DGCS

Office IX Evaluation

ETHIOPIA
Italian Contribution
to the Health Sector Development Programme,
2010–12
AID 9459

PICTURE OF THE PROJECT

Primary Hospital – Zway - Oromia

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LIST OF CONTENTS

ACRONICS AND ABBREVIATIONS

SECTION “A”
BACKGROUND AND CONTEXT

A.1 - ETHIOPIA: THE LOCAL CONTEXT

A.2 - HEALTHCARE FRAMEWORK
SECTION “B”
THE PROJECT AID 9459: ITALIAN CONTRIBUTION
TO THE HEALTH DEVELOPMENT PROGRAM (HSDP) 2011-2012
B.1 - INTRODUCTION
B.2 - PROJECT FORMULATION
B.3 - THE INTERGOVERNAMENTAL AGREEMENT
B.4 -PROGRAMME CHANNELS AND THE BUDGET LINES
B.4.1 – C1
B.4.2 – C2
B.4.3 – C3
B.5 - OBJECTIVES, EXPECTED RESULTS AND INDICATORS
B.6 - FINAL FINANCIAL STATEMENT AND CONTRACTS
B.7 - MONITORING & AUDIT
SECTION “C”
EVALUATION MISSION AND INTERVIEWS
C.1 - TIMETABLE OF THE MISSION TO ETHIOPIA
C.2 - EVALUATION INTERVIEWS

SECTION “D”
THE EVALUATION
D.1 - THE EVALUATION
D.1.1 - OROMIA
D.1.2 - TIGRAY
D.1.3 – QUESTIONNAIRES ANALYSIS
D.1.4 - THE EX POST & IN ITINERE PROJECT EVALUATION
D. 2 – RELEVANCE OF THE OBJECTIVES
D. 3 – ACHIEVEMENT OF THE OBJECTIVES
D. 4 – PROJECT ANALYSIS
D.41- RELEVANCE
D.4.1 – EFFICIENCY
D.4.2 – EFFECTIVENESS
D.4.3 – IMPACT
D.4.4 – SUSTAINABILITY
SECTION “E”
LESSONS LEARNED & RECOMMENDATIONS
E.1 – LESSONS LEARNED
E.2 – RECOMMENDATIONS

ANNEX 1: Tables
ANNEX 2: Questionnaires
ANNEX 3: Photo Report
ANNEX 4: Documents

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ACRONICS & ABBREVIATIONS

AA – Addis Ababa
AN- Anaesthesiologist Nursing
ANC – Ante Natal Care
ANC4+ - Antenatal care with 4 or + controls during pregnancy
AOSCF - Azienda Ospedaliera S.Camillo Forlanini
APR - Annual Performance Report
ARM - Annual Review Meeting
BB - Blood Bank
BSc - Bachelor in Science
C - Channel
CAR - Contraceptive Acceptance Rate
CCM - Country Coordination Mechanism
CPR - Contraceptive Prevalence Rate
CTU - Central Technical Unit
DGDC - Directorate General for Development Cooperation
ET: Evaluation team
ETB - Ethiopian Birr
EFY -Ethiopian Fiscal Year
EMT - Emergency Medical Technician (Ambulance)
ER - Expected result
FMoH - Federal Ministry of Health
G -Goal (MDG)
GH -General Hospital
GoE - Government of Ethiopia
GoI - Government of Italy
HC - Health Centre
HDA - Health Development Army
HDI - Human Development Index (UNDP)
HEP - Health Extension Program
HEW - Health Extension Worker
HHRI - Health & Health Related Indicators EFY 08
HM - Harmonisation Manual
HMIS Health Management Information System
HO - Health Officer/Operator
HP - Health Post
HPI-UNDP - Human Poverty Index
HQ - Head Quarter
HRB - Health Regional Bureau
HSC - Health Science College
HSDP - Health Sector Development Programme
HSTP - Health Sector Transformation Programme
HZB - Health Zone Bureau
IESO - Integrated Emergency Surgical Officer
IHP - International Health Partnership
IMR - Infant Mortality Rate
LLIN - Long Listing Insecticide Net
LF- Logical framework
LMF - Local Management Fund
LTU - Local Technical Unit
MoFA- Ministry of Foreign Affairs
MMR - Mother Mortality Rate
MoE - Ministry of Education
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MoFED - Ministry of Finance and Economic Development
MDGF - Millennium Development Goals Fund
MDG- Millennium Development Goal
NHA - National Health Account
OHB - Oromia Health Bureau
OPD - Out Patient Department
PASDEP - Plans for Accelerated Sustainable Development and End of Poverty
PBME - Planning Budget and Monitoring Evaluation (OHB)
PFSA - Pharmaceutical Fund Supply Agency
PH - Primary Hospital
PNC - Post Natal Care
PPFDG-Policy Planning and Financing/General Directorate (FMoH)
RH - Referral Hospital
RHB - Regional Health Bureau (OHB e THB)
SAR – Semi-annual Report
SDG - Sustainable Development Goals 2030
SBA - Skilled Birth Attendance
SM- Short Mission
TAMU -Technical Assistance and Monitoring Unit
TH - Teaching Hospital
THB - Tigray Health Bureau
UFMR - Under 5Yrs. Mortality Rate
UNDP -United Nations Development Program
WBHSP - Woreda Basic Health Sector Planning
WDG - Women Development Group
WHO - World Health Organization
ZHB - Zone Health Bureau

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SECTION “A”
BACKGROUND AND CONTEXT 

A.1 - ETHIOPIA: THE LOCAL CONTEXT

Ethiopia is a landlocked 1.127.000 Km2 country, with around 90 million people (76 habitants /Km2)). In
1974 Haile Selassie was deposed by the Derg, a Marxist–Leninist military dictatorship led by Mengistu
Haile Mariam who ruled the country until 1991 when the Federal Republic was established. Ethiopia is
divided in 9 Regions (Afar, Amhara, Beneshangul-Gumuz, Gambela, Harari, Oromia, SNNPR, Somali
e Tigray), subdivided in 78 Zones, 809 Woreda and two Autonomous Metropolitan Administrations
(Addis Ababa and Dire Dawa). The 64% of the population adheres to Christianity among which 45%
are Orthodox, while Catholics and Protestants are 19%; the remaining 33% of the population is Islamic
with a small percentage (3%) belonging to other Religions. The current Government has been engaged
in important reforms identified in the Plan for Accelerated and Sustained Development to End of Poverty -
2005-2010” (PASDEP) and in the “Growth and Transformation Plan 2011-2015” (GTP). Such commitment
made Ethiopia a reliable international partner and a priority recipient country for the Italian
Cooperation. Despite registering a remarkable economic growth in its GDP (10%/year) and a
significant decrease in poverty rate from 39% in 2005 to 26% in 2013, Ethiopia is still underdeveloped
ranging 174/188 in the Human Development Index 2015 (HDI-UNDP)1.

A.2 THE HEALTH CARE FRAMEWORK

The Health Sector Development Programme (HSDP) 1998-2015 represented the true turning point for
improving the Ethiopian health conditions and showed to be instrumental in achieving all the
Millennium Development Goals 2015 (MDG) with a particular focus on:

¾ G4: 2/3 reduction of the under 5 mortality rate

¾ G5: 3/4 reduction of the maternal mortality rate
¾ G6: stop and invert the HIV/AIDS, malaria and TB incidence

The HSDP (EFY/1991/2007- Greg.1998/2015) represents a four stages process which is split as
follows:
• HSDP I -1998/2002
• HSDP II-2002/2005
• HSDP III-2006/2007
• HSDP IV- 2007/2015 2

                                                            
1 UNDP, Accelerating Inclusive Growth for Sustainable Human Development Report, 2015 
2
 http://www.nationalplanningcycles.org/sites/default/files/country_docs/Ethiopia/ethiopia_hsdp_iv_final_draft_2010_‐2015.pdf 
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From 2011 the last stage of the Program has been received the support of Aid 9459 targeting Oromia
and the Tigray Region aiming at:
• strengthening the local health system at a district level by integrating the basic healthcare
services devoted to care and prevention with the hospital based services;
• harmonising and coordinating the actions taken by the Ethiopian Government with the
community of Donors according to the Health Harmonisation Manual (HHM) laying down the
rules of the international aid and in line with the International Health Partnership (IHP) (2007 and
2008) which sets the guidelines to enter into bilateral and multilateral cooperation agreements;
• programming and monitoring health results according to the transparency rules (accountability
and ownership);
• strengthening the government organisational leadership in order to achieve the expected health
results, and;
• enhancing a performed-based involvement of local communities compared to planned targets;
in this regard, a formalisation of the Health Development Army (HDA), officially recognised
by the Government as a social movement for the improvement of rural health, is crucial to
achieve this objective. Within such movement particularly worthy of notice is the Women
Development Group (WDG) which acts as representative of the civil society to foster and protect
maternal health.

In 2004 during the realisation of the second phase of the HSDP, the Government promoted the Health
Extension Package that has led to an increase of health staff at all level with the recruitment of more
than 32.000 trained health professionals; as a result of the reform a new professional figure has been
introduced: the Health Extension Worker (HEW) who works closely with the Women Development
Group as contact point for basic health care in rural areas. Most of the newly hired HEWs are young
women who following a one-year training course are pairing assigned to rural Health Posts (+16.000).
Based on the experience and on results obtained, HSDP IV emphasised 4 main principles to improve
basic healthcare in rural areas: a) access and usability; b) quality and innovation, c) empowerment and
community involvement; d) emergency management of maternal and child health. In order to achieve
the planned objectives, HSDP have made use of the Millennium Development Goal Fund (MDGF)
directly managed by the Ethiopian Government and enhanced by a specific aid component of the Aid
9459. Health has been the main sector supported by the international Donors with a special focus on
the achievement of the G4, G5 e G6 in the most vulnerable rural areas. The most recent National
Healthcare Account (5° NHA 2010-2011) amounted to 26.5 billion ETB (1.2 billion US dollars) of
which 11.8% were assigned to Oromia Region with 33 million of inhabitants and 7.8% to the Tigray
Region where live about 5.5 million people (APR/EFY/2007). Just the16% of the National Healthcare
Account is composed by assets while the 34% came from patients own contribution, except as to child

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and maternal health and HIV/AIDS; malaria and TB. The remaining 50% is provided by the
international aid amounting to 600 million USD, 1.3% of which comes from the Italian contribution to
the MDGF and to the HSDP IV in Tigray and Oromia.
The HSDP IV was concluded in June 2015 thanks to an additional contribution from the Italian
Cooperation (Aid 1008 and Aid 10418). Recent dates issued in the Health & Health Related Indicator
(HHRI-EFY/08) confirm that in 2015 the national healthcare expenditure was in line with the previous
years and split as follows:

o 502 million USD from the Ethiopian Government;

o 379 million USD from international Donors;
o 251 million USD from the MDGF.

At the moment 268 million USD in relation to the past years are not yet disbursed by the international
donors. Furthermore in the total amount of the international aid contribution to Ethiopia some
relevant projects funded by USAid (Channel 3) have not been harmonised (See Box 52-
APR/EFY/2007). Despite between 2004 and 2011 there has been a 138% increase in expenditure on
health, the health per capita expenditure (16.1 USD) is still far from the 60 USD average for bringing
the public national health standards into the line with WHO norms (WHO 2015). At the moment
without external aid the Ethiopian Federal Health System would not be able to maintain the current
health standards; economic and the professional support from international Donors represent
indispensable tools to enhance local capacity building towards the achievement of the three 2015 health
MDG that should be better structured by the Health Sector Transformation Program (HSTP -EFY
2008/2012). Ultimately, in order to secure better health conditions for the Ethiopian population,
economic sustainability will be delayed until the MDGs 2030 are achieved. 

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Ethiopian Regions 

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SECTION “B”
THE PROJECT AID 9459:
ITALIAN CONTRIBUTION
TO THE HEALTH CARE SECTOR DEVELOPING PROGRAM

B.1 Introduction
From the time of introduction of the Italian Aid Funds and later with the Law 49/87 on Development
Cooperation, Ethiopia has always been declared a priority country for Italy; such policy remained
unchanged even in times of crisis when targeted humanitarian actions and infrastructural interventions
continued to reach the country. In the healthcare sector, in line with the Italian support provided to the
Ethiopian 20 years- HSDP, the Intergovernmental Agreement, signed on 10 November 2010 in Addis
Ababa between the Italian Ambassador and the Ethiopian Minister of Finance, has resulted in Aid
9459. Starting on 18 March 2011 and concluded in 16 September 2014, the Program contributed to the
MDGF and supported the implementation of HSDP IV in the Oromia and Tigray Region. In order to
ensure continuity to the development of the national health system the Italian Ministry of Foreign
Affairs-General Directorate for Development Cooperation recently approved two Programs (Aid
10081-Resolution 121 19/ 09/ 2013 and Aid 10418 Resolution 140- 11/11/2014) that are currently on-
going.

B.2 - Program formulation

The development of the Program has been carried out from January to April 2010 by the Central
Technical Unit and Local Technical Unit (DGCS-MAECI) closely with Ethiopian counterparts; The
program aimed to achieve the implementation of the health related MDGs 2015 paid a particular
attention to reduce children under 5 mortality rate (UFMR), mothers mortality rate (MMR) and stop
and reverse HIV/AIDS, Malaria and TB incidence. The attainment of those goals has been supported
by strengthening the local health staff, recruiting additional health professionals to be distributed at the
basic health services in Oromia and Tigray and by enhancing the health management information
system (HMIS). With a budget of to € 8,2000.00, the program falls into the expenditure Chapter MFA
2182 as donation; € 7,000.00 of the financing package has been disbursed as untied aid while the
remaining € 1,200.00 was tied. Aid 9459 splits into three channels, C1, C2, and C3, paid according to
Art.15 of the Regulation of the Italian Law 49/87. € 6,400.00 aid donation falling into the Channels 1
and 2 was granted to the Federal Ministry of Health in order to support the MDGF and to the Oromia
Health Bureau OHB) and to Tigray Health Bureau respectively to implement HSDP IV with a
€1,800.00 specific financial contribution for the Local Management Fund and for the Expert Fund
(Technical Assistance and Monitoring Unit).

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The Program aims to:
• a 2/3 reduction of the under 5 mortality rate (U5MR);
• a 1/3 reduction of maternal mortality rate (MMR);
• reduction of HIV/AIDS, malaria and TB.
The Program implementation strategy planned to:
1. strengthening the regional healthcare system with a special emphasis on ante-natal and post-
natal care;
2. upgrading local human resources for health while training and recruiting new health personnel;
3. promoting family planning and contraception;
4. extending children vaccination programs and further information campaigns on nutrition and
against intestinal worms;
5. introducing an early detection system of poverty related diseases in line with G4, G5 and G6;
6. developing a national health information management system.

B.3 - The Intergovernmental Agreements (IA)

As stressed above, over the years the Italian Ministry of Foreign Affairs has always renewed its
commitment to Ethiopia trough a set of Bilateral Agreements that in accordance with the principles of
the Paris Declaration on Aid Effectiveness (2005) jointly drown up an action plan to develop the
Ethiopian heath system so as to improve the local health conditions. In order to start up the Program
four Agreements have recently been concluded:
• International Health partnership (IHP) Global compact (2007);
• Ethiopia IHP Country compact (2008);
• Annual Review Meeting (ARM) of the Ethio-Italian Country Programme (2009);
• Agreement-Aid 9459 - Italian contribution to the "Health Sector Development Programme"
(HSDP IV) 2010.
The Agreement3 - Aid 9459 was approved by the Resolution (n°65 of 17 June 2010) of the Italian
Directorate General for Development Cooperation - Ministry of Foreign Affairs (DGCS/MAECI)
and, as stressed above, focused on:
• improvement of access to and quality of prevention and treatment health services in Tigray
and Oromia;
• improvement of maternal health;
• optimising the allocation of financial resources for health by developing an efficient health
information system able to analyse relevant data at both federal and regional level.

