OBJECTIVES

After reading this module, you will be able to:

 Explain the meaning and purpose of management;

 Elucidate scientific management, different levels of management and the managerial
skills required;
 Describe managerial functions or elements of management and their importans.
 Explain general principles of management;
 Describe the history of health service in Ethiopia
 Understand the concept and strategies of primary health care.
MANAGEMENT –

It is very difficult to accurately define management. There is no universally accepted definition

of management. Management involves both acquisition and application of knowledge. It does
not go by rule of thumb or intuition alone even though it is considered to be an extension of
common sense. Hence, management is a combination of both an art and a science. The scientific
approach lies in decision-making, planning and in the appropriate use of technology. The artistic
approach to management can be found in the tasks of communicating, leadership and goal-
setting. A few commonly used definitions of management are given below:

• Managing is an art or process of getting things done through the efforts of other people.

• Managing is the art of creation and maintenance of an internal environment in an enterprise

where individuals, working together in groups, can perform efficiently and effectively towards
the attainment of group goals.

• Management is the process of setting and achieving goals through the execution of five basic
management functions (i.e. Planning, Organising, Staffing, Directing and Controlling) that utilise
human, financial and material resources.

• Management is a process or an activity that brings together several varied resources like
persons, materials, techniques and technologies to accomplish a task or tasks.

• Management, as a distinct field of study, is also the body of organised knowledge which
underlies the art of management.

LEVELS OF MANAGEMENT AND MANAGERIAL SKILLS

A manager is anyone, at any level of the organization, who directs the efforts of other people.
S/he is the catalyst who makes things happen. It may be noted that the management of an
organisation is performed at different levels. Although the distinctions are by no means clear it is
useful to think of managers as being divided into three groups (or levels):

(i) Supervisory (or- First line or Operational) Managers are those who directly oversee
the efforts of those who actually perform the work. Performance of various routine
 tasks to obtain desired outputs of every unit and concomitant activities is taken care
of at this level;
(ii) (ii) Middle managers are above the supervisory level but subordinate to the most
senior executives of the organisation; they have the responsibility to develop
implementation strategies for the concepts determined by top management.
Execution, supervision, monitoring and other related functions are taken care of by
them;
(iii) (iii) Top managers are the most senior executives of the organisation. Top managers
are responsible for providing the overall direction of the organisation. They carry out
planning, maintenance of relations with other agencies, policy making,
standardisation, control, evaluation, resources mobilisation, etc. As far as libraries are
concerned, often two hierarchies of management operate within libraries. One is that
of the library, and the other is that of the organisation to which the library belongs.

Each level of management requires a different composition of managerial skills. Skill is an

ability to translate knowledge into action that results in a desired performance. Normally, three
kinds of basic skills are identified to be required by managers –

(i) Technical skill is the ability to use specific knowledge, methods, processes, practices,
techniques or tools of a speciality in performing the work;
(ii) (ii) Human skill is the ability to interact with other persons successfully, i.e., ability to
understand, work with, motivate and get along with other people; and
(iii) (iii) Conceptual skill deals with ideas and abstract relationships. It is the mental ability to
comprehend abstract or general ideas and apply them to specific situation. It requires a
holistic approach to understand the relationship of parts to the whole, the whole to the
parts and cause and effect. In other words, viewing the organisation as a whole and to
see how the parts of the organisation relate to and depend on one another and the ability
to imagine the integration and coordination of the parts of the organisation are essential
for this skill. The importance of these skills depends on levels of management.
Technical skill is most important for supervisory level managers and becomes less
important as the manager move up to the middle and top levels. Conceptual skill is
increasingly important as manager moves up the levels of management. However,
 human skills are important at every level in the organisation. It may be noted here that
there are other kinds of skills required for managers and they are not discussed here. For
example, top and middle managers need to have diagnostic and analytical skills.
Diagnostic skill is the ability to acquire, analyse and interpret information to determine
the cause of change either in inputs or outputs or in the transformation process.
Analytical skill (which is complimentary to diagnostic skill) is the ability to determine
the cause of change and either to provide corrective action or take advantage of the
situation.

All functions or elements of management (to be discussed in next section) will be common to all
levels of management in some form or the other. However, the duties and responsibilities of the
staff operating at different levels will vary. The chart given below indicates how these three
levels of management share their duties and responsibilities as well as the skills required for
them.

