine EPI expenditures (3.4 percent), less than $1 per infant.
  • According to the WHO/UNICEF JRF, the Ethiopian Government spent US$ 1,393,280 to immunize about 3,229,000 infants in 2009, an investment of less than $1/infant. This amount represented 12% of the total 2009 routine EPI budget.
  • According to the 2010-2014 cMYP, total EPI expenditures in 2009 were $56.7m. This figure suggests the government’s share was about 3 percent.
  • In 2010, the Ethiopian Government financed over 50% of the operational costs (around US$3.2m) of a round on measles immunization campaigns (SIAs). Over half of the national contribution came from subnational governments. (NOTE: Only seven of eighteen African countries that had them paid 50% of more of their 2010 measles SIA operational costs.
  • Amount spent (USD) by the government of Ethiopia on routine immunization per infant (2000-2010)
    

  
  Source:
  WHO Vaccine Preventable Disease Monitoring System, 2008. Immunization Profile: Ethiopia. All data derived from the WHO/UNICEF Joint Reporting Form as follows:
  a: C_6450. This % excludes any external financing from donors.
  b: C_6490. This % includes all recurrent, immunization-specific spending financed solely with government funds. This includes vaccines, injection supplies, salaries, and per diems of health staff working full-time on immunization, transport, vehicles, and cold chain maintenance, training, social mobilization, and monitoring and surveillance.
  "NA" indicates data not available.

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  Budgeting:

  • During the period 2002-2005, government funds accounted for around 45% of the country's development budget; official development aid accounted for the rest. (Source: 2007 PEFA Report).
  • Ethiopia adopted its 2nd generation Poverty Reduction Strategy Paper (Sustainable Development & Poverty Reduction Program) in 2006. This document provides the policy basis for the national development budget.
  • The government uses a medium-term expenditure framework. The Ministry of Finance and Economic Development, with the line ministries, prepares the proposed annual budget. The proposed national budget includes budgets from the eleven regions and over 600 operational weredas. This bottom-up budgeting process is hampered by the large proportion of external funding that is earmarked for specific programs or provided outside of regular government channels.
  • By 7 June, the MoFED must submit the proposed budget to parliament (House of Peoples' Representatives). Parliament votes on the budget by 7 July, the end of Ethiopia's fiscal year.
  • The MoFED notifies regions, by 16 January, of the provisional amounts to be transferred. The regions review and propose changes in the provisional budget. However, actual budgeted amounts are communicated in November, long after the fiscal year has begun.
  • According to the 2007 PEFA Report, this budget calendar has been followed closely since 2005.

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  Budget Flows and Reporting:

  • According to the 2007 PEFA review, cash forecasting from federal to regional, and from regional to wereda levels, is routine. Budgetary ceilings, however, are quite low. Actual block grant disbursements are predictable and match forecasted amounts.
  • Sub-national entities have little allocative flexibility. Nearly all of the funds are for salaries and other fixed recurrent costs.
  • The budget uses clear, functional classifications. Funds disbursed are traceable to service delivery points. However, decentralization and block grants make it difficult to follow funding to particular sectors and programs.
  • The MoF Social Budget Department and the Economic Budget Department receive monthly expenditure reports from each budgeted government entity. Every three months these reports are consolidated. Voted and executed budgets are compared according to the budget's functional classification, down to project level.
  • An annual fiscal report is consolidated in October.
  • As of 2008 the regional health bureaus were still not accounting adequately for external immunization funds they had received.
  • In 2008-09, the MoH did not generate real-time reports for quarterly disbursements to the regional health bureaus. Many Woredas had difficulty reporting financial data to the MoH due to shortages of skilled personnel. Regions did not fully utilize their budgets. (Source: Fed. Ministry of Health, Annual Performance Report HSD-III 2009-09.)

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  Budget Performance:

  • In 2008, Ethiopia’s routine EPI Program immunized 2,173,426 children with DTP3 and spent around US$19.5 per DTP3 immunized child (US$42,355,219 total), down from $27 per DTP3 immunized child in 2006. (Source: GAVI Annual Progress Report, 2008 and GAVI Annual Progress Report, 2006)
  • Country Policy and Institutional Assessment:
    The World Bank 2007 CPIA gave Ethiopia's budget and financial management systems (Indicator #13) a score of 4.0, up from 3.5 in 2005. (mean 2007 score for all IDA countries: 3.2) Read more here.
  • The 2007 PEFA review gave Ethiopia's budget high ratings with respect to credibility, procedures and implementing pro-poor spending policies. An annual budget calendar is followed, a budget circular is issued to all institutions and the latter have input to the final budget.
  • However, over 10% of government expenditures were off-budget during the 2002-2005 period. Service delivery was weakened due to disbursement uncertainties. One reason was that originally agreed primary expenditures were changed in-year.
  • In-year and end-of-year budget reports are completed, however, there is no in-year budget monitoring by regional or national legislatures. As with budgeting, reporting is hampered by the significant amounts of earmarked and off-budget aid flowing into the regions and weredas.

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  Parliamentary Notes:

  • The Parliament of Ethiopia is bicameral: The House of Federation (135 seats) is the higher chamber; the House of People's Representatives (547 seats) is the lower.
  • The House of People's Representatives Budget and Finance Standing committee reviews and proposes amendments to the annual budget. The Public Accounts Committee reviews annual audits, conducts hearings and formulates follow-up recommendations.
  • According to the CABRI/OECD (2007) survey, each ministry presents its programmatic results annually to the parliament. The Ministry of Health reports to the Standing Committee on Social Affairs.
  • The most recent parliamentary elections were held on 23 May 2010 (Source: ElectionGuide).
  • Chapter III, Article 41 (Economic, Social and Cultural Rights) of the Ethiopian Constitution states: “The State has the obligation to allocate an ever increasing resources to provide to the public health, education and other social services”

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  Immunization Performance Indicators:^*

  Percent of districts reporting at least 80% coverage (DPT3), 2008^*: 46%
  

  ^*Source:
  WHO Vaccine Preventable Disease Monitoring System, 2008. Immunization Profile: Ethiopia. Data derived from the WHO/UNICEF Joint Reporting Form, Indicator GSA17ap. "NA" indicates data not available.

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  Disease Burden:

  Population (2008): 80,713,000
  Births (2008): 3,093,000
  U5 Deaths (2008):
  - total 321,000
  - preventable by routine EPI: 44,940¹
  - preventable by routine EPI and new vaccines: 80,250²

  ^{(Source: UNICEF "State of the World's Children" 2009 )}

  ¹ Assumes use of BCG, DPT, polio, and measles vaccines prevent 14% of U5 deaths.
  ² Assumes use of BCG, DPT, polio, measles, HepB, Hib, yellow fever, and pneumococcal antigen-containing vaccines prevent 25% of U5 deaths.

  Note: Vaccine preventable death estimates assume that force of infections, individual susceptibility, and probability of exposure are constant at all mortality levels.

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  Useful Links:

  • SIF Sabin Ethiopia Country Fact Sheet.
  • SIF Sabin Ethiopia Country Poster .
  • Country Profile from Africa: The Good News
  • Poverty Reduction Strategy Paper 2006
  • CABRI/OECD : Africa Budget Survey
  • Sabin Global Network Neglected Tropical Diseases Country Page
  • GAVI Country Data
  • Millennium Development Goal Monitor