                                                            
3  Diplomatic litigation (n° 310334 of 22 September 2010) Protocol n° 3787/2010  

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In order to ensure continuity with work already undertaken, after the end of the Aid 9459 (16
September 2014) two new Programmes were approved in 2013 and 2014 respectively (Aid 10081 and
Aid 10418).

B.4 Programme channels and the budget lines

AID 9459 aimed both to finance the MDGF and support the implementation of HSDP IV in Oromia
and Tigray; the financial contribution was divided into three different channels:
C1: 35% devolved to the MDGF;
C2: 43% for implementing HSDP IV in Oromia and Tigray;
C3: 22% for financing technical assistance of local and expatriate consultants (Technical Assistance
Monitoring Unit).

B.4.1 - Channel 1 (C1)

The contribution falling into the Channel 1 amounts to € 2.900.000,00 has been used to support the
MDGF at national and regional level as both to reduce child and maternal mortality rate and stop
poverty related diseases (malaria, HIV/AIDS and TB). Another relevant purpose of the MDGF was to
develop a Health Monitoring Information System able to collect, analyse and disseminate from local to
federal level. The MDGF, established in 2007, aimed at supporting and promoting the achievement of
health related MDGs in 50 Developing Countries; Ethiopia was among the countries which benefited
most from the Fund and the allocation of the Channel 1 marked a formal resumption of the Italian
financial contributions to the Fund which was temporarily interrupted. The Channel 1, paid in one
solution, was directly managed by the Federal Ministry of Health and partly integrated through the
Channel 2 devoted to the training of new skilled health professionals (Health Extension Workers and
Health Development Army) and supply of medicine in Oromia and Tigray.
Despite the MDGF amounted to 251 million USD to support the achievement of the heath-related
Millennium Development Goals (G4, G5 and G6), according the operating procedures of the Fund the
Federal Ministry of Health could not ask for details from the international Donors. The situation
turned out to be better at regional level where the Channel 1 has taken forward targeted actions in both
academic and training field, paying a special attention to the HEWs to be spread over local Health
Posts. Furthermore confirming the strong commitment of the Federal Government to supply, storage
and distribution of medicines, each regional administrative unit has got a Pharmacy with essential
medicines which are free of charge for the maternal sector and for the prevention and treatment of
poverty related diseases. 
 
 

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B.4.2 - Channel 2 (C2)

The channel, amounting to € 3,500,000, has been disbursed to support the HSDP IV in Oromia and
Tigray Regions; the contribution has been paid in two instalments per year (€ 1.750.000,00) to the
Federal Ministry of Health who was itself responsible to pay the entire amount to the Oromia Health
Bureau and to Tigray Health Bureau. Channel 2 is split into two sub-components: C2a and C2b as
follows:

• C 2a (Oromia Region): the € 1,150,000 contribution had been paid in two tranches of € 500,000
and € 650,000 respectively; all amounts received have been paid by the Federal Health Ministry to
the Oromia Health Bureau which took step to plan ETB 27,535,5034 actions to achieve the G4, G5
and G6.
• C 2b (Tigray Region): the funding amounted to 2,350,000 and has been split into two tranches per
year of € 1,250,000 and € 1,100,000 and utilised by the Tigray Health Bureau to reach the G4, G5,
and G6 MDGs.

Channel 2 aimed to foster the regional implementation of HSDP IV through a set of targeted specific
actions whose consolidated cost statements have been disseminated during the Meetings organised in
Addis Ababa and Mekele on 6 February 2016 and on 19 February 2016 (see par. B6 and Box 3 and 4) 

B.4.3 - Channel 3 (C3)

The Channel amounted to € 1,800,000 and was directly managed by Local Technical Unit of the
Directorate General for Development Cooperation. The contribution, in this case too, was divided into
2 sub-components:
                                                            
4 ETB 55.845.811,00

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• € 1,200,000 was allocated to the Expert Management Fund in order to employ external consultants
who provided technical assistance to Ethiopia in the framework of short-term missions that
totalled to 44 months of work.
• € 600,000 for the following logistic and functioning costs of the Tamu:
(a) contracts of employment for expatriate experts;
(b) contracts of employment for local consultants and current staff at the Technical Assistance
Monitoring Unit (Tamu);
(c) Tamu's office services and utilities;
(d) car maintenance;
(e) scientific publications and research.

The consolidated cost statement of the three channels is detailed in the box here below:  

C1 € 2,900,000.00 MDGF
C2 € 3,500,000.00 HSDP IV
C2a € 1,150,000.00 OHB
C2b € 2,350,000.00 THB
C3 € 1,800,000.00 Expatriate Technical Assistance
FGE € 1,200,000.00 Expert Italian missions
FGL € 600,000.00 TAMU office
Total € 8,200,000.00

 
B.5 - Objectives, expected results and indicators

General objective: improve the health conditions of the Ethiopian population in line with the G4, G5
and G6 of the MDGs.
Specific objectives:
i) enhance and improve both regional coverage and quality of the prevention & treatment healthcare
services;
ii) strengthen the Health Management Information System as to up-grading the current human
resources for health and improving access to primary health care services in Oromia and Tigray
regions.
Indicators:
• per capita annual attendance of the basic healthcare services;

• percentage of updated catchment areas relating both to local Districts and health care centres;

• percentage of healthcare facilities staffed with skilled personnel.

Expected results:
1. Federal Ministry of Health granted with sufficient financial resources to implement the HSDP;
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2. capacity of collecting, organizing, processing health information at all levels enhanced;
3. information and awareness rising material (APRs and bulletins) better disseminated among
development stakeholders and decision makers;
4. health and medical reports more timely and comprehensive;
5. health staff relationships bettered at all levels;
6. number of health professionals per health facility increased;
7. access to quality and use of mother and child health care services improved;
8. access to quality and use of prevention services improved;
9. access to quality and use of care services improved.
Result 1 – Indicators:
• funds supplied according to the plans;
• number of Italian Experts within the federal Health institutions.
Result 2, 3 and 4 –Indicators:
• percentage of timely and complete official health reports;
• regular issuing of the Annual Performance Reports and bulletins by the Federal Ministry of
Health.
Results 5 and 6- Indicators:
• Health staff ratio to the resident population according the current national benchmark (medical
doctors: 1/36,158; nurses: 1/3,870; Health Extension Workers (HEW): 1/2,544).
Results 7, 8 and 9- Indicators:
• percentage of deliveries assisted by skilled health staff (benchmark: 10%);
• measles immunisation coverage (benchmark: 77%);
• percentage of houses provided with insecticide-treated bed nets (benchmark 66%);
• success rate of Tb treatments (benchmark: 84%);
• number of Hiv/Aids infected people treated with antiretroviral drugs (benchmark: 152,472).

B.6 - Final financial statement and contracts

The Channel 1 merged in a single payment into the MDGF managed by the Federal Ministry of Health
without the obligation of issuing a detailed reporting of the actions undertaken to each international
Donor; the quarterly reporting by the Federal Ministry of Health merely confirmed the utilisation of
the contribution during scheduled management meetings towards the achievement of G4, G5 and G6.
A consistent part (64.4%) of the MDGF has been provided to technical equipment, while the 22% has
been used to favour the strengthening of the health system. The remaining funding has been divided as
follows:

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• 1.4% maternal and child health;
• 1.3% human resources for health development;
• 2.4% prevention and control of communicable; and non-communicable diseases;
• 3.5% training of health extension workers.

In practice the MGDF mainly supported: a) regional medicine supply; b) medical and diagnostic
equipment for obstetrics; c) development of the Health Management Information System to inform
the annual planning of the health needs; d) training; e) increase in the health staff (health extension
workers)

The Channel 2 was disbursed through 2 instalments each one targeting different topics:
C2a (Oromia Region)
A) human resources development
B) statistical system monitoring
C) supply and equipment
D) other healthcare services
E) HQ HMIS-OHB 
C2b (Tigray Region)
F) human resources development
G) goods and services;
H) other healthcare services 

The sub-Channel C2a and C2b amounted respectively to € 1,138,863.00 and € 2,318,537.40 respectively
and, converted at the variable exchange rate of the ETB, produced a € 43,675.00 savings which has
been allocated to the continuation of the actions listed above.

The Channel 3 was managed by the Directorate General for Development Cooperation and Local
Health Unit /Italian Embassy in Addis Ababa, subdivided into the Expert management Fund (EMF)
and Local Management Fund (LMF).
• The Expert Fund funded the technical assistance of 3 experts (one medical doctor and one
administration officer) for a total amount of 44 months and 12 days of work. When the Aid
9459 expired in 16/09/14, the Expert Fund had still a € 385.441,81 residual cash flaw which
shows that the average cost of an expert is about € 18.500,00 per month.
• The final balance of the Local Management Fund has been attached to the Programme Activity
Report which provided a comprehensive analysis of the objectives achieved and has been
detailed as follow:

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Channel C3: Local Management Fund
1 Purchase of equipment 0.00
2 Management 566,746.11
2.1 TAMU's offices rent (June 2011- August2014) 80,860.45
2.2 Utilities and taxes 17,681.95
2.3 Stationery and printed matter 12,126.20
2.4 Transfers and Transportation 30,354.43
2.5 Insurances 9,455.99
2.6 Maintenance 26,623.62
2.7 Local staff (8 employment contracts for Tamu's staff) 82,449.90
2.8 Overheads 307,193.58
3 Activities 33,253.89
3.1 Researches and studies 30,379.07
3.2 dissemination of result 2,874.82
TOTAL 1+2+3 600,000.00

The expenditure item 2.7 "Local staff" includes 8 employment contracts of the TAMU 's staff: 1
accounting assistant, 1 secretary, 3 drivers, 2 guardians, 1 cleaner (See Attachment- Box 2: List of local
personnel). The 2.8 - Overheads is the largest item of expenditure including:

a) the salaries of 5 member staff entrusted with technical tasks during the periods laid down in the Box
2 (see Attachment: List of the local staff)
b) the salary of a consultant with a local contract (the deployment of such consultant was necessary to
ensure the continuity of the Aid 9459 when the Expert Management Fund did not employ experts
consecutively (See Attachment - Short missions by experts).  
 
B.7 – Monitoring and Audit
Thanks to the contribution of the Channel 3, Tamu's Office was responsible to monitor the activities
implemented in the framework of C1 and C2; monitoring actions have been carried out by 2 medical
doctors and one administrative assistant with the support of 5 consultants and other experts all hired
through a local contract. Despite the danger of interfering with the Federal health planning
undermining the national ownership, Tamu's Office ensured that the level of operational functionality
of the Programme was maintained over time by implementing actions that received particular praise at
local level. Monitoring results have been regularly disseminated through Bulletins and Reports5 by the

                                                            
5
Federal Ministry of Health, Annual Health Performance Report and Midyear Health Performance Report

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Federal Ministry of Health documenting difficulties that arose during the implementation of the
Programme such as the impossibility of improving the regional health performance that is still below
the target levels, particularly as regard the maternal mortality rate (G5). The constant monitoring
activity has been also instrumental to unable changes and modifications in line with the regional
specific health needs. At the end of the programme two monitoring meeting have reported the
activities implemented in Oromia and Tigray by detailing the expenditures statements (see Tab 3& Tab 4)
   

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SECTION “C”
EVALUATION MISSION AND INTERVIEWS
On January 2016 following an in-depth desk analysis the evaluation team approached the Tamu's Office
and the former Local Technical Unit to organise the evaluation of the Aid 9459; the mission timetable
involved 4 different steps to be undertaken both in Italy and Ethiopia:

Step 0: Rome, Italy;

Step 1: Addis Ababa, Ethiopia;
Step 2: Oromia Region, Ethiopia;
Step 3: Tigray Region, Ethiopia.

Step 0: Rome, Italy

In February 2016 the evaluation team, composed by Mr. Gianluca de Vito MD and Mr. Carlo Vittorio
Resti MD, made contact with Mr. Pasquale Farese MD, Head of the Tamu's Office who made available
program’s documentation while providing information on its operational conditions. During this
preparatory phase the position of Mr. Edao Simba (Graduate in Public Health) as local Expert has
been reconfirmed. After receiving an update from the Italian Embassy in Addis Ababa of
organisational arrangements for the mission, the evaluation team moved to Ethiopia from 28 February
to 13 March 2016. In order to better assess the activities undertaken in the framework of the HSDP IV,
during the stay in Ethiopia 83 meetings with interviews and as so many visits on the field have been
organised; furthermore 98 questionnaires have been submitted to local health staff, students and
healthcare users.

C.1 - Timetable of the mission to Ethiopia 

Step 1: Addis Ababa, Ethiopia
The stay in Addis Ababa took 4 days (29 February-3 March 2016 and 10 -12 March 2016) and required
the presence of the entire evaluation team:
o Mr Gianluca de Vito- Medical doctor (Referent for the evaluation in Tigray)
o Mr Carlo Vittorio Resti - Medical doctor (Referent for the evaluation in Oromia)
o Mr Edao Simba - Graduate in Public Health (Evaluation assistant)
12 relevant stakeholders for the three Channels have been reached during 20 technical and information
sessions organised at the following duty stations6:
o C1: Federal Ministry of Health, Tamu's Office and Pharmaceutical Fund Supply Agency
o C2: Oromia Tigray Bureau, Addis Ababa Univ. Services (C2a) and Tamu's Office (C2a and C2 b)
o C3: Tamu's Office and Local Techical Unit
                                                            
6
For further details see Tab 5 

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Step 2: Oromia Region mission
The evaluation mission has been carried from 2-9 March 2016 by Mr Gianluca de Vito with the
support of the evaluation local expert Mr Edao Simba and the health officer from the Oromia Health
Bureau Mr. Girmai Alemayen. The ET carried-out 23 field visits that involved a 1.350. km drive to
Adama, Bokogj, Asela, Sahashamane, Ziway, Woliso, Ambo and Addis Ababa (see the route in the
figure below).
During such visits there have been intensive talks with 27 health directors who provided information
on the steps undertaken both to improve child and maternal health and implement HSDP IV.

Figure: Map of the Oromia travel.

Field visits sorted by category:
• Health Zone Bureaux (Adana, Asela and Wolisso);
• 3 Universities and Health Science College (Ambo, Asela and Shashamane);
• 2 Health Management Information System (Adana and Asela);
• 2 Blood Banks (Adana and Woliso);
• 3 Referral Hospital (Asela,Woliso and Shasahmane);
• 4 Primary Hospital (Bokogi, Shashamane, Welenchiti and Ziway);
• 4 Health Centre (Dole, Neghele, Welenchiti and Wolisso);
• 2 Health Posts: (Wolisso Zone - Rural Communities & Mountain Zone).
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The evaluation work focussed on:
• direct inquiry;
• photographic record;
• consultation of the official sources of information;
• interviews with health contact persons;
• interviews with health and academic focus groups;
• interviews with contact points for logistics and organisation.