Table showing levels of management, their responsibilities, duties & skills

Skills Levels Duties & responsibilities

Conceptual Top Planning, Policy making, Quality control and
Evaluation, Resources Mobilisation
Human Middle Execution of Activities, Supervision, Monitoring
Technical Supervisory Routine tasks, concomitant activities
In the above table, while all the activities are shared by the three levels of management, the
proportion of responsibilities, duties and skills with reference to the activities vary. It should be
noted, however that the system will work efficiently only if the three levels work in unison. Top
management does very little routine operations, while the operational management level staff
does not do much planning. But the middle level management is involved in both planning and
routine operational work.
MANAGERIAL FUNCTIONS

We have already seen that there are several definitions given by experts to explain the meaning
and scope of management. One way is to view management as a set of common processes or
functions which, when carried out well, lead to organisational efficiency and effectiveness.
These processes or functA function is a type of work activity that can be identified and
distinguished from other work. Experts have identified several managerial functions as important
elements of management.

While Newman and Summer have identified four functions namely, organising, planning,
leading and controlling, Henry Fayol has recommended five basic functions namely, planning,
organising, commanding, coordinating and controlling.

Planning

Planning is a bridge taking us from where we are to where we want to reach. It is the process of
determining in advance what should be accomplished and how to do it. In other words, it is an
analytical process of establishing goals, objectives and targets, assessing the future, premising,
generating and evaluating alternatives, selecting programs, projects or courses, estimating
resources, preparing the plan document with derivative plans and implementing the plan.

Four important characteristics of planning are

(i) The purpose of every plan and all derivative plans is to facilitate the accomplishment
of enterprise purposes and objectives;
(ii) (ii) Planning is the “first” function and logically precedes the execution of all other
managerial functions;
(iii) (iii) Managers at all levels are involved in planning;
(iv) (iv) The efficiency of a plan is measured by the amount it contributes to the purpose
and objectives as offset by the costs of other unsought consequences required to
formulate and operate.

In other words, planning is characterised by its primacy, efficient contribution to purpose and
objectives and all pervasiveness. Some types of plan usually developed and operated include
objectives (or goals), strategies (or grand plans), policies, procedures, rules, programs and
budgets. The process of developing a plan consists of a few logical and basic steps. Being aware
of opportunities and a sort of SWOT (Strength, Weaknesses, Opportunities and Threats) analysis
is the first step followed by establishing specific and clear objectives. The third logical step in
planning is premising, i.e., taking note of planning assumptions. Establishing complete premises
and keeping them up-todate is a difficult and complex task. The success of a plan depends on the
degree of accuracy in premising. The fourth step is to search for and examine alternative courses
of action. The step is immediately followed by a systematic evaluation of alternative courses
with the purpose of selecting the best course of action in the next step. The seventh step is
formulating smaller derivative plans. The final step is to numberise the plan along with
derivative plans by converting them into budgetary figures.

Many scientific techniques and models are available to determine the goals and objectives assess
future trends, formulate policies, choose among different alternatives (decision making),
preparation and production of plans, etc. There are rational approaches and principles to follow
in the planning process. A few of them, in addition to those mentioned above, are listed below:

• Planning should start with where we are (premising) rather than with where we want to be;

• Individuals involved in the planning process should agree to use consistent planning premises;

• Flexibility must be built into the plans;

• The plans must be closely integrated;

• The plans should be documented and distributed to all members of the management team;

• Planning has value only if it is transformed into action; and

• Plans should be reviewed periodically throughout the year.

Inputs to a plan have to come from every unit of the organisation to ensure the involvement and
participation of the staff working at the operation supervisory level, besides the top management
which is more directly connected with the planning process and responsible for it. A plan
document provides a directive course of executive action incorporating every aspect of the
development of the organisation. Policies are framed to help the implementation process. Every
plan has to fit into a time frame annual, five year, long range or perspective - and also has to be
flexible to accommodate any unanticipated change at any point of time.

The significance and advantages of planning are:

• It offsets uncertainty and change;

• provides a framework for execution and direction; focuses attention on objectives;

• improves services, leads to operations and facilitates control;

• ensures rational and effective development;

• Permits the anticipation and future resources needs; and

• brings the skills and experience of staff members to the planning process.

Organising

Organising is the process of prescribing formal relationships among people and resources (i.e.,
personnel, raw materials, tools, capital, etc.) to accomplish the goals. Organising involves:

• analysing the entire activities of an organisation into homogeneous types of works and jobs;

• sorting and grouping the resulting works and jobs into a logical structure;

• assigning these activities to specific positions and persons; and

• providing a means for coordinating the efforts of individuals and groups.

The term organisation refers to both the process of organisation and the result of that process.
Organisation refers to the structure which results from (i) assembling the resources necessary to
achieve the organisation objectives, (ii) identifying and grouping work, (iii) defining and
delegating responsibility and authority, and (iv) establishing activity-authority relationships. In
other words, organisation differentiates and integrates the activities necessary to achieve the
objectives. Activities are grouped into working divisions, departments, or other identifiable units
primarily by clustering similar and related duties. The result is a network of interdependent units.
Organisational structures usually comprise departments, divisions, sections, units or cells,
obtained on the basis of division of works and jobs, These structural patterns reflect horizontal
and vertical positions, indicating distribution of work, authority and responsibility, span of
control, nature of duties, outflow of work, means for evaluation of work output, staff discipline
mechanism, smooth flow, functional points and coordination points, etc.

Studies have been conducted to develop techniques for activity and workload analysis, work and
job analysis, job definitions and descriptions, models of organisational structure and similar
others. Organisation charts, block diagrams, work flow charts, etc., portray the functions of an
organisation vividly, indicating its managerial strength. Some basic principles of organising are
listed below:

• The key activities should be clearly defined;

• The activities should be grouped on some logical basis;

• The responsibilities of each division, department, unit and job should be clearly defined;

• Authority should be delegated as far down in the organisation as possible;

• Responsibility and authority should be made equal;

• The number of persons reporting to each manager should be reasonable;

• The organisation should be designed to provide stability, flexibility, perpetuation and self-
renewal; and

• The organisation structure should be evaluated on the basis of its contribution to enterprise
objectives.

Libraries are generally organised on the basis of their functions, viz., collection development,
technical processing, users’ services, etc. But, they can be organised on the basis of user groups
served, subjects/areas handled, products and services generated, or a combination of these.
However, organisational structure varies according to the types of libraries, viz., national, public,
academic and special libraries.
Staffing

If organisational structure creates positions at different levels for performing various functions,
staffing deals with providing the right type of persons to man them. Indeed persons are the key to
the effective functioning of any organisation. In fact, the real strength of an organisation is its
personnel; they can make or mar the organisation.

Staffing is the formal process of ensuring that the organisation has qualified workers available at
all levels to meet its short and long term objectives. This function includes

(i) Human resource planning

(ii) (ii) Recruitment and selection
(iii) (iii) Training and development
(iv) (iv) Rewards and compensations
(v) (v) Health and safety
(vi) (vi) Career planning and management
(vii) (vii) Employee assistance, coaching and orientation
(viii) (viii) Performance appraisal.

Some important basic concepts of staffing are job analysis, job description, job specification, job
enlargement and job enrichment (see key words at the end of the unit). Personnel management
has assumed very great importance in modern management studies. Attention is increasingly
given to composition of staff, their types and levels, proper recruitment methods and procedures,
work distribution and assignment, staff training and development, salary, status and career
development opportunities, incentives and other related aspects. With the increasing
complexities of libraries and the services they are expected to offer, the staffing pattern is
constantly changing. Different categories of specialists are being recruited to operate at various
levels in libraries.
Directing

Directing is the managerial function concerned with the interpersonal aspect of managing by
which subordinates are led to understand and contribute effectively and efficiently to the
attainment of enterprise objectives. It is aimed at getting the members of the organisation to
move in the direction that will achieve its objectives. In other words, directing is the managerial
function that enables managers to get things done through persons, both individually and
collectively. Directing is related to staffing in the sense that these two functions are concerned
with the employees of the organisation. While staffing is concerned with providing and
maintaining human resources, directing deals with leading and motivating the human resources
to give out the best. It is the most interpersonal aspect of management. Directing is closely
related to the communicating function and motivating; actuating and leading are sub-functions of
directing (see key words at the end of this Unit).

Directing is not the singular function of the top management. In fact, it pervades the organisation
at all supervisory levels. This calls for good interpersonal communication, both oral and written.
Written communications are often through memos, letters, reports, directives, policy guidelines,
staff and work manuals and similar others. It is essential to get them drafted unambiguously to
give proper direction to the employees. This is supported by oral communication, formally at
staff meetings and informally on other occasions.