Step 3: Tigray Region mission

The evaluation in Tigray took place from 2-9 March 2016 under the direction of Mr Carlo Vittorio
Resti assisted by the Tamu's consultant Mr Million Admassie and supported both by Mr Ebrahim
Hassan, Senior Adviser at the Tigray Health Bureau and by Mr Hailu G. Michael (Ngo CCM). In order
to carry-out the planned field visits the evaluation team used a car rental service with an 814 km trip on
the route between Mekele- Adigrat- Mekele (see map below).  

 
Figure: Map of the Tigray travel

Field visits sorted by category:

• 2 Health and Science College (Axum and Mekele);
• 1 WoHO (Gantafeshum);
• 1 T/Refferal Hospital (Mekele);
• 4 G/Primary Hospitals (Adigrat, Axum, Mekele and Wukro): n. 4;
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• 4 Health Centres (Adwa, Agula, Mekeleand, Zalanbessa);
• 3 Health Posts (Adwa, Gola and Solodda).

The evaluation work focussed on:

• direct inquiry;
• photographic record,
• consultation of the official sources of information,
• interviews with health contact persons,
• interviews with health posts focus groups.

C.2 - The evaluation interviews

During the mission to Ethiopia the evaluation team visited 40 programme sites. In order to review
expected results and achieved objectives 83 interviews have been done and 98 questionnaires submitted
to health personnel, students and patients. Above a detailed list of interviews carried out:

In ADDIS ABABA
Meeting and interviews Location Interviewees 
3 management meetings for Italian Embassy Mr.Giuseppe Mistretta, Italian Ambassador
introducing the programme Ex UTL Mrs Ginevra Letizia, Head of the LTU 
and organisational issue  
9 logistic, operational and TAMU Mr. Pasquale Farese MD, Programme manager
evaluation meetings (C1, C2 Mr. Paolo Melilli - Administration officer
and C3) Mr. Million Admassie - Local consultant
Mr. Yilma Abdisa - Local consultant
Mr. Solomon Hagos - Local consultant
Mr. Tibebe Akalu - Local consultant  
2 management meetings (C1) PFSA Mr. Meskele Lera - Head of Pharmaceutical Fund Supply
Agency (PFSA) 
FMoH Mrs. Mekolen Enkossa MD (Head of MDGF)  
3 management meetings (C2a) OHB Mr.Lemma Desu, Deputy Process Owner PBMB
HMIS Mr.Serbesa Dereje, Health Officer HMIS
Mr.Eyob KifleABH - University Services  
In OROMIA
Meetings and interview Location Interviewees 
Mr. Teshone Hunde, Head - Adama
6 managing meetings for Zone Health Mr.Mebvotu Assefa, Deputy Head - Adama
information and review (C1 and Bureau Mr. Abebe Shevanghizaw, Zonal Coordinator - Adama
C2a) Mr Haji Abdela, Deputy Head - Asela
Mr.Tefera Feysa, Head - Woliso
Mr. Suitan Ebranim, Planning Team Leader - Woliso  
2 managing meetings for Health Mr. Serbeza Dereje, Coor. Residential Course Adama
information and review Information Mr. Addisu Abebe,Resp. - Asela  
Management
System
2 managing meetings for   Mr. Gebru Gebre, Head - Adama
information and review  Blood Bank Mr. Olana Badate, Head - Woliso  
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4 managing meetings for University Mr. Eyob Kifle, Resp. ABH Services (Univ.Jimma)
information and review Health Science Mr. Gabi Hussein, Academic Affairs Officer - Asela
College Mr. Kali Hussen, Dean HScS - Shashamane
Mr. Hani Gruma, Head Pharma Dept. - Ambo 
12 managing meetings for Primary Mr. Gindo L. Gutama, Chief Officer PH - Welenchiti
information and review Hospital   Mr. Bethelem Worku, MD Director PH - Welenchiti
  Mr. Teshome Yibru, IESO PH Welenchiti
  Mrs. Urgeessa Mirkessa, Chief Nurse HC - Welenchiti
  Mr. Wegene Tadesse, MD Director PH - Bekogi 
   
Health Centres Mr. Infermiere di guardia HC - Neghelleù
  Mr. Infermiere di guardia HC - Dole
  Mr. Akililu Hailu MD Director PH - Ziway
Mr.Stefano Contini MD Director RH Cuamm - Woliso
 
Mr. Infermiere in servizio, HC - Woliso  
Health Posts  
Health Extension Worker - Health Post - pastoral area
Health Extension Worker - Health Post - rural area  
In TIGRAY:
Meeting and interviews Location Interviewees 
Mr. Hagos Godefay, Head, Tigray RHB
8 information and evaluation THB Mr. Goitom Gigar, D/y Head, Tigray Regional Health Bureau
sessions Mr. Ebrahim Hassan, Advisor to TRHB Head
Mr. Tedros Tsehaye, Head PPD
Mr. AmlaG/Mariam, Head of HRD
Mr. Ataklti Taddese, acting Head Financial Department
Mr. Solomon Negussie, HMIS Expert
WoHO Mr.Taeme G/Kirkos, Head Gantafeshum WoHO 
8 information and evaluation GH Mr Mehari Desalegn, MD Wukro Hospital
sessions PH Mrs.Astede Girmay, MatronWukroHospital
Mr. Meskel Beyene, CEO Adigrat Hospital
Mr. Tewodros Fesseha, MD AdigratHospital
Mr. Habtom G/Hiwot, CEO Mekele Hospital
Mr. Adeba Zewdie, PR, MekeleHospital
Mr. Mical W/Gabriel, CEO, AxumHospital
Mr. Tsegazeab Tsehaye, MD Gyn.AxumHospital 
Mr. Meheret Girmaye, HEW Gola Genhanti HP
Health Mr. Beriha G/Michael. MW Bizet HC
Centres  Mr. Mariam Beyene, HIT, Bizet HC
12 information and evaluation   MrGedey Berhane, HEW, Soloda HP
sessions   Mr. Berkti Abera, HEW, Soloda HP
  Mr.Sellassie Awetahegne, HO Adwa HC
  Mrs.Tsainesh Egsiabier, MW Adwa HC
  Mr. Mussie G/Giorgis, Head Agula HC 
   
Health Posts Mr. Sintayehu Belay, HEW Level IV Mesanu HP
Mr. Bezu Taddese, HEW Level IV Mesanu HP
Mr. Hailu G Michael, PH Expert Adi Shum Dhun HC 
3 information and evaluation University Mr. Tsegaye Kenfe, Tutor Mekele HcSC
sessions HScS Mr. Dagnew W.Giorgis, Dean Mekele HScC
Mr. Prof Dejen Yemane - Head, Ayder School 

The list of interviewees clearly shows the lack of women in management roles while there is a high
female representation in nursing and midwives sector. With the exception of few young women doctors

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in position of responsibility (e.g. Health Directors of the new Primary Hospitals) the majority of
female health staff is employed in the healthcare services. This is the case of the Health Extension
Workers who following a one-year training course are often based at rural Health posts (75%) with the
lowest salary in the healthcare waging setting framework. Despite women play a lesser role in the
Ethiopian health System, the Government is largely in favour of their inclusion into the healthcare
sector. During the mission the evaluation staff enjoyed a friendly and supportive work-environment
where local counterparts provided all the information needed; also when moving to the planned field
visits, they did not experienced unexpected problems, despite the recent tensions inside the Oromia
region and a severe drought affecting the Tigray.

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SECTION “D”
THE EVALUATION AND PROJECT ANALYSIS

D.1 - Project evaluation

According to regional and national information gathered, Oromia and Tigray have done a long way and
made quite considerable progress in improving basic healthcare. The 20-year-HSDP has considerably
strengthened:
a) health buildings (new primary hospitals, health centres, health posts);
b) diagnostic equipment;
c) medicine supply;
d) academic, professional and specialist training;
e) human resources for health and local healthcare services;
f) prevention (immunisation, family planning and contraception);
g) health information management system.

The enhancement of the basic healthcare network has made possible the achievement of the health
related MDGs; the evaluation work paid a particular attention to the under 5 mortality rate that showed
a significant decrease, thus making it easier to reach the G6 (fight against malaria, HIV/AIDS and TB)
especially in the child and maternal sector. The evaluation staff pointed-out the under performance of
the maternal mortality rate with respect to the target set out in the G5 (1/3 decrease); in this regard
there is a discrepancy between the data recorded by the World Health Organisation (WHO) and those
by the Federal Ministry of Health. While the WHO reported a national maternal mortality ratio of 350
deaths/100,000, the Federal Ministry of Health confirmed 676 deaths/100,000.

D.1.1 - Oromia Region

Oromia reported results and health performance which are better than Tigray which has always
benefited from international aid for the health sector. Considering that Oromia is the most populated
(33.692.000) region with very poor health conditions, such results are even more significant.
Adama situated at 70 km from Addis Ababa is the Oromia capital where the Oromia Health Bureau is
based. The city is easily accessible by the new motorway to Djibouti and very soon it will reachable by
train thanks to the railway partly funded by the Chinese Government. Oromia is bordered by
Beneshangul Gumuz, Amhara and Afar (north) Somalia (east), Gambela (west) and Kenya (south). It is
politically split into 13 Districts with 2 Special Towns (urban areas); furthermore the region is also
divided in Health Zones consisting of 310 Woredas and more than 7.000 Kebelas.

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Maps of Oromia region and zones

Following the HSDO IV, the regional healthcare system is composed by:
• 5 Teaching Hospitals;
• 4 Referral Hospitals;
• 13 General Hospital (managed by the Oromia Health Bureau);
• 53 Primary Health, mostly built through HSDP III and IV;
• 1.325 Health Centres;
• 6.500 Health Posts located in remote areas.

The current net of health facilities has been enhanced in the framework of HSDP IV by realising new
single floor health buildings which are reasonably equipped. The next step was to launch a recruitment
plan and at same time upgrade the health personnel currently on-duty.
The professional categories enriching the Oromia health system were in details:
• 220 integrated emergency surgical officer who are newly graduated professionals working for
the maternal emergency service within the Primary Hospitals
• 674 up-graded nurses specialised in the framework of the C2a (Level 3) in obstetrics,
anaesthesia, pharmacy, radiology
• 480 up-graded operators with a specialisation (Level 4) at the Health & Science College who are
in charge of contraception and family planning.

The ways through which such up-grading can be implemented provides a 3 months paid leave (summer
months) for training for 4/6 consecutive years as to limiting the absences from work. At the University
of Asela and Ambo there were 83 trainees (35 midwives and 48 pharmacy technicians) who graduated
in June 2016; a forthcoming increase in healthcare workforce is expected at the end of academic year.
In order to manage the emergency in obstetric and neonatal care and to ensure the transportation of
blood bags from the blood banks to hospitals, 40 new vehicles and 840 ambulances have been placed in
all over the region. The improvement in emergency transportation has been positive influenced by a
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better road network and by a car maintenance service provided by the Aid 9459 through the Channel
2a. An important result in the child and maternal care has been achieved by the enhanced coverage of
ante-natal care services which registered a high involvement of pregnant women; 92% of the mothers
to be accessed to the first obstetric visit while 72% continued to access to more than 4 obstetric follow-
ups during pregnancy. In Oromia the average of deliveries attended by skilled health professionals
reached the 70% compared with the national average of 72% and with the Tigray average of 100%.
The development of ante-natal services at the primary hospitals strongly contributed to reduce
maternal mortality by preventing delivery complications and by providing women with echo graphic
monitoring and emergency surgical services. The new figure of Integrated Emergency Surgical Officer
(IESO) is an innovation within the primary hospitals at which is added a regular be-weekly blood
supply from the Blood Banks. However blood transportation from the five regional blood banks to
remote healthcare facilities is very difficult because of long distances and poor roads. It follows that
transportation costs are very high and vehicles qualified for blood transportation often encounter a
rapid wear. Unfortunately this situation is unlikely to be eliminated in the near future: the availability of
vehicles coupled with a car maintenance service (Aid 9459) currently ensures that blood bags cover at
least emergency cases albeit at high costs. The 5 regional Blood Banks - of which Adama acts as focal
point, deal with blood collection, frozen storage and distribution - result to be closely related to the
achievement of G4 and G5.
A part of the channel C2a has been utilised for delivering the following supplies:
• medicines, technical devices and hospital furniture distributed to 120 Health Posts and 32
Primary Hospitals;
• spare parts for vehicles and maintenance for 60 ambulances;
• computer equipment for developing the Health Information Management System;
• 5 electrical generators for the regional 5 Blood Banks.

The evaluation staff identified problems with regard to diagnostic devices provided by Chinese
suppliers without a maintenance contract; despite many of these devices resulted unusable just at
installation there is no obligation by suppliers to repair them.
This problem has been also identified with the 5 electronic generators for maintaining the cold chain in
the event of power failure: they were found to be completely oversized in relation to the electrical
power required by 2 chillies, 1 freezer and the normal lighting in the offices. What is telling about this is
the case of the Woliso Blood Bank where a small portable generator was able to make-up the lack of
electricity during a power failure whereas the maxi-generator after 10 months it has been purchased was
not already in place because of difficult installation coupled with high energy consumption deriving
from its excessive power.

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Despite the difficulties that are identified, Oromia and Tigray are the best performing regions towards
the achievement of G4 G5 and G6 objectives, particularly as regards access to and quality of maternal
and child health services.
In summary the evaluation confirmed:
o proper involvement of the local population in rural and remote areas, especially women;
o regular supervision of the health extension workers entering the service into Health Posts;
o fair coverage of the rural healthcare network (Health Posts, Health Centres and Primary Hospital);
o central role of Health Centres in managing:
• contraception and family planning
• immunization campaign to be made at Health Posts
• deliveries assisted and monitored (ante-natal care)
• referral of urgent cases to Hospitals
• epidemiological data storage at all levels in particular:
a. each health post is endowed with a physical archive consisting of patient medical files hold by
the household head and containing medical conditions and history of all family members;
b. health Posts and Health Centres record and detain epidemiological details by utilising 23
different types of registries;
c. Health Zone Bureaux developed the digitisation and transmission of health data to the
Oromia Health Bureau.

 
Performances Registers

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D.1.2 Tigray Region
Tigray region is divided into 52 Districts (Woredas) and 792 villages (Kebelas). The resident population
is 5.055 million people (H&HRI/EFY08) 23% of which are women of reproductive age. Because of
severe droughts and water shortages agriculture is abandoned so fuelling an increasing urbanisation 
 

 
Maps of Tigray region and zones

Following the HSDP IV the regional healthcare networks consists of:

• 1 Teaching Hospital - Ayder University in Mekele;
• 14 General and Primary Hospitals connected with:
- 225 Health Centres
- 668 Health Posts
During the evaluation mission 17 programme sites have been visited with 30 health directors
interviewed as key informant persons on the achievement of G4, G5, and G6.
• Hospitals
1. Wukro General Hospital, 45 Km N from Mekele;
2. Adigrat General Hospital, 122 Km N from Mekele,
3. Axum General Hospital, 196 Km NW from Mekele;
4. Mekele General Hospital and Kwiha Centre;
5. Adyer campus & Referral and Teaching Hospital, Mekele.
• Health Centres
1. Bizet Health Centre, N from Adwa;
2. Adwa Health Centre;
3. Zalanbessa Health Centre (on the border with Eritrea);
4. Agula Health Centre, East from Wukro;
5. Adi Shun Duhm Health Centre, in Mekele.