It is necessary to note some important principles of directing. The more effective the directing
process, the greater will be the contribution of subordinates to organisational goals (the principle
of directing objective) and the more individuals perceive that their personal goals are in harmony
with enterprise objectives (the principle of Harmony of Objectives). The more completely an
individual has a reporting relationship to a single superior, the less the problem of conflict in
instructions and the greater the feeling of personal responsibility for results (the principle of
Unity of Command). Interestingly, reporting is the converse functionof directing. In other words,
between two persons in the hierarchy, if A directs B, then B reports to A.
Controlling

Another important aspect of directing is exercise of control over the system. Control does not
merely mean restrictions or restraints to be forced on the system, but they are guidelines for the
organisation to perform according to set standards of efficiency and quality. What is implied in
this is, accountability, and the obligation of the staff at all levels, of reporting to a higher
authority on their productivity both in terms of quality and quantity. But these would need
yardsticks and measurement tools and techniques for evaluating performance. Thus, both
directing and reporting are closely related to the controlling function.

In simple terms, controlling can be defined as the process of comparing actual performance with
standards and taking any necessary corrective action. Hence, the control process consists of;-

(i) establishment of standards

(ii) (ii) measurement of performance, and
(iii) (iii) correction of deviations.

The standards may be physical standards, cost standards, revenue standards or even intangible
standards. Some of the common traditional control measures are budgets, statistical data, special
reports, breakeven point analysis, internal audit and personal observation. Other control
measures include time-event network analysis like milestone budgeting, program evaluation and
review techniques (PERT/CPM), programme budgeting, profit and loss control, return on
investment (ROI) and general key result areas like profitability, market position, productivity,
public responsibility, etc.

It has already been stated that establishing standards for quality, quantity, cost and time,
measuring performance against set standards, and correcting deviations are the three basic steps
involved in measurement of performance. Performance is closely related to techniques of
operations and technology employed. Modern management uses techniques of Operations
Research, Programme Evaluation and Review Technique (PERT) and Critical Path Method
(CPM), system analysis and others for improving quality.

A good control system should be forward looking, objective, flexible, economical,

understandable, reflect nature and needs of activity as well as the organisation pattern, promptly
report deviations and exceptions at critical points and lead to corrective actions. The other
important principles of controlling are listed below:

• Controls require a clearly defined organisational structure;

• Controls must be based on plans;

• Controlling is a primary responsibility of every manager charged with executing plans;

• The control itself should be exercised where the malfunction is likely to occur;

• Controls must focus on key variables;

• Controls must be meaningful and economical;

• Controls must provide accurate and timely feedback;

• Feed forward controls should be used to supplement feedback control; and

• Controlling requires action.

Devising effective control instruments for libraries is difficult due to their service and not-for-
profit nature. In the absence of realistic, objective and precise standards for measuring
performance, libraries resort to use of objectives, budgets, internal audit and the like.

Other Managerial Functions

There are some more managerial functions other than the five most important elements discussed
above. Motivating, actuating and leading are already mentioned as sub-functions of directing. In
addition, communicating, delegating, coordinating, reporting, budgeting, innovating, influencing,
representing, etc., are often mentioned as managerial functions. Let us try to understand some of
them.

Coordinating;- This is the process of linking several activities to achieve a functional whole in
the organisation. In other words, it is the process of ensuring that persons who perform
interdependent activities work together in a way that contributes to overall goal attainment.
Coordinating is the management of interdependence in a work situation. It is much more than
just cooperation and it involves an information giving function. We have learnt in the organising
function that the work of an organisation is divided into various functional units and it is the
coordinating function that ensures that all these units efficiently contribute to the objective. It is
in the coordinating process that a manager has to act like a leader and her/his leadership skills are
put to test. The best coordination occurs when individuals see how their jobs contribute to the
goals of the organisation. To avoid splintering efforts, the dominant goal of the organisation
should be clearly defined and communicated to everyone concerned. Goals of subordinate
departments should be designed to contribute to the goals of the organisation. Coordination calls
for skill of leadership, communication and delegation.

Communicating;- As mentioned earlier, communicating is the transfer of information, ideas,

understanding or feeling between people. In other words, it is the process of passing information
and understanding from one person to another. It needs no further emphasis amongst library and
information people.

Communication is an all-pervasive phenomenon. Librarians have to communicate with each

other in issuing or responding to directives and in carrying out the functions of management.
They also communicate continuously with users and authorities. Communication, both written
and oral, is used to obtain and give information for planning and decision making. Even though it
may be outside the scope of this unit, you may note that there are many obstacles or barriers to
effective communication.

Reporting;- It has already been said that reporting is converse of directing. Reporting serves the
purpose of keeping authorities and the public at large informed about the performance,
achievements and shortfalls for a specific period. This function not only helps with a healthy self
assessment but also by maintaining good public relations. Libraries usually generate a great
amount of statistical data and reports.

Budgeting; - The budget is one of the plan documents. It is a statement of planned allocation of
resources expressed in financial or numerical terms. Budgeting includes financial planning,
accounting and controlling.

Innovating; - As every organisation has to constantly grow bigger and better, innovation
becomes an important function of a manager. Innovation means creating new ideas which may
either result in the development of new products or finding the new user for the old ones.
Representing;- Today’s manager is required to spend a part of his time representing his
organisation before various outside groups (stake holders) like Government officials, labour
unions, financial institutions, suppliers, customers, etc. Lastly it is neither desirable nor feasible
to list and explain all other managerial functions. Many of them are closely related to and even
overlapping with the functions discussed so far.

Fayol’s Principles

Noting that the principles of management are flexible, not obsolete and must be usable regardless
of changing and special conditions, Fayol listed fourteen principles based on his experience.
They are summarised below:

• Division of work: Specialisation allows workers and managers to acquire an ability, sureness,
and accuracy which will increase output. More and better work will be produced with the same
effort.

• Authority: The right to give orders and the power to exact obedience are the essence of
authority. Its roots are in the person and the position. It cannot be conceived of apart from
responsibility.

• Discipline: Discipline is composed of obedience, application, energy, behaviour and outward

marks of respect between employers and employees. It is essential to any business. Without it no
enterprise can prosper. It is what leaders make it.

• Unity of command: For any action whatsoever, an employee should receive orders from one
superior only. One person, one boss. In no case is there adaptation of a social organism to a
duality of command.

• Unity of direction: One head and one plan should lead a group of activities. It is necessary that
all sing the same objective and that is one head, one plan.

• Subordination of individual interest to general interest: The interest of one person or group
in a business should not prevail over that of the organisation.
• Remuneration of personnel: The price of services rendered should be fair and should be
satisfactory to both employees and employer. A level of pay depends on an employee’s value to
the organisation and on factors independent of an employee’s worth - such as cost of living,
availability of personnel and general business conditions.

Centralization: Everything that serves to reduce the importance of an individual subordinate’s

role is centralisation. Everything that increases the subordinate’s importance is decentralisation.
All situations call for a balance between these two positions.

• Scalar chain: The chain formed by managers from the highest to the lowest is called a scalar
chain or chain of command. Managers are the links in the chain. They should, communicate to
and through the links. Links may be skipped or circumvented only when superiors approve and a
real need exists to do so.

• Order: This principle is the simple advocacy of a place for everyone, and everyone in her/his
place; a place for everything, and everything in its place. The objective of order is to avoid loss
and waste.

• Equity: Kindliness and justice should be practised by persons in authority to extract the best
that their subordinates have to give.

• Stability of tenure of personnel: Reducing the turnover of personnel will result in more
efficiency and fewer expenses.

• Initiative: People should be allowed the freedom to propose and to execute ideas at all levels of
an enterprise. A manager who is able to permit the exercise of initiative on the part of
subordinates is far superior to one who is unable to do so.

• Esprit De Corps: In unity there is strength. Managers have the duty to promote harmony and
to discourage and avoid those things that disturb harmony.
HEALTH SERVICES IN ETHIOPIA.

To participate in the medical development of a young country is one of the most exciting things a
doctor can do in this second half of the twentieth century. Ethiopia is such a country. Though old
historically, with legends dating back to the Queen of Sheba, Ethiopia is young technologically.
Its modem birth came with the coronation of Emperor Haile Selassie I in 1930, and in the
intervening 36 years the country has swallowed centuries under his leadership.