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• Health Posts
1. Gola Genahti Health Post, Adigrat District;
2. Solodda Health Post, Adwa District;
3. Mesanu Health Post, East from Agula.
• Woreda Health Office (WoHO)
1. Gantafeshum WoHO, just outside Adigrat Town.
• Health Science College (HScC)
1. Mekele HScC;
2. Axum HScC.
The evaluation mission identified a healthcare and prevention network which is in line with the federal
standards with health posts, health centres and primary hospitals staying at the basis of the pyramid of
the regional health system. In the framework of HSDP IV there has been an increase of health posts
(+35%) each of which is staffed by 2 trained health extension workers. Health Posts represent the first
contact of patients with the health system by providing basic healthcare services most of which are
supplied free of charge (e.g. child and maternal care, immunization, contraception and family planning).
Moreover it is important to stress the close cooperation between the Health Extension Workers and the
WDG Leader who for several years have been actively working to support and promote reproductive
health in rural areas. Health centres staffed with up-graded personnel, represent the first focal points
for ante natal care; they are also qualified for treating urgent patients from Health Posts and, if
necessary, refer them to Primary Hospitals which are able to rely on emergency surgical service mainly
supplied by the Emergency Surgical Officers. Lastly, Specialist and Teaching Hospitals directly
depending on the Federal Ministry of Health constitute the vertex of the health system pyramid. Funds
for improving the existing healthcare service channelled into three relevant areas:
• human resources development
• supply of medicine, medical technical devices, goods and services
• development of the Health Information Management System

As demonstrated by the Tigray Health Bureau Annual Profile 2007/EFY the regional health system can
be distinguished by a strong governance and leadership which have led already to an increase in the
local community involvement. Through an in depth analysis of health data the Report reviewed both
the achievement if G4 and progress made towards the G 5 and G6. All health facilities visited received
funding from the Italian Cooperation (C1 and C2b), especially the Axum and Mekele Health and
Science Colleges both to improve education and training of middle level personnel and up-grade
Health Extension Workers currently on-duty. Moreover the supply of goods and services channelled
through the Aid 9459 showed to be instrumental in improving the quality of health services in Tigray.

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According a participated SWAT analysis carried-out through relevant focus groups, the strengths
characterising the Tigray health system can be summarized as follows:
• formal and informal contacts with the local population in rural and remote areas;
• sound degree of involvement and ownership of the health facilities by local communities,
including in kind contributions (cereals to prepare meals for mothers to be);
• respect for the traditions in rural areas which results in a strong civil cohesion and mobilisation;
• monthly monitoring by issuing performance reports;
• significant progress in the initiative "zero home delivery in all health facilities" in order to
mitigate the 3 leading causes of delays leading to maternal deaths: 1) choice to ask for help, 2)
choice of the health facility , 3) suitable treatment for the difficult delivery;
• Sound referral system for deliveries managed by skilled staff both at Health Posts and Health
Centres according to the Comprehensive Emergency Obstetric and Neonatal Care. Despite Primary
Hospitals usually do not have areas to accommodate women who have travelled long distances,
they provides an assessment of the appropriateness of the more urgent cases;
• extended catchment areas able to treat patients from both neighbouring Eritrea and Afar
Region;
• better data collection with a special focus on the registration by the Health Extension Workers
of child and maternal details (e.g. expected date of delivery);
• development of an economic incentives system able to provide health staff with a formal
recognition of achievements as regards both quality and management of healthcare services.

Weakness points relates to:

• poor health buildings; most of the visited health facilities are old buildings with insufficient
maintenance;
• reception conditions are critical (paediatrics department at Axum Hospital);
• low ratio of health staff to the resident population despite improvements in education and
training which resulted in a task shifting (simple malaria and pneumonia treated by the Heath
Extension Workers);
• difficulties in the distribution of medicines and health equipment in the most remote areas
despite considerable improvements of the regional supply chain;
• lack of periodic maintenance for medical devices: during the evaluation visits some medical
equipment resulted underused and not suitably installed (e.g. radiant cradles for newborn);
• frequent power and water failures that put at risk the regular provision of health service;
• lack of an impact evaluation of the in-service and pre-service trainings including their suitability
to meet local needs;

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• monetary and in-kind contribution of local communities to the regional health system is not
clearly identified; at the moment the National and Regional Health Account not include a
specific funding component from the communities. In order to address the problem there are
on-going pilot studies on the Community Health Insurance.

Opportunities for the Tigray Health System through the Italian Cooperation are:
• strong political leadership resulting in a consistent social participation;
• constant increases in health investments whereas they are very far from reaching the 15% of
GDP as recommended in the Abuja Declaration (2015)
• sound economic support from the Federal Ministries and ability to attract investors and donors
• rapid development of Biomedical and Public Health Research Centres (Adi Shun Dhum
centre);
• extensive information campaign on available healthcare services and an effective regional
network dealing with gender and child and maternal related topics; over the last ten years after
the introduction of the Health Extension Package a marked increasing in access to healthcare,
immunisation and family planning services have been recorded. Over 5 years the average
proportion of deliveries assisted by skilled staff has increased from 24% to 69% with a
declining maternal mortality ratio;
• efficient community-based health services (Health Posts) where Health Extension Workers, also
thanks to a better data collection system, have a direct knowledge of local community health
conditions.

D.1.3 - Questionnaires analysis

In order to review the perceived results of HSDP, during the evaluation mission 94 questionnaires,
sorted in 4 different formats, have been distributed to four target groups:
• Managers and consultants;
• Patients and their families;
• Courses attendants and students;
• Health staff.

The First questionnaire:

The 1st Questionnaire, distributed to 11 health managers and consultants, stresses once again the
commitment of the FMoH in improving child and maternal health. Target G4 scored higher, followed
by G6 and G5. All respondents except one rated good the information received, regarding the mother
& child health activity carried out at federal and regional levels: they sure enough attended the
numerous meetings that were held on the matter. The acknowledgement of the progress made by the
public health care service since 2011 was unanimous in both regions and the suitability of the staff for

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the meeting of targets G4, G5 and G6 was also recognized by all. The prevention, diagnosis and care
activity was rated sufficient by 70% and was praised by 30%. The APR 07 data showed that the gender
policies realized by the FMoH worked well too. The mothers and children’s health improved and the
family-planning, contraception and the vaccine services were appreciated by the population. It surfaced
that in the mother & child sector the emergency management inefficiencies were mostly caused by: a)
lack of diagnostic equipment; b) insufficient training of the newly employed staff; c) too limited human
resources to keep the health rural needs running round the clock. The efficiency of the ambulance free-
transport service in obstetric emergency, from HC to equipped primary hospitals (PH), was frequently
compromised by the poor vehicle maintenance. In Tigray the ambulances are also few and the rural
roads in poor conditions. Furthermore, the health care facilities’ catchment areas were too wide and not
in line with federal targets. According to the people interviewed an average of 50% of the population
benefited from HSDP IV while 20% in Tigray and 30% in Oromia respectively were still outright
excluded or did not benefit at all from the public health care services. The final satisfaction score for
the training activity was 8/10 and 7/10 for the quality of the health care services provided.

The 2nd Questionnaire, given out to 14 patients/families (users) 50% women and 50% men, most of
them farmers and housewives with families (20% with families bigger than 4 people), showed that the
service overall improved during the implementation of HSDP IV. 50% lamented the distance of the
HCs and the HPs, while 50% said they are close enough to be reached on foot. The mother (according
to G5) and child (according to G4) mortality rate was deemed to be in general decreased in local
villages. According to the people interviewed, the remaining cases of child mortality were not caused by
the health care inefficiencies or shortcomings, but by extreme poverty, ignorance and distance from the
health care centres. 90% said they trust the basic health care service. Overall, the mother & child free
health care service was rated suitable. Regarding G6 all of the interviewed people knew the
transmission mechanisms of Hiv/Tb. They all used mosquito malaria prevention nets at home and
went with children U5 to the HPs and to the HCs to be tested with immediate disposable diagnosis kits.
The final satisfaction score for the health care services was 7/10.

The 3rd Questionnaire given out to 20 MD students of Asela and Ambo Universities and to Nurses &
Midwifes trainees at the Ziway Primary Hospital, particularly:
a Upgrading Midwifes (Asela University.) and Pharmacy Technicians (Ambo University.) with 5/10
years hospital experience (Lev.3) (C2a)
b Students enrolled in Medicine university courses.
They all belonged to 4 or more people families. The most relevant family cost is the health care one,
followed by food and lastly by studies. Half of them were hospital trainees (MD students and
Upgrading Health operators) and all confirmed an increase of HCs and HPs in their area during the
implementation of HSDP IV, and rated the professional expertise of the hospital staff to be fair. The

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majority of them thought the family-planning service should have to be strengthened in order to reach
G4 and G5, also envisaging the involvement of women. They also stressed the necessity of an upgrade
of the hospital diagnostic equipment, besides adequate training courses for the staff. They also pointed
out that the outpatient ANC service at the HCs was very simple, envisaging just obstetrics inspections
for mothers and HIV/AIDS and Malaria screenings, with eventually the transport of more complicated
cases to equipped h/24 surgical primary hospitals. The pregnant women ultrasound-scan based
diagnosis, deemed fundamental by all the interviewed, at present carried out just in hospitals (where
often the instruments are out of order), should instead be available in the HCs, they suggested.
Although doubts surfaced regarding the surgical expertise of the IESOs in the hospitals (PHs) they
helped in reducing mortality rate in the complicated deliveries. It appears from the questionnaires that
in order to reduce the mother & child mortality rates the upgrade of the equipment and the increase of
the diagnosis services would be necessary together with the strengthening of the family planning and
contraception action. The final satisfaction score for the training activities was 8/10 and for the quality
of the health care services 7/10.

The 4th Questionnaire was given out to 52 HOs (Health Operators) provided with university diploma or
degree (4-year course at least) and employed in PHs, HCs and HPs: 37 HOs questionnaires in Oromia
and 15 HOs questionnaires in Tigray. Most of them came from 4 people or more families. They had
been working for as long as 1 to 5 years, being adequately paid for their work. 2/3 of them were
carrying out burdensome round the clock surveillance services making also for the staff deficiencies
(75% complained about their demanding shifts at their workplace). They said their family cost were first
of all directed toward the food purchase, then toward studies and lastly toward health care. They all
shared the idea that the mother & child health care deserved the greatest attention from the HSDP IV.
80% rated the professional upgrade, the supply of upgraded equipment and the involvement of women
to be the first tools in order to reach a decrease of the mother & children mortality (G4 e G5). They
unanimously said that in their area the health care services provision improved. The health care staff is
rated sufficient by most of them, while 10% instead rate them very good. The majority considered the
ANC service to be efficient in the HCs although to be upgraded. They pointed out that the ultrasound
system service for the population was poor: 65% of the service is provided by hospitals, the remaining
35% is provided by private urban centres because of the poor maintenance of the public health care
facilities equipment. According to the interviews the EISOs made a good job: they reduced the mother
& child mortality performing as surgeons in h/24 emergency service, although some of them were
considered not up to the task, considering too short the triennial practical university courses and then
mostly with any tutoring on the field. These were considered the top priorities in order to upgrade the
child and mother sector: a) strengthening the ambulance service; b) upgrade the equipment and the
medicine supply; c) implement family planning and contraception. Orthopaedic and Trauma surgery
was considered among the health care priorities to be provided to the population for free. The
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satisfaction score for the training activity was 7,5/10 and for the quality of the service provided to the
population 7,6/10.

D.1.4 - Project evaluation

The Channel C2, subdivided into two sub-channels C2a for Oromia and C2b for Tigray, to finalize the
activities as below described, was financially reported during two meetings called by the ET in Addis
Ababa at Oromia Regional Bureau premises (OHB) on 06.02.2016 and in Mekellè at Tigray Regional
Bureau (THB) on 19.02.2016.
Sub-channel C2a was utilized by the OHB for the following activities:
A. Human resources development: Aa) 119 graduated nurses; Ab) 146 graduated obstetricians and Ac)
124 pharmacists; Ad) 30 graduated health care environment technician; Ae) 47 graduated laboratory
technicians; Af) 18 HOs in training at ABH Service PLC of Addis Ababa (Jimma University); Ag) 72
Hospital radiologists.
B. Monitoring of the Info-statistics System: Ba) support to the ZHBs and OHBs x HMIS; Bb) 150
HOs in training WBHSP at ZHBs and OHBs.
C. Supply and equipment: Ca) 120 HCs and 20 Hospital supplied with drugs; Cb) 5 Electricity Maxi-
Generators for the 5 BBs; Cc) Inventories for 30 new Hospitals; Cd) 270 Metallic shelving supplied
to 12 Hospitals and 90 HCs; Ce) Spare parts for services vehicles; Cf) 10 PC e 23 Laptops supplied
to ZHOs and to OHBs x HMIS.
D. Other health care services: Da) 300 “Urban” HEW graduated; Db) 60 ambulances repairing; Dc)
Publications.
E. HQ HMIS-OHB: Ea) Telephone/internet costs; Eb) Contract for an IT technician.
Sub-channel C2b was utilized by the THB for:
F. HRD - human resources development: Fa) 211 H.A. graduated nurses; Fb) 566 HEW Clinic Nurses
graduated; Fc) 60 HOs + 20 Sanitarians in MPH; Fd) 40 Anaesthesiologists; Fe) 20 Pharmacists; Ff)
25 Laboratory technicians; Fg) 20 Radiologists; Fh) 15 Psychiatry nurses; Fi) 20 staff of THB; Fl)
20 staff of THB; Fm) project for a study: “progress in achievement MDGs”; Fn) 22 district managers
enrolled to universities for an MPH; Fo) Goods and services procurement for THB; Fp) PC for
HMIS Procurement; Fq) past graduation courses at Has Axum College; Fr) 40 Clinic Nurse for HOs;
Fs) Different training sites: goods and services procurement.
G. Goods and services: Ga) Drugs and biomedical equipment for Hospitals and HCs; Gb) Drugs,
equipment and consumer goods and tests disposable kits for HCs and HPs; Gc) Furniture for the
PHC Units of the Region; Gd) Furniture, beds, cradles, hospital trolleys; Ge) 60 District staff
supervising over activities and purchases; Gf) 24 G.I.S. experts coming from different districts for
the 3-day workshop; Gg) 1200 bulletin issued and given out at the PHC units; Gh) Other
equipment, beds, consumer goods.
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H. Other health care services–HMIS Capacity building: Ha) 284 IT technicians trained; Hb) workshop
for 142 health care operators about family statistics; Hc) employment of 1 technician for the
processing of HMIS data; Hd) 6,304 copies of the health care profile issued and given out; He)
2,000 copies of the Health Bulletin printed and given out; Hf) 50 laser printers purchased and
delivered; Hg) 9 digital cameras and telephone services for HMIS; Hi) 17 jet printers and stationery; Hl)
IT HMIS equipment; Hm) spare parts for the services vehicles and motorbikes in the Districts; Hn)
stationery and supply for the PHC Unit; Ho) data processing service; Hp) vehicles and ambulances
maintenance; Hq) internet-web Telecom for HMIS.
During the implementation of the HSDP IV the improvement of basic out-patients health services has
been monitored through performance indicators; in particular the sectors where such monitoring
activity has been displayed focused on:
1. family planning and contraception;
2. ante-natal care provided by the HPs;
3. referral and treatment of obstetric urgencies;
4. post natal care provided by the HCs;
5. mandatory immunisation coverage coupled with de-worming treatments;
6. nutrition and micronutrients deficiencies treatments.