An Orthodox Christian stronghold in the Moslem Horn of East Africa, Ethiopia maintained its
identity and independence over the centuries because it was so physically inaccessible. The heart
of the country consists of an 8,000-foot plateau interrupted by 13,000- Foot Mountains and cut
by deep gorges. To the east it drops precipitously down to the Danakil Desert, part of which is
actually below sea level and among the hottest areas on earth. To the southwest it slopes gently
down into lush tropical verdure characteristic of central Africa. Scattered within this geological
and geographical variety are about 22 million people whose faces, ranging from Nilotic to
Cushitic to Semitic, seem to reflect the variety of their surroundings. To provide modem health
services for these people is a challenge.

TRADITIONAL MEDICINE

Though the development of modem health services dates only to the accession of Haile Selassie,
Ethiopia has not been without 275 traditional health services. The best sources for information
on these are the early European travelers to Ethiopia whose accounts have been collected by
Richard Pankhurst, Director of the Institute for Ethiopian Studies in Addis Ababa. Most of the
travelers noted the inseparable relationship of traditional medicine and the Church, a relationship
which persists to this day. One of the most famous priests in present-day Ethiopia, for instance,
is a man whose specialty is exorcising Zar spirits from depressed or agitated sufferers afflicted
with them. His walls are adorned with bottles full of roundworms, tapeworms, etc., that he cast
out along with the Zar spirits.

Traditional medicine emphasized disease as being connected with the supernatural; indeed,
nowhere in the world has medicine yet lost this connection completely. Epidemics were handled
with surprising insight by traditional medicine. Records exist of trade caravans being turned back
and cities being closed to control a raging cholera epidemic in 1866. Smallpox was handled by
burning the afflicted household, often including its inhabitants, to prevent the spread of the
disease. Inoculations against smallpox are recorded early in the nineteenth century using a
method of variolation. Bleeding and cupping were widely practiced, especially for headaches and
rheumatism. Thermal water was also in wide use. Counter irritation, the practice of burning the
body surface with a hot iron over the point of internal pain or infection, enjoyed great popularity.
One traveler said that “one could often tell a man’s medical history from the site and number of
his scars.”

The traditional Ethiopian pharmacopoeia was extensive and included leaves, flowers, seeds,
bark, sap, roots, honey, butter and sheep’s fat. Bone-setting was performed commonly and with
considerable skill. This was often the first medical skill that the traditional practitioner mastered.
Other forms of surgery were occasionally practiced, especially amputations and uvulectomies.
The latter was done for diarrhea or slow growth in a small child. Nor are the traveler’s accounts
devoid of more dramatic proofs of the Ethiopians’ skill in surgery, as this description of a man
who operated on himself will attest:

He first filled a wooden bowl with butter, which he covered with a bladder, like a very fine net,
of a cow recently killed. Then, sitting down on the ground, he opened the lower stomach with a
razor, took out his intestines and placed them in the net, which was still hot, cleaning them, and
placing them carefully back in their proper place. He then sewed up the wound, and lying down
on his back, took as little food as possible till the wound was healed, and a complete cure
effected.

Many of these traditional forms of medicine are still commonly practiced in rural Ethiopia. It is
the exception rather than the rule to escape childhood with an intact uvula or without the scars of
counterirritation, and much more old butter than chloroquine is used to treat malaria.

EVOLUTION OF MODERN H EALTH SERVICES

Growing up alongside these practices, beginning at the turn of the century, have been modem
forms of medicine. In 1909, the Russian Red Gross built Ethiopia’s first hospital in Addis Ababa.
Slowly others came into existence over the next 25 years, so that in 1936, when the Italians
invaded, the country could count 11 hospitals, two leprosaria, and a serological institute for the
production of vaccine.
The Italo-Ethiopian War brought only an overburdening of the existing health facilities.
Communicable diseases spread rapidly as whole populations were moved around. The five-year
occupation by the Italians following the war was the only period in its history when Ethiopia has
been under the control of a foreign power. Even today one can see in Ethiopia that colonialism
was a two-edged sword; schools, roads and hospitals built by the Italians are still in use
everywhere, along with the fierce pride in being independent that was carved by the other side of
the blade. Because the colonialization was brief, however, less mistrust of foreign governments
is found in Ethiopia than in many other African countries.

Following liberation in 1941, health services were slowly reorganized. Hospitals and clinics were
added gradually, and in 1946, a Public Health Laboratory and Research Institute was opened.
The following year a new Public Health Proclamation established the legal basis for a modem
health program, which was transferred from the Ministry of the Interior to the newly created
Ministry of Public Health.