The enhancement of these key-sector resulted in an improvement of in the U5MR that in 1997 was
217 deaths/1000 live births to 88 deaths/1000 live births in 2011during the IV stage of the program
supported by the Italian Cooperation. When in 2015 the program concluded the U5MR decreased yet
again (80 deaths/1000 live births) exceeding the G4 target (75 deaths/1000 live births). More optimistic
data issued by the United Nations report the outstanding result of 68 deaths/1000 live births. The
neonatal mortal rate steady declined since 2000 and continued to remain stable over 5 years with 37
deaths/1000 live births. Such results have been possible thanks to a network of health services
including immunisation coverage, family planning, obstetrics and paediatric controls and post natal
care.
In particular prevention services revealed to be pivotal in addressing demographic growth and limiting
teen age pregnancies also by sustaining the activities carried-out by the HHW who organised home
visits and school group meetings with the support of the Women Development Groups (WDG). There
are 195.864 groups in Oromia and 30.206 in Tigray each of which counts about 30 women who have
build a network of 880.975 in Oromia and 151.095 in Tigray. The WDG has proved to be crucial in
improving maternal health especially in rural settings.
The obstetric services provided a free of charge ante natal care service with 96.6% coverage; the
service is provided by an increasing number of HCs staffed with skilled personnel and when needed, a
free ambulance service to the Primary Hospitals is available.

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Primary Hospital is staffed with IESOs who are qualified to surgically treat the most urgent cases.
Post natal care services and paediatric controls allowed to achieve the 90% of performance also thanks
to the improved coverage of rural heath posts which acts as focal point for child health. Health posts
are usually managed by the HHW who can provide prevention and primary healthcare services by
utilising federal protocol for the treatment of the most common child diseases, referring to health
centres the most complex cases. Health Posts located in remote setting usually host also immunisation
campaign and de-worming treatment with the possibility of obtaining HIV/AIDS and malaria rapid
screening. The improvement of the territorial healthcare services contributed to reduce drastically child
deaths, child diseases (bronchopneumonia and gastroenteritis) and paediatric fevers.
The results that have been obtained document the commitment of the federal and regional
Government to achieve the G 4 and G6; as regard the G5 because of the introduction of IESOs in the
emergency management relevant data on obstetric urgencies still need to be analysed.
As reported in the project’s Logical Framework, the analysis of the objectives, the result indicators and
the expected results are the following:

General objective: improving the health of the Ethiopian population according to HSDP and in
compliance with the health care MDGs (G4, G5 e G6).
• The bettering health conditions of the local population obtained by the increased rural health care
net services, with adequate catchments areas, linked with the high registered performances (HMIS),
is measured on the basis of the average life expectancy, from 45 years in 1990 (WB/2011) to the
actual 63,7 years, (UNDP/2014).

Specific objectives: increase coverage and the quality of the prevention and care services by
strengthening the health information system (HMIS), up-grading the human resources.
• The welfare coverage and the quality of the basic health care services have been greatly improved,
with reference to the previous poor situation before the implementation of HSDP, from 1990 on,
with the quality set-up of the clinic local services, supported by a regular and efficient statistics and
epidemiological (HMIS) data collection, allowing a prompt evaluation of the population’s health.

Evaluation of the 3 Indicators

1) Annual outpatient services attendance (OPD) per capita (benchmark 0,3)
The benchmark (Vb) of the out patients health services (OPD), thanks to the implemented rural
health net, by passed the targets in mother & child sector. The OPD performances increased at
national level at 4.8% (H&HRI/EFY/08). The Tigray Region has achieved the best result in pro
capita OPD attendance to the population, up to 0.87%. Sufficient OPD result is reported in Oromia
Region, with 0.37% performances pro capita reported. The total number of the OPD performances
has registered 43.463.879 over a population of 90 million people. The Somali Region has reported
the worst OPD result with only 0.05% health performances pro capita.
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2) Percentage of Districts and HCs’ catchment areas adequately upgraded

The development of the federal and regional health rural net, mostly realized during HSDP IV,
envisaged the setup of standards for specific catchment areas as the rural target required in
APR/EFY/04:
• 1 Health Post (HP) /3,000/5,000 people;
• 1 Health Centre (HC) /15,000/25,000 people;
• 1 Primary /General Hospital (PH+GH)/60,000/100,000 people.
The completion of HSDP IV in June 2006, left several gaps causing delays in the usability of the not
yet finished health rural net, especially for the hospital services. The following chart shows that the
catchment areas targets of HPs and HCs were met both in Oromia and Tigray; not so it was for the
Hospital catchment areas that are still more than three time the standards:

Health OROMIA TIGRAY

facility
Complete Under Total People Complete Under Total People
and working constructio and working constructio
n n
HP 6,519 0 6.519 5,168 712 0 712 7,101
HC 1,320 93 1.413 25,524 202 0 202 25,030
PH 53 63 116 635,698(*) 15 0 15 337,067

(*) People and PHs - source: Bulletin Health and Health Related Indicator EFY/08 - (H&HRI/EFY/08)

On the below schema, published by the H&HRI/EFY/08, it should be considered that in Oromia
Region more than 50% of PHs are still under construction, with a considerable actual limit of the
specific standards catchment area. Moreover the 18 Referral/Teaching Hospitals, managed by the
FMoH, located in the urban area, are not included in the primary hospital rural net. So the standard
hospital catchment area is in progress, considering the total number of urban and under construction
hospitals referred to al list 246.268 habitants each, soon.
3) Percentage of health care facilities staffed according to standards
In the rural HPs the greatest effort was put in order to adapt the health staff to standards. The total
number of HEWs working in the HPs reached the remarkable figure of 42,336 at a national level
spread among the 16,447 suburban HPs (2or 3 HEWs average for each HPs). Despite the
strengthening of the hospital staffs the employment of a remarkable number of Laboratory
technicians, Anaesthesiologists, Radiologists and Ultrasound technicians, Pharmacists, IESOs, several
health-hospital facilities remain still understaffed.

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Project Indicators Synthesis Yes % Remarks

1. Annual outpatient services X 100% National 0,48 %
attendance per capita (benchmark Oromia 0,37%
0,3) Tigray 0,87 %
2. Percentage of Districts and HCs’ X 60% Optimized in HCs & HPs; in PHs the catchment
Catchment areas informed areas not yet optimized.
3. Percentage of health care facilities X 60% HPs up to the use; HCs suitable; not yet suitable
properly staffed according to the PHs 
standards
Total score 73% H&HRI/EFY/08

Evaluation of Expected Results:

1) FMoH provided with adequate financial resources for the realization of HSDP:
To achieve the health MDGs (G4/G5/G6), during the period from 2004-2011 the Health National
Account (HNA) increased 138%, amounting to 26,5 billion Ethiopian Birr /year, equivalent to
USD 1,2 billion. However the 50% of which was provided by the international donors (1.3% by the
Italian Cooperation) in bilateral and multilateral health aids. Considering the increased Health
Federal Budget (HNA), it is possible to document enough resources to conclude HSDP IV,
assuring an adequate health rural net at the population, documented by the high number of health
performances.

2) Data processing capability improved at all levels:

The HMIS, assisted by Tamu (C3), registered correctly statistics and epidemiological data both at
regional and federal level, documented periodically and officially a relevant scientific vision of the
national health situation, to spread better the health budget, according to the rural annual needs and
priorities. The SAR, APR and Health Bulletins regularly published and discussed in specific
meetings have confirmed this expected result.

3) Development partner and decision makers better informed through APRs and bulletins:
The issue of detailed SARs, APRs and bulletins was regular. They also contained information
regarding the top regional health care priorities provided in the following forms: Mid-Term Review
(MTR), Joint Review Missions (JRM) and Annual Review Meetings (ARM) that also represented a shared
institutional system of periodic monitoring with the support of Tamu MD experts and local
consultants and the participation of all the decision makers and partners.

4) Promptness and completeness of the routine health reports and relations improved:
The health data’s elaboration, performed by the HMIS, collecting basic paper registrations in the
community HPs and HCs, computerized in the PHs and in the Zone Health Bureaus, then
transmitted to the regional and federal levels for the statistical analysis, has obtained an international
accreditation, documenting periodically the local health situation in scientific form, as APRs and
Health Bulletins regularly documented. In 2015, at the end of HSDP, a Special Bulletin 17° Annual
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Review Meeting was published with the related Annual Performances Report/EFY/07, finally
synthesized on the Health & Health Related Indicators EFY/08. With the technical assistance of
Tamu' Office, the statistic and epidemiological FMoH publications should be considered a further
demonstration of the periodic monitoring and information supply to fortify the rural health net.

5) Health care staff increased:

Part of the C1 (4,8%) and of the C2 were spent for: a) upgrade of the already employed health
staff; b) health operators specialist training; c) staff increases was intended to strengthen the
territorial health care network (HPs, HCs and PHs) each managed by their own ZHBs above which
are the autonomous RHBs. The collected data confirm a remarkable increase in the staff number at
all professional levels APR EFY/07& bulletins:

In Oromia
• 1,805 Health Officers (0.54/100,000 people);
• 3,324 BS graduated obstetricians (1 /10,000 people);
• 13,679 nurses (10.000 people).
In Tigray
• 620 Health Officers (1.23/10,000 people);
• 647 BS graduated midwifes (1.24/10,000 people);
• 3,797 nurses (7.5/ 10,000 people).
At a National level
• 6,933 Health Officers (0.77 / 10,000 people);
• - 7,922 BS graduated obstetricians (0.88/ 10,000 people);
• - 44,418 nurses (4.93/10,000 people).

6) Increased percentage of the health net with personnel in line with federal standards
In accordance to the Indicator 3, considering adequate the health staffs in HPs and HCs at national
level, with maternal and child services improved, but still limited in the PHs, HSDP IV has realized
remarkable health educated staff increases, compared to the pre-existent poor situation. Although
the PHs still understaffed in 24/h duty especially can be ensured the emergency services through
overtime-work by their current personnel. In June 2016, thanks to the C2, newly graduated
specialist staff was employed in the primary hospital net.

7) Access to, quality and use of mother and child services:

According to the performance data APR/EFY/07 the access, usability and quality of the mother
and child services improved at all levels outpatient care, pre and post natal.
• Antenatal Care (ANC): pregnant women with only 1 pre-natal visit were 97% at national level
compared to 100% in Oromia and Tigray;
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• ANC: pregnant women with 4 pre-natal visits were 68% at national level;
• Deliveries assisted by skilled staff were 61% at national level.

Normally the deliveries are assisted only in the HCs, transferring in ambulance the complicate
pregnancy and the obstetric emergencies to the PHs, equipped by the 24/24 surgical service
(EISO). However in rural vast catchments areas, the childbirths were performed by HEWs in HPs
too, in order to avoid home-deliveries risky. Post-natal health under 5/yr. control performed 84%
at a national level. The employment of IESOs who are qualified to surgically treat urgent cases
(11% of the total deliveries) allowed reducing mother mortality rate, even if a careful assessment
of their surgical skills is absolutely essential.

8) Access, quality and use of prevention services increased

The national immunisation and de-worming campaigns reached an almost full coverage with a
special focus on measles (90.3%); this percentage reached 100% in Tigray while the penta-valent,
PCV and Rotavirus vaccination are 98%, 93%, 90% respectively. The innovative family-planning
and contraception services reached 70% of the women population nationwide while it was
estimated that in 2002, 85% of the population were provided with LLIN infused anti-Malaria
mosquito nets.

9) Access to, quality and use of the improved health care services
The access to the healthcare services, especially at the HPs and HCs showed to be improved,
mainly thanks to regular supply of blood bags and basic drugs which are provided free of charge.
Catchment areas are too extensive in comparison to national standards. As stressed by the per
capita average number of provided healthcare services (0.48) HCs and HPs provide an efficient
healthcare network easily accessible even in rural context and remote areas. In particular the HPs
remarkably increased their health care services provision to rural population through therapeutic
protocols implemented by HEWs who are qualified to treat the most common communicable
diseases. Overall, both regional and federal basic health care system has greatly improved during
HSDP IV: it is especially the mother and child sector that now can rely on round-the-clock usability,
free of charge healthcare services and surgical treatments in case of urgency.
At a national level the healthcare net is composed of:
• 336 Hospitals (Teaching-TH, General and Primary Hospitals -PH). 147 are under construction;
189 Primary Hospitals are currently staffed with IESO and equipped with medical devices to
provide a round-the-clock service. They are often well above the targets with an average of
476,593 patients.
• 3.547 HCs equipped with ANC service to address natural deliveries; the facilities have a free
of charge ambulance service allowing them emergency transport to the nearest referral
hospitals. Catchment areas with 25,395 people are in line with standards.
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• 16.447 HPs provide basic health care services to rural communities by screening for
HIV/AIDS and Malaria with disposable sets. Health posts are also qualified to assist natural
deliveries without complication. With a 5,477 people catchment area HP's are in line with the
standards.

Chart B.5 Expected Results (ER) Yes % Remarks 

1) FMoH endowed with enough financial X 50 Increased 138%;
resources for the HSDP HNA: 16% from the Government; 34%
Householders; 50% International donors
2) Data processing and use of information X 100 HMIS operative and running 
improved at all levels
3) Decision makers and development X 100 Regular and participated 
Partners better informed through APR
sand bulletins
4) Staff ’s relations increased according to X 50 Updated according to HEP 
their role
5) Staff ’s relations increased according to X 50 Considerably improved 
their role
6) Percentage of HC facilities staffed X 60 Not enough was done at a hospital level yet 
according to standards
7) Access, quality and use of the child and X 80 High performance percentages(APR) 
mother services increased
8) Access, quality and use of the preventive X 80 High performance percentages (APR) 
services increased
9) Access, quality and use of the care X 80 Medium performance percentages(APR)
services increased (APR)
Total 9 72%

Evaluation of the Expected results

Result 1 Indicators:
• Aid contributions paid as planned;
• Number of Italian experts in the federal and national health institutions.

Following the regular payments of aid contributions (C1 and C2,) 2 TAMU's medical doctors entered
the Steering Committee of HSDP IV, both for Tigray and Oromia regions; moreover 1 Tamu's expert
Office was required to take part of MDGF, as a no voting member. Unfortunately the Italian influence
decreased as the aid funds were been temporary suspended before Aid 9459 starting.

Results 2 and 3 - Indicators:

• % of prompt and complete reports;
• regular issue of APRs and FMoH bulletins.

The indicators were measured by 100% statistical and epidemiological data worked-out by HMIS
according a management and control pyramid (Kebelas, Woredas and Regional Health Bureau). All data
processed and analysed has been promptly disseminated through the Annual Performance Report and
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scientific Bulletins. The only fault was that the final publication of the National Health Account is
issued by the MoFED one or two years away (EFY).

Results 5 and 6 - Indicators:

• Health staff ratio per inhabitants (benchmark: 1 physician/36,158; 1 Nurse/3,87; 1
HEW/2,544).

In order to improve the ratios recruitment and upgrading plan have been launched; in particular:
ƒ 3,644 newly hired Health Extension Workers who have been trained at the HScC;
ƒ 8,637 specialised permanent health operators who have been placed at 3547 health posts of which
1,444 are specialised in obstetrics;
ƒ 220 nurses (Lev.3) who have been up graded as anaesthesia technicians and assigned to 189 hospital
dealing with obstetrics and surgical emergency;
ƒ 151 newly hired anaesthesia technicians while other 310 are going to complete their training;
ƒ 479 newly hired IESO with a 3 years study in emergency obstetrics, while other 251 are completing
their training at the Universities of Mekele, Jimma, Hawassa and Horomaya;
ƒ 281 newly hired paramedical dealing with ambulance service;
ƒ 1376 young graduates in medicine; there are currently 15.000 students enrolled in the 27 Federal
Medical Schools who are expected to graduate within 3 years so increasing the number of doctors
per inhabitants (1/100.000) in line with the standards recommended by WHO for developing
countries.

Qualification Benchmark (Vb) H&HRI EFY 2008 Yes % Remarks 

MD 1/36,158 people. 1/17,160 people. X 147 Upward trend 1/10,000
Nurse 1/ 3,870 people. 1/1,993 people. X 150 Upward trend 
HEW 1/2,544 people. 1/2,000 people. X 125 Suitable standards. 

Results 7, 8 and 9 Indicators:

• % of skilled birth attendance - benchmark (Vb): 10%.
As stressed above, the skilled birth attendance (SBA), with free ambulance transport from the HCs to
the PHs for the obstetric emergencies, registered a significant improvement with the 60.7% of
deliveries attended by skilled personnel (HEWs, Midwives, and IESOs) increasing the 20%, compared
with EFY 06 data. However the hygienic standard in the rural health facilities decreased of 3.9% during
HSDP IV, probably for the consistent number of obstetric performances, with low attention at the
cleaning services. This bad hygienic performance has been confirmed in the HPs’ visits, but not in the
HCs, mostly sufficient clean.
• Measles immunisation coverage (benchmark 77%).

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Immunisation has always been a priority for the HSDP providing for 5 types of vaccines. a)
pentavalent, b) Pneumacoccal Coniugate-PC, c) Rota virus, d) measles. According the HSDP IV the
planned target for a complete immunisation (a+b+c+d) was 90%, but the performance indicator
reached only 86.4%. A significant breakthrough was achieved as regard the measles immunisation
coverage indicator which in the logical framework has been fixed 77%; despite it resulted to be lower
than the ambitious target of 95%, the national average performance indicator reached 90.3%.
• Percentage of households with at least one insecticide-treated mosquito net – benchmark (Vb):
66%).
From 2002 to 2015 76 million of insecticide-treated mosquito nets have been distributed in areas
affected by endemic malaria with an 85% coverage.
• Tb treatment success rate - % of new cases - benchmark (Vb): 84%.
The 94% target set in the logical framework has not been achieved with the regional and national
performance indicators reaching 92% and 90% respectively. The G6 has been achieved in the reduction
of TB incidence rate and treatment success rate among still infected patients.
• Number of persons living with HIV/AIDS receiving anti retroviral - ART treatment
(benchmark: 152.472).
Ethiopia has always promoted low cost prevention policies to fight HIV/AIDS through free condom
distribution; despite discrimination and stigmatisation of HIV infected persons are still a barrier for an
effective ART treatment leading to under report the potential exposure to HIV, since 2002 there has
been a 50% increase of people living with HIV/AIDS receiving anti retroviral treatment (from 473,772
to 871,334). In Oromia and Tigray are 135.000 and 50.000 respectively the persons living with
HIV/AIDS under treatment.
Oromia and Tigray are the 2 best performing Regions in the child and maternal healthcare, in
particular:
ƒ SBA registered 70% in Oromia and 65% in Tigray that are both above the national average
(60.7%);
ƒ Mandatory Immunisation reached a coverage of 95% in Oromia and 85% in Tigray in line the
national standards;
ƒ Since 2009, 78 million of insecticide-treated mosquito net have been distributed to residential
households, with 17 million distributed only in 2014/2015;
ƒ The TB treatment success rate, Oromia reached 90% and Tigray 89% compared with the average
national rate of 92.1%;
ƒ For the HIV-related indicators, the 1.1% is the prevalence of Hiv/AIDS at national level, with the
percentage incidence of 0.03%; 871,334 are the HIV diagnosed persons of which only 375,871
accessed the free antiretroviral treatment (ART). Oromia counts 135.000 HIV diagnosed persons
receiving ART, while 50.000 are the treated patients in Tigray.
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Despite significant results have been achieved in preventing and treating the most common
communicable a non-communicable diseases, serious problems have been identified in Somali region
where the number of teenage pregnancies is still high due to a widespread resistance to implement
family planning policies. While Somali region recorded the worst result as regard contraception (5%),
Tigray and Oromia reached 60% and 74%. In the Oromia case the target and performance indicators
are identical, while Tigray over performed by reaching 74% compared with its targets.

RESULTS INDICATORS Y % Remarks

RA1:

• Funds transfers occurred according to X 100 See Channel 3

plans

• Italian Expert members of governing

bodies
X 80 Interruption of transfers to MDGF 

RA 2, 3 and 4:
• % of prompt and complete reports
issued X 100 100%

• Regular issuing of APRs and FMoH

Bulletins X 100 Regular issuing 

RA 5 and 6:
• Ratio: Qualified health care National Oromia Tigray 
personnel/people: Basic value (Vb):
1 MD x 36,158 people; X 100 MD x 17,160 people. No data No data 

1 Nurse x 3,870 people; X 100 Nurse x 1.993 people. 2,117 1,333 

1 HEW x 2,544 people. X 100

HEW x 2,000 people. No Data No data
H&HRI/EFY/08 

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RA 7, 8 and 9: National Oromia Tigray

• % Skilled birth attendance (Vb 10%); X 100 60.7% 70% 62% 

• Measles vaccine coverage (Vb 77%) X 100 95% 98% 82% 

• % households provided at least with X 100

one LLIN net (Vb 66%) 85% No data No data 

X 100 92.1% 88% 90% 

• % Success in Tb treatments (Vb 84%)

X 100 871,334
• HIV/AIDS infected people in anti-
retro-viral treatment (Vb 152,472) APR/EFY/07 

Total 100%

D. 2 - RELEVANCE OF THE OBJECTIVES

Since the HSDP was launched in 1997 in Ethiopia, child (U5MR) and mother (MMR) mortality were a
national emergency. In a country that just emerged from the war, it seemed that the lack of resources
for health, severe droughts, shortage of health personnel and healthcare facilities would slow-down the
pace of the Development programme. The relevance of the objectives is the result of a close
cooperation between Italy and Ethiopia which have agreed on taking action in favour of the Ethiopian
health development. The Italian Local and Central Technical Unites supported the regional Health
Bureaux to prepare a plan to achieve the health-related MDGs. The objective of the Aid 9459 are
absolutely relevant in the lights of condition characterising the country where in 2011 the 71% of the
rural population still lived under the poverty line with very poor healthcare services (Undp, HPI 2011).
The precarious conditions characterising Ethiopia, broadly justify the signing of Bilateral Agreements
to support the regional implementation of HSDP IV and MDGF in Oromia and Tigray.

D. 3 – THE ACHIEVEMENT OF OBJECTIVES

During the mission to Ethiopia the evaluation team was able to benefit from the local participation and
support; this was made possible by the Italian experts and local consultants (Tamu'Office) who during
the years were able to establish trust-based relationship with local counterparts. They have contributed
to facilitate the evaluation tasks which have been guided by the programme logical framework defining
the basic needs of the target population.
Fig.3-APR/EFY/2007 shows the trends of the national child mortality rate (U5MR) during the
implementation of Aid 9459 supporting HSDP IV through human resources development, free

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obstetric and out-patients services, immunisation campaigns, diagnosis and treatment of the
communicable diseases.
Further parameters measuring the achievement of the objectives are displayed in Fig.6-
APR/EFY/2007
The results of the main four health activities for reaching G4 and G5 are focused on:
a) women voluntary contraception (CPR) from 9% to 42%;
b) Antenatal care coverage at least four visits during the pregnancy (ANC4+) from 12% al 67%;
c) Skilled birth attendance (SBA) from 6% to 60%;
d) under five pre-natal care (PNC): from 5% to 90%.

A relevant result in the prevention of mother to child transmission (PMCT) from 1% to 69%: thanks
to scientific progresses and cost reduction, the access to the detection and treatment of HIV/AIDS
during pregnancy radically improved thus leading to the application of protocols to prevent HIV
transmission to children.
It is also important to stress that all results achieved contributed to improve the Ethiopian health
conditions resulting in the rise of life expectancy from 59.7 to 64 years (UNDP 2014).

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D. 4 –PROJECT ANALYSIS

The evaluation of the project is based on the four OECD/DAC criteria: relevance, efficiency, efficacy,
impact and sustainability. The analysis takes into consideration the information gathered from the
project paperwork, field visits and the interviews. 

D.4.1 – Relevance
Project Aid 9459 showed to be relevant in supporting the Ethiopian health care policy in rural areas
(HSDP) by achieving significant results in reducing child and mother mortality rate and preventing
poverty related diseases (HIV, malaria and TB) after the expiry of 2015 MDGs. The C1, C2 and C3
contributed to achieve the G4, G5 and G6, both integrating MDGF (C1), and carrying out HSDP IV
in Oromia and Tigray (C2). As stressed above, the main intervention areas were identified in the
development of rural healthcare system by enforcing maternal health, improving local personnel and,
last but not least, enhancing the management of health information for a better planning of economic
resources for health. The implementation of the project and its monitoring activities (Tamu) were
shared with the local partners through the programme Logical Framework containing the main health
needs to be addressed. Such needs, which include a strong gender component, have been associated
with indicators which have been remotely monitored to assess the improvement of regional health
conditions. As mentioned above the rise in life expectancy from 49 (2000) to 64 (2014) provides an
ample evidence of the general improvement of health conditions at national level. It is important to
stress that also women benefited from such improvement reaching a life expectancy of 65 years. This
positive result has been made possible by a combination of regional policies aimed to reduce maternal
mortality; the enhancement of health facilities addressing maternal health allowed a decrease of

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maternal mortality rate ranging from 990 maternal death/100.000 live births in 1995 to 676 maternal
deaths/100.000 live births in 2011. Despite this improvement is associated with an increase in overall
surgical performance as recorded by the HMIS, a further decline in maternal mortality rate has been
forecasted for 2015.
In July 2014 the UN Statistic Division issued even better data registering 510 maternal health/100.000
live births in 2005 with a downward trend (378 maternal health/100.000 live births) during 2014
(World Bank Group 2015). During the evaluation mission the reduction of child mortality rate (U5MR)
represented one of the most relevant topics to be assessed. In 1997 U5MR registered 217 deaths/1.000
live births, while in 2011 the deaths were 88/1000 live births. In 2015 at the conclusion of HSDP IV
and with the deadline of MDGs, U5MR decreased to 80/1000 live births (APR/EFY/07). Sources
from the UN Statistics Division reported more optimistic data with 68.3 deaths/1000 live births even if
such data did not receive confirmation from the Federal Ministry of Health. The result assessment has
shown the relevance of policies implemented by the Ethiopian Government both in maternal health
sector and in family planning. Contraception awareness represented the core of the regional action
plans for demographic control especially in poor rural areas where, despite the population growth is
considered a problem, family planning and contraception still clash with local life style and traditional
values. Moreover, the institutional commitment to the fight to reduce poverty-related diseases also
represent a relevant step to restore the dignity of affected people who until recently experienced
stigmatisation and discrimination. In this respect, the increase of the number of health staff per
resident population (+147%) was a remarkable result that once again emphasizes the relevance of the
Aid 9459 whose actions will continue in the framework of further two Italian interventions
(Aid.10081/2013 and Aid 10418/2014).

D.4.2 - Efficiency
The willingness of the Ethiopian Government to accept international aids allowed promoting efficient
and sound health policies benefiting the rural population particularly in the mother and child sector
(G4 e G5) and in the fight against communicable diseases (G6). The very low standards of the
Ethiopian health system required huge contributions from international Donors during the years; such
contributions amounting to 50% of the National Health Account are have been managed by the
Federal Ministry of Health and since 2007 the Ministry of Finance and Development has the task of
harmonising the funds granted by the international community. The federal and national policies aimed
at improving healthcare facilities focused on human resources development, improvement of ante-natal
and post-natal care, enhancement of access to healthcare services in rural areas. In 2015 the number of
Health Posts and Health centres registered a significant increase:
ƒ Health posts: from 10.621 (2000) to 16,447 (2014);
ƒ Health Centre: from 2,142 (2000) to 3,586 (2014).

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The out-patients performance indicators, included in the logical framework, are almost doubled in the
last five years from 0.29% per capita to 0.48 per capita confirming the efficiency of the recently
activated rural referral system especially for the maternal health. The ante-natal service coverage (90%)
has been reviewed as an efficiency indicator stressing the involvement of women in the maternal health
services free of charge.
Despite the rural health care network has radically improved since the adoption of HSDP, inefficiencies
have been identified in the hospital management system that, so far, has been unable to downsize the
catchment areas which cover on average 350.000 resident people against the 100.000 residents
recommended standard. This inefficiency is mainly caused by health staff shortages and delays
concerning the construction and testing of new health facilities.

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N° Hospitals H&HRI/EFY/08 
Regions Operative Under Total EFY 2008
construction (2016)
Tigray 15 0 15 
Afar 6 2 8 
Amhara 42 36 78 
Oromia 53 63 116 
Somali 9 2 11 
Benishangul Gumuz 2 4 6 
SNNPR 41 36 77 
Gambella 1 0 1 
Harari 7 0 7 
Addis Ababa 2 1 3 
Dire Dawa 11 3 14 
National 189 147 336 

The evaluation work paid particular attention to the figure of IESO who following a three years
training in surgery, deal with obstetrical emergencies by providing a round to clock surgical service
representing the 11% of the total amount of deliveries. The evaluation showed how they can represent
important resources for the maternal health care provided that their performance is carefully
monitored; since IESOs are qualified to provide highly invasive surgical services without a supervision
of medical doctors, their skills must be constantly assessed in order to avoid that they can pose a direct
threat to the safety of patients. A further element of inefficiency is the delays in the transport of urgent
patients; in a country where roads are usually in poor conditions and there are long distances to cover,
the emergency management network still needs to be improved. Despite the inefficiencies identified,
the Ethiopian Reform Implementation Guidelines (APR/EFY/07) shows a significant increase in the
efficiency characterising basic health care services ranging from +76% in FEY/06 to +83% FEY/07.

D.4.3 – Effectiveness

Project Aid 9459 worked effectively in supporting mother and child health, especially considering the
starting conditions of the Ethiopian health services in rural settings when the HSDP was launched in
1997. The decrease of child mortality (U5MR) and the improvement of MMR resulted in the
implementation of effective policies ranging from prevention to family planning and contraception. In
particular the national contraception rate reached a significant 70%, despite the 85% target has not
been achieved; it interesting to note that at regional level, instead, the target of contraception rate was
significantly exceeded in Oromia (75%) or, in the case of Tigray not achieved at all (60%)
(APR/EFY/07). The extended coverage of ante-natal and post-natal care associated with
immunisation campaigns have demonstrated the effectiveness of the action plans undertaken in the
framework of the HSDP. The health development actions have often been accompanied by the
involvement of local communities and especially of women. Remarkable achievements there have been
also in immunisation coverage (see Box 14) and TB treatment (see Box 31) demonstrating the

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effectiveness of the regional and federal policies in terms of prevention and care and good
participation of population.

However, there is still low local involvement in the diagnosis and treatment of communicable diseases,
first of all HIV/AIDS, for which stigmatisation and mistrust are still widespread.

Despite in Ethiopia HIV/AIDS is not as rampant as in other Sub-Saharan countries thanks to prompt
low-cost preventing actions which started in 1998, HIV/AIDS patients experience difficulties accessing
diagnosis and treatment especially in the most remote Regions where HIV policies are limited or
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completely lacking. The effectiveness of health actions undertaken by the Government are usually
frustrated by the shortage of economic resources; despite Ethiopian health development Plan is usually
offered as an example by international organisation, the average annual per capita health spending (16,1
USD) remains lower than the WHO recommended standards (60USD); notwithstanding the
demographic growth increased the federal budget for health, the average annual per capita health
spending has remained unchanged since 2010. However, the health system showed to be better at
regional level where Oromia and Tigray have on average been performing better that those of the rest
of Ethiopia: both the regions have improved the provision and use of maternal healthcare services;
while noticeable results in the prevention and treatment of communicable diseases have been also
tracked. As regard the training sector, the federal human resources development plan has introduced
up-grading programmes for health personnel currently on-duty and meanwhile has started-up standard
academic courses with the employment of young health operators. The evaluation has paid particular
attention to the health extension workers, most of whom women, who currently staff health pots in
rural settings. The human resources development was closely linked with the downsizing of HP and
HC catchment areas with the aim of guaranteeing the actual 90% health care coverage for maternal
health, prevention and treatment of communicable diseases (HIV/AIDS, malaria and TB).

D.4.4- Impact

The Aid 9459 contributed to support the national health policies in achieving the MDgs by providing
access to a section of the population who was until now excluded from both health care and decision
making process. Ante-natal e post-natal performance rates are an example of the high involvement of
women in accessing health posts and health centres which are more numerous and better equipped
than in the past. This has contributed to redefining heath catchment areas (16,447 for HPs and 35,869
for HCs) bringing them up to planned standards. The hospital networks, instead, is still characterised by
catchment areas which are 3 times greater than standards, negatively impacting on the management of
obstetric emergencies.
Hospitals usability is often hampered by the poorly functioning of medical and diagnostic equipment
which, despite recently purchased, are currently utilised just to address emergencies. As obstetric
ultrasound scan is something entirely new for patients, consistently utilised, it would promote the
involvement of families.
The evaluation identified the WDG as strategic actors for the implementation of prevention and family
planning policies; they play a crucial role in mobilising rural communities and supporting women
empowerment. Aiming at a comprehensive response to maternal health, there is a growing awareness
on the importance of pursuing family planning policies which are also needed to avoid teenage
pregnancies. Last but not least, the life expectancy rate has increased more for women (64 years) than

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for men as a result of the many women-centred actions undertaken by both federal and regional
Government.

D.4.5 - Sustainability

The HSDP IV, supported by Aid 9459 in Oromia and Tigray, carried out many sustainable developing
activities both quantitatively & qualitatively, especially in the mother & child sector by addressing the
lack of skilled personnel in the emergencies management. The introduction of IESO, for example,
acting as leading figures in obstetric surgical procedures makes it necessary for them to be granted with
the high technician professional status. In addition to ensuring surgical services, IESOs play an indirect
role in supporting rural households by avoiding the premature death of pregnant women. The ante-
natal service played a crucial role in preventing and monitoring complications in pregnancies since the
emergency cases, when needed, are transferred to the nearest primary hospitals.
The family-planning & contraception services (CAR) provided by the HPs and HCs act in an
innovative manner on local traditional values so contributing to contain the population growth.
Despite the Ethiopian per capita annual health expenditure is well below (16 USD) the threshold of 60
USD; the Health Low Cost Strategy is generally considered a best practice for its operational capacity in
rural settings. Therefore it appears that the concept of human development sustainability should be
reviewed in the light of the significant benefits that have accrued from better health conditions. Despite
such concept is not always economically sustainable there is no doubt that it can produce benefits in
terms of a more widespread well-being especially in rural areas.
Despite the outstanding results achieved in basic health care and in human resources development the
Ethiopian Health system is still dependent on international donors who provide funds amounting to
the almost half of the National Health Account during the implementation of HDSP IV. Of 1.2
billion USD, 600.000 USD came from external aid of which 1.3 million from Italy. The currently debt
position of Ethiopia should be considered as provisional as the federal Government, in agreement with
the international Donors, postponed to 2030 the budgetary adjustments. The next national health
programme will no longer be focused on development but on transformation with a particular
attention to the measures aimed to foster economic sustainability through international aids for capacity
building. Among the viable measures there is both the introduction of collective health insurances
divided into professional categories or income groups and the collection of VAT already under way
through the emission of receipt by dealers.

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SECTION “E”
LESSONS LEARNED AND RECOMMENDATIONS

E.1 - Lessons learned

The lack of smoking is one of the health determinants in Ethiopia where the damage to health by
smoking is generally recognised also without public awareness campaigns. On the contrary the
environmental pollution, especially in big-city areas, is negatively affecting the health of residents.
These are the extremes better representing the Ethiopian model of development which is characterised
by national pride, interethnic coexistence and great tax compliance. The key word of the current
Ethiopian health policy is transformation; as a second step, following the development of the national
health system, the Ethiopian Government intends to ensure the economic sustainability of reform
achievement. That intention may also be interpreted as an attempt of social liberation which can be
perceived in the intensive urbanisation process.
In Oromia and Tigray the HSDP IV played a strategic role in implementing concrete and dynamic
actions which showed to be instrumental in fully achieving G4 and G5 while G6 target has almost been
reached.
During the mission to Ethiopia, the evaluation team identified some weaknesses resulting from the
complexity and scale of the Programme; their identification allowed the evaluators to develop some
lessons learned (LL) whose dissemination could prove a helpful model for future projects.

LL 1: Relation building: despite evaluation has become an integral part of the projects, is frequently
seen as an unwanted meddling in the internal development policies causing initial diffidence in the local
partners who sometimes wrongly supposed that it could undermine the principle of ownership. The
allocation of Channel 2 did not sufficiently take into consideration the differences of territorial
extension and population size between the 2 recipient regions: in particular the C2a assigned to Oromia
was not suited to the health needs of a very large population, while Tigray, despite a much smaller
population, was granted with more substantial funds. Furthermore the contribution for Oromia,
instead of being injected into a specific priority area, has been parcelled-out into a multitude of cost
centres (A/B/C/D/E/F/G/H). The local counterpart demonstrated appreciation for particular cost
items such as: a) repair and maintenance service for ambulances; b) supply of metallic shelves for HP
and HC's pharmacies; c) computer equipment for HIMS. Since C1 represented a direct contribution to
MDGF no assessment could be made; as a multi-donor fund MDGF already owns a specialised control
body (CCM) which, according the Joint Financing Agreement issues quarterly reports on progress updates
in achieving MDGs.

LL 2: Health facility construction and rural primary health care: (HP-HC-PH): albeit the improved
coverage of the rural primary health system in both Oromia and Tigray, health staff and medicine

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supply are not already in line with the standards recommended by WHO for developing countries.
Delays in health facility construction and testing partly hamper the access to maternal health care
service, despite it is provided free of charge. The situation is different with regard to trauma, non-
communicable and age-related diseases for which no tax exemption is allowed, leaving to patients the
burden of care. During the field visits the evaluation staff found that many health care facilities due to
cheap materials were in poor conditions, while electric and water installations have deteriorated because
of cursory testing and lack of maintenance. Moreover heath facilities didn’t have a waste management
service; medical and ordinary wastes are burnt in external incinerator without any filters and close to
the patient wards.

LL3 - Biomedical equipment: The health facilities are equipped with low quality medical devices that
are supplied without warranty of any kind. This problem impacts negatively not only on the provision
of health care service but also on the health staff that has been properly trained to use such devices.
The many faults experienced by Hospital diagnostic services lead many pregnant women to drop
controls after the fourth visit, so undermining the prevention and identification of complications. The
recently installed RX ray film devices, in addition to producing high polluting RX developer liquids that
are being dispersed into the environment, resulted underutilised or out of order. Moreover no radio-
protection protocol for patients and health staff is currently followed.
LL4 - Non medical staff training: In the framework of the Health Extension Package more than
32.000 health operators have been hired; professional differentiations of non-medical professionals
have been carefully set up: RX, Laboratory and Anaesthesia technicians, health operators for ambulance
service, health managers and technical officer dealing with HIMS. The difficulties characterising the
non-medical training in Oromia and in Tigray are outlined below;
A) over-utilisation of free up-grading programmes for the health staff on-duty. If on one hand such
programmes showed to be very useful to provide health personnel with new skills and at the same
time support generational turn-over, on the other hand newly graduated students did not enjoy any
facilitation during the HSDP IV and they have not been offered a job after graduating. It is also
worth noting the difficulty in assessing both up-grading and standard academic programmes even if
newly gradated students could complete their studies with a on-the job-training modules under the
supervision of staff on-duty.
B) The management of obstetric surgical urgencies, amounting to 11% of the total deliveries should
be carefully monitored. At this regard IESOs represent the new figure in charge with surgical
services at health centres. As they are qualified to provide highly invasive surgical services without a
supervision of medical doctors, their skills must be constantly assessed in order to avoid that they
can pose a direct threat to the safety of patients.

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C) The quality of up-grading training courses is considered unsatisfactory; moreover during the 3
months residential courses the trainees leave understaffed health facilities producing inefficiencies
and disorganisation.
D) Field visits provided evidence that a repairing and maintenance service for vehicles, installations and
health buildings is absolutely essential; frequent malfunctioning undermines the quality of health
care delivery and threatens to frustrate the development of the national health system.

E.2 - Recommendations

R1 Health facility construction and equipment:

• It is recommended to identify some middle level health facilities (e.g. primary hospitals) which
will be followed during the construction and equipment in order to provide the bases for
construction, management and maintenance especially for complex diagnostic and surgical
services by establishing a regulatory framework applicable in the hospital network
• Purchase easy to use medical equipment, provided with warranties and maintenance service.
Many suppliers of medical devices offer tropical version of the their products (this is the case of
ecographs); an investment in the purchase of such devices coupled with the training of
personnel who is able to utilise them could support a better coverage of ante-natal care service
with greater involvement of women and their families
• support and sustain repairing and maintenance service for vehicles, installations and health
building as frequent malfunctioning undermines the quality of health care delivery and
threatens to hamper the development of the national health system. According targeted
questionnaires to pregnant women, they would be more willing to undergo more than 4 visits if
the diagnostic service was always available.

R2 Upgrading training
A. Up-grading programmes should avoid that health personnel leave unattended their post
especially when the health facility is staffed with health operators in their first job. Health
professionals playing key-roles should be involved in rolling up-grading programme but without
producing an excessive workload for the personnel who remains in service. The up-grading
should also be targeted on one priority sector (e.g.: maternal health) instead of parcelling it into
many specialisations. In this regard a component of the C3 could be allocated for the technical
assistance of Italian consultants able to implement the transformation pursued by the Federal
Government. The quality assessment of training should be improved by giving out
questionnaires or by organising interviews with students with the support of Tamu's Office.

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B. Within the limits of the budget available, training activities should focus on some key-roles in order
to enhance their skills. This is the case of obstetric urgencies that should be addressed by setting up
a strict intervention protocol ranging from ambulance service to the surgery practices to put in
place. Therefore it urgent the training of IESO, who are often the first to concern about the
sensitivity of their role; they should be involved in refresher courses where experienced expatriate
health professionals supervise and guide their surgical activities.

Acknowledgements

Gianluca de Vito, Carlo V. Resti and Edao Simba would like to express their gratitude to the Office IX-
Directorate General for Development Cooperation, Mr Ambassador Giuseppe Mistretta, the Head of
Italian Agency for Development Cooperation in Addis Ababa Mrs G. Letizia, the experts Mr Pasquale
Farese and Mr Sandro Accorsi, the administrative officer Paolo Melilli, Tamu's Office consultants, the
Director General of THB Hagos Godefay, the executive Mr Lemma Desu and Mr Girmai Alemhayen
from OHB.

Rome, 18/11/2016
Rev. 23/12/2016

Gianluca de Vito MD
gianluca.devito@virgilio.it
Carlo Vittorio Resti MD
carlo.resti@virgilio.it
Edao Simba

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ANNEX 1 - TABLES

TAB. 1 – Short Expert Missions:

Expert Fund (FGE) 44 months +12 days. Local Fund (FGL) 40 months +15 days.
N°Miss. Name Expert Period Contract

1 Dr. Pasquale Farese MD 15/03 - 08/07/2011 FGE

2 Head project 01/10 - 23/12/2011 FGL
3 23/01 - 23/04/2012 FGL
4 14/09 - 21/12/2012 FGE
5 27/02 - 22/06/2013 FGE
6 11/08 - 06/12/2013 FGE
7 01/02 - 30/05/2014 FGE
8 24/08 - 20/12/2014 FGE
Sub total Expert Fund (FGE) 21 months +7days.
Local Fund (FGL) 4 months + 23 days
Total mission’s months 26 months
Other
Aid
9 15/02 - 08/06/2015 FGE
10 09/07 - 20/07/2015 FGE
11 05/09 - 20/12/2015 FGE
12 21/01 - 20/03/2016 FGE
Expert Fund (FGE) 9 months + 7days.
Sub-Totale mesi di missione 35 months + 25 days

13 Dr. Sandro Accorsi MD 20/06 - 22/07/2011 FGE

14 HMIS Medical Expert 20/09 - 20/10/2011 FGL
15 15/11- 16/12/2011 FGL
16 05/02 - 10/03/2012 FGE
17 12/04 - 12/05/2012 FGE
18 03/06 - 07/07/2012 FGE
19 01/12 - 20/12/2012 FGE
20 15/02 - 24/02/2013 FGE
21 25/04 - 27/05/2013 FGE
22 10/07 - 31/07/2013 FGE
23 05/09 - 15/11/2013 FGE
24 15/01- 16/02/2014 FGE
25 17/03 - 15/04/2014 FGE
26 26/05 - 27/06/2014 FGE
27 03/09 - 08/11/2014 FGE
di cui Expert Fund (FGE) 14 months + 11 day
Local Fund (FGL) 2 mesi
Sub-Total mission’s months 16 mesi + 11 gg.
Other
Aid
28 08/12 - 20/12/2014 FGE
29 20/01 - 08/03/2015 FGE
30 11/04 - 10/05/2015 FGE
31 09/07 - 20/07/2015 FGE
32 06/11- 20/12/2015 FGE
Expert Fund (FGE) 5 months + 3 days.
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Sub-Total mission’s months 19 months + 3 days.

2 MD Sub-Total MD mission’s months FGE 35 months+ 18 days FGE

Sub-Total MD mission’s months FGL 6 months + 23 days FGL
Total MD mission’s months 42 months + 11 days FGE+FGL

33 Amm. Paolo Melilli 21/10 - 31/12/2013 FGL

34 Project Administrator 14/02 - 12/06/2014 FGE
35 24/08 - 20/12/2014 FGE
Expert Fund (FGE) 8 months + 24 days FGE
Local Fund (FGL) 1 months + 10 days FGL
Sub-Total mission’s months 10 months + 4 days FGE+FGL
Altri Aid
36 21/01 - 19/05/2015 FGE
37 24/08 - 20/12/2015 FGE
di cui Expert Fund (FGE) 8 months
Sub-Total mission’s months 18 months + 4 days.

38 Amm. Maurizio Consorte 23/01 - 23/04/2012 FGL

39 Project Administrator 19/06 - 31/12/2012 FGL
40 21/01 - 21/07/2013 FGL
Sub-Total mission’s months 15 months + 12 days FGL

Ass.Amm. Raffaele de Martino 25/10 - 31/12/2011 FGL

Sub-Total mission’s months 2 months + 6 days FGL

41 Ass.Tec Dr. Elena Della Valle 01/06 - 30/09/2011 FGL

42 11/10 - 23/12/2011 FGL
Sub-Total mission’s months 5 months + 12 days FGL

43 Ass.Tec. Dr. Elisabetta Borzini 01/02 - 30/04/2012 FGL

44 19/06 - 31/12/2012 FGL
Sub-Total mission’s months 9 months + 12 days. FGL

TOTALE mission’s months 95 mesi FGE+FGL

di cui Expert Fund (FGE) 44 months + 15 days. FGE
Local Fund (FGL) 40 months + 15 days FGL

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TAB. 2-FGL – Local Staff
Name & qualification Period Remark
1 Sillas Baarez - Tamu segretary 10/10/2011 - 31/12/2011
2 11/01/2012 - 30/06/2012
3 01/07/2012 - 31/12/2012
4 01/01/2013 - 31/12/2013
5 01/01/2014 - 30/04/2014
6 01/05/2014 - 31/08/2014
7 01/09/2014 - 31/12/2014
Other Aid support
8 01/01/2015 - 31/12/2015
9 04/01/2016 - 03/07/2016 In charge

10 Shewaye Dandena - cleaning service 21/01/2011 - 30/06/2011

11 21/07/2011 - 31/12/2011
12 11/01/2012 - 30/06/2012
13 01/07/2012 - 31/12/2012
14 01/01/2013 - 31/12/2013
Other Aid support
15 01/01/2014 - 30/04/2014
16 01/05/2014 - 31/08/2014
17 01/09/2014 - 31/12/2014
18 01/01/2015 - 31/12/2015
19 04/01/2016 - 03/07/2016 In charge

20 Andualem Lemma - Driver 21/01/2011 - 30/06/2011

21 21/07/2011 - 31/12/2011
22 11/01/2012 - 30/06/2012
23 01/07/2012 - 31/12/2012
24 01/01/2013 - 31/12/2013
25 01/01/2014 - 30/04/2014
26 01/09/2014 - 31/12/2014
Other Aid support
27 01/01/2015 - 31/12/2015
28 04/01/2016 - 03/07/2016 In charge

Sisay Beyene - Driver 21/01/2011 - 30/06/2011

29 21/07/2011 - 31/12/2011
30 11/01/2012 - 30/06/2012
31 01/07/2012 - 31/12/2012
33 01/01/2013 - 31/12/2013
33 01/01/2014 - 30/04/2014
34 01/05/2014 - 31/08/2014
35 01/09/2014 - 31/12/2014
Other Aid support
36 01/01/2015 - 31/12/2015
37 04/01/2016 - 03/07/2016 In charge
38 Tesfaye Deme - Guardian 21/01/2011 - 30/06/2011
39 21/07/2011 - 31/12/2011
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40 11/01/2012 - 30/06/2012
41 01/07/2012 - 31/12/2012
42 01/01/2013 - 31/12/2013
43 01/01/2014 - 30/04/2014
44 01/05/2014 - 31/08/2014
45 01/09/2014 - 31/12/2014
Other Aid support
46 01/01/2015 - 31/12/2015
47 04/01/2016 - 03/07/2016 In charge

48 Mamush Degu - Guardiano 21/01/2011 - 30/06/2011

49 21/07/2011 - 31/12/2011
50 11/01/2012 - 30/06/2012
51 01/07/2012 - 31/12/2012
52 01/01/2013 - 31/12/2013
53 01/01/2014 - 30/04/2014
54 01/05/2014 - 31/08/2014
55 01/09/2014 - 31/12/2014
Other Aid support
56 01/01/2015 - 31/12/2015
57 04/01/2016 - 03/07/2016 In charge

58 Million Admassie - Consultant M&V 21/01/2011 - 30/06/2011

59 21/07/2011 - 31/12/2011
60 11/01/2012 - 30/06/2012
61 01/07/2012 - 31/12/2012
62 01/01/2013 - 31/12/2013
63 01/01/2014 - 30/04/2014
64 01/05/2014 - 31/08/2014
65 01/09/2014 - 31/12/2014
Other Aid support
66 01/01/2015 - 31/12/2015
67 04/01/2016 - 03/07/2016 In charge

68 Tibebe Akalu - Consultants HMIS 01/09/2011 - 31/12/2011

69 11/01/2012 - 30/06/2012
70 01/07/2012 - 31/12/2012
71 01/01/2013 - 31/12/2013
72 01/01/2014 - 30/04/2014
73 01/05/2014 - 31/08/2014
74 01/09/2014 - 31/12/2014
75 01/01/2015 - 31/12/2015
76 04/01/2016 - 03/04/2016 In charge

77 Yilma Abdissa – Consultant HMIS 01/01/2013 - 30/06/2013 In OHB

78 01/07/2013 - 31/12/2013 In OHB
79 01/01/2014 - 30/04/2014 In OHB
80 01/05/2014 - 31/08/2014 In OHB
86 01/09/2014 - 31/12/2014 In OHB
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Other Aid support
87 01/01/2015 - 31/12/2015
81 04/01/2016 - 03/04/2016 In charge

82 Miriam Andu - Administration 21/01/2011 - 30/06/2011

83 21/07/2011 - 31/12/2011
84 11/01/2012 - 30/06/2012
85 01/07/2012 - 31/12/2012
86 01/01/2013 - 31/12/2013
87 01/01/2014 - 30/04/2014
88 01/05/2014 - 31/08/2014
89 01/09/2014 - 31/12/2014 In charge
Other Aid support
90 01/01/2015 - 31/12/2015 Not in Charge

91 Tadesse Alemayehu - Consultant HMIS 01/03/2013 - 30/06/2013

92 01/07/2013 - 31/12/2013
102 01/01/2014 - 30/04/2014
103 01/05/2014 - 31/08/2014 Not in Charge

104 Yohannes Berhe - Consultant 18/03/2011 - 30/06/2011

105 21/07/2011 - 31/12/2011 Not in Charge
106 Ilham Nurhussein - Secretary 18/03/2011 - 30/06/2011

107 21/07/2011 - 31/12/2011 Not in Charge

108 Tesfaye Meskele - Driver 18/03/2011 - 30/06/2011
109 21/07/2011 - 31/12/2011
110 11/01/2012 - 30/06/2012
111 01/07/2012 - 31/12/2012 Not in Charge

112 Tamirat Tadesse - Driver 01/09/2012 - 31/12/2012

113 01/01/2013 - 31/12/2013
114 01/01/2014 - 30/04/2014
115 01/05/2014 - 31/08/2014
116 01/09/2014 - 31/12/2014 Not in Charge

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TAB. 3 - C2a budget detail - Oromia
A - Totale Human Resources OHB - Subtotal € 195.097,00
Aa - 119 Nurses up-graduated BCs - Liv4 37.212,00
Ab - 98 Midwives up-graduate BCs - Liv4 41.863,00
Ac - 78 Tec.Pharmacits up-graduate BCs - Liv4 31.216,00
Ad - 30 Health officers up-graduate BCs- Liv4 29.760,00
Ae - 47 Tec.Laboratory up-graduate BCs - Liv4 31.280,00
Af - 18 Health Office graduate at ABH-Service AA 15.500,00
Ag - 72 Tec. Radiologists up-graduated BCs - Liv4 8.266,00

B - Info-Statistic Monitoring OHB - Subtotal € 55.458,00

Ba - Tec/Computer Assistance ZHB ed OHB x HMIS 22.125,00
Bb - 150 Health Officers up-graduate to WBHSP in ZHB & OHB - Liv 4 33.333,00

C - Equipment and materials OHB - Subotal € 754.689,00

Ca - Cb - Essential Drugs in 120 HC+20 PH (1.1.1,2,3/2.1)+5 BB Generator 578.041,00
Cc - 30 Equipment protocol in PH 15.505,00
Cd - 270 Metallic shelves in 12 PHs + 90 HCs 79.233,00
Ce - Blood Vehicles maintained 28.425,00
Cf - 10 PC and 23 Laptop in ZHO & in OHB x HMIS with Tec.Assit.(2.2,6) 53.485,00

D - Other Health Services- Subtotal € 122.947,00

Da) 300 “urban” HEW up-graduate x HMIS (2.1.1,2) - Liv 4 26.180,00
Db) 60 Ambulances maintained 86.062,00
Dc) Publications & Research 10.705,00

E - Equipment HQ HMIS-OHB - Subtotal € 10.672,00

Ea) Telephone line CDMA and internet (3.5.1,2) 7.297,00
Eb) 1 Informatics Technician (1 Yr.) 3.375,00
TOTAL: A+B+C+D+E € 1.138.863,00

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TAB. 4 - C2b Budget Detail Tigray

F - HRD - Human Resources THB - Subtotale speso 856.680,31
Fa - 211 H.A. upgradate Clin. Nurse 23.752,47
Fb - 566 HEW graduated Clin. Nurse 116.670,00
Fc - 60 HO + 20 Sanitarians in MPH University Mekele 161.775,77
Fd - 40 Tec. Anaesthesiologists per BSc Ayder campus 79.621.04
Fe - 20 Tec. Pharmacists Bsc Ayder campus 44.522,13
Ff - 25 Tec. Lab. Bsc and Master Micobiology Mekele 46.674,65
Fg - 20 Tec. Rad.s BSc 14.655,00
Fh - 15 Nurses Psychologists upgraduated HO 19.522,13
Fi - 20 staff in THB for MPH 38.436,41
Fl - 20 staff di THB for the Master in Inf. Diseases 32.100,00
Fm - Project elaboration “progress in achievement MDGs” 10.585,00
Fn - 22 Managers in Woredas upgraduated MPH 31.516,42
Fo - Procurement THB 110.181.83
Fp - Procurement PC x Woreda with Tec. Assitance 60,125,00
Fq - Course diploma iploma Has Axum College 8.046.82
Fr - 40 Clin. Nurse upgraduated in Adigrat University 16.546,36
Fs – Educational Procurement 41.949,28

G – Equipment & Materials - Subtotal 1.085153,93

Ga - Drugs & equipment for Hospitals and HCs 250.000,00
Gb - Drugs & equipment: kit test (HivTb/malaria) for HCs and HPs 384.969,37
Gc – Forniture PHC units 295.570,00
Gd - Equipment for Hospitals (Beds Etc.) 104,923.85
Ge - 60 participants monitoring health procurement 11.370,00
Gf - 24 Experts in G.I.S. Da workshop 3days 658,00
Gg - 1200 bulletins and publications at the PHC units 1.624,30
Gh - Other tec. equipment 36.038,41

H - Other Health Services 199.226,31

Ha - 284 HOs upgraduated for HMIS Tigray 17.877,85
Hb - workshop for 142 HOs on family statistics and plan. 14.970,94
Hc - 1 Tec. Reponsable HMIS THB 1.192,79
Hd- 6304 educationale publications 1.987,96
He - 2000 copies of Health Bulletin 49.432,00
Hf - 50 laser printers for HMIS 28.950,00
Hg - 9 digital cameras for HMIS 1.840,27
Hi - 17 jet printers e cancelleria for HMIS in the PHC units 19.440,47
Hl - IT equipment HMIS unit of THB 19.587,82
Hm - Maintenance District Vehicles and motos 10.364,00
Hn - Stationery for PHC units 12.877,40
Ho - Informatics consulting 279,23
Hp - Maintenance ambulances 14.083,00
Hq - Internet & web telecom for HMIS 6.342,58

F+G+H = Total €
2.318,537.40

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TAB. 5 - Step 1 AA - Agenda
Date h Site Meeting & Interviews
28.02 15,00 Hotel Hilton Experts: Dr. Pasquale Farese MD, Adm. Paolo
Melilli; Director Ginevra Letizia UTL e Staff
Tamu.

18,00 Guest House Local Assit. Edao Simba,

29.02 09.00 Tamu Experts: Dr. Pasquale Farese MD, Adm. Paolo
Melilli;
Local Consulatants: Yilma Abdisa,Million
Admassie, Solomon Hagos, Tibebe Akalu
Sig. Million Admassie

15,00 Tamu
11.00 UTL Ginevra Letizia Director UTL e staff

12.30 Tamu Mr. Yilma Abdica and Mr. Million Admassie

Pasquale Farese e Paolo Melilli

14.00 ABH-Univ Services Eyob Kifle, Coordinator (University of Jimma).
15.30 OHB - PBME Lemma Desu, Deputy Process Owner: PBME
GdV, E. Simba & Y.Abdisa
16.45 OHB - HMIS Serbesa Dereje
HMIS H.Officer
18.30 Tamu Dr. Pasquale Farese MD
01.03 08.45 Tamu Y.Abdisa Consultant
09.30 OHB - PBME Lemma Desu
GdV, E. Simba eandY.Abdisa

Mr. Serbeza Dereje

15.30 OHB – HMIS HMIS officer

Mr. Million Admassie

15.30 Tamu
17.30 Tamu Pasquale Farese
02.03 9.00 Tamu Pasquale Farese, Paolo Melilli
12.00 UTL Ginevra Letizia
12.30 Italian Embassy Ambassador Giuseppe Mistretta
13.30 Tamu Departing Tigray C.Resti- aereport.
16.00 Departing Oromia - GdV + ES auto
10.03 10.00 PFSA Mr. Meskele Lera - Head
11.03 09.00 MDGF Dr.ssa Mekolen Enkossa Head

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TAB. 6 - Fase 2 Oromia - Agenda

Date h Site Meeting & Interviews
03.03 08,00 Adama Hotel Mr Ghermai Alemayehn funzionario OHB
09.00 HZB Mr.Teshone Hunde Head
Mr. Mebvotu AssefaVice
Mr. Abebe ShevanghizawZona Planning Coordinator
10.00 HQ BB Mr.Gebru Gebre Head
11.30 Welenchiti HC Mr Urgeessa Mirkessa Chief Nurse
14.30 Welenchiti PH Mr. Gindo L. GutamaChief Executive Officer; Dr.
Bethelem Worku MD Director, Mr. Teshome Yibru
IESO
04.03 08.30 Adama Hotel Mr. Serbeza DerejeHMIS officer - Couse Coordinator
11.30 AselaArsi Health Univ. Mr. Gabi Hussein Academic Affaires Officer
14.30 HZB - Arsi Mr Haji Abdela Deputy Head
16.00 HZB - HMIS Mr. Addisu Abebe Resp HMIS
05.03 09.00 Bekogi PH Dr. Wegene Tadesse MD
06.03 08.30 Shashamane Infermiere di guardia
PH Melka Oda
10.00 Shashamane HScC Mr. Kali Hussen Dean
12.45 Neghelle HC Nurses in duty
40 Km nord from
Shashamane
13.30 Arsineghelle PH Under construction

14.30 Dole HC Nurses in duty

Reef-Valley
07.03 08.30 Ziway PH Batu Dr. Akililu Hailu MD Director
15.30 Woliso HZB Mr. Suitan EbranimPlanning Team Leader
17..00 Woliso BB Mr. Olana Yadate Head
08.03 08.30 Woliso HZB Mr. Tefera Feysa Head
10.30 HP rural area Rural HEW in servizio
12.30 HP rural Rural HEW in servizio
14,30 Wolisso HC Infermieri in servizio
16.00 Woliso RH S.Luc Dr.Stefano Contini
Cuamm Health Director
09.03 08.30 Ambo University Mr. Hani Garuma Head Pharma Dept.

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