The next major step in the development of health services came in 1954, with the opening of the
Gondar Public Health College and Training Center. Assistance in this project was provided by
World Health Organization, UNICEF, and United States AID. The college was designed to train
health officers, community nurses and sanitarians to staff the provincial health centers. This fit in
with a newly emerging emphasis on generalized, decentralized health services, moving both
health services and decision-making out of the few large cities into the provinces. Finally, the
most recent major development in health services came in September, 1965, when the Faculty of
Medicine of Haile Selassie I University in Addis Ababa opened its doors.

One likes to think of development as an orderly, sequential process, turning the pages of change
one by one. In fact, however, the development of health services in a country like Ethiopia is
fragmented in time. Centuries exist side by side, comfortably at times, uncomfortably at other
times. The incongruities that emerge from this necessarily fragmented development are among
the most inspiring and amusing aspects of working in a developing country.

Current Health Services in Ethiopia

The Government of Ethiopia is working to strengthen the healthcare system to align it with the
Sustainable Development Goals. Ethiopia has a large, predominantly rural population with poor
access to safe water, housing, sanitation, food, and health service. The government has made
significant investments in the public health sector that have led to improvements in health
outcomes. Nevertheless, communicable diseases like HIV/AIDS, TB, malaria, hepatitis B&C,
respiratory infection, leprosy, and diarrhea remain a serious challenge in Ethiopia. Premature
death, suboptimal quality of life, and nutritional diseases constitute a major health challenge.
With a growing middle class, the GOE is facing an increase in non-infectious diseases such as
cancer, diabetes, heart diseases, and high blood pressure. Mental health and eye problems are
also becoming major issues in Ethiopia.

The Ethiopia Food and Drug Authority (EFDA) is being strengthened to provide increased
regulatory oversight for the registration, importation and quality control of medicines, supplies,
and equipment into the Ethiopian market. EFDA has a mandate to regulate practices, facilities,
professionals, and products in the health sector. The agency is also responsible to ensure the
safety and quality of food; efficacy, the safety and quality of medicine; and the safety and
performance of medical devices, cosmetics, tobacco and tobacco products control, as well as the
provision of up-to-date regulatory information.

The GOE is implementing a plan to transform EFDA to make its operations more efficient with
the aim of ensuring 100% availability of vital and essential drugs at all levels of the healthcare
delivery system without stock shortages. Currently, EFDA is trying to implement a “zero
backlogs” strategy for medicine registration and licensing activities. EFDA has digitized the
importation and registration of health commodities to Ethiopia using the below listed programs:

i-Register: Used by importers for application of market authorization and product registration
(new products, request registration exceptions and renew existing registrations).

i-Import: Used by importers to apply for and receive permits to import all health commodities.

Ethiopia Pharmaceuticals Supplies service (EPSS) is the public procurement agency responsible
for purchasing pharmaceuticals, medical supplies, and equipment throughout Ethiopia. (EPSS)
has developed a suite of applications for ensuring proximity of (EPSS) distribution hubs to health
facilities across Ethiopia and to establish efficient systems for inventory, fleet, and information
management. These improvements are targeted to increase efficiencies and improve the
availability of commodities throughout the public sector. (EPSS) has recently implemented a
more streamlined procurement process to reduce the amount of lead time required to obtain
medical equipment and supplies.

The GOE encourages private sector participation in quality of care and quality of service. The
government is also working with the private sector to build advanced tertiary care hospitals to
meet domestic demand that would otherwise be met through outbound medical tourism. The
Ethio-American Hospital, which is under construction, and the recently announced Roha Group
medical center, which will be built with a cost of $300 million in Addis Ababa are examples of
the government’s commitment to developing major new healthcare facilities.

These projects also demonstrate the government’s commitment to encouraging foreign

investment in the sector through PPP arrangements. Standardization and expansion of hospitals
located in different regions is also the focus under health infrastructure development in the
country. The following health care facilities are available in Ethiopia:

 Health Posts: 17,534 available and 77 under construction

 Health Centers: 3,587 available and 89 under construction
 Hospitals: 3643 available and 57 under construction
 Private Clinics: 3,867
 Private Hospitals: 43

In addition to increasing the number of healthcare facilities in the country, the MOH is working
to improve services to reduce health related burdens. The GOE has started to address the high
out of pocket costs for health services through the introduction of community-based health
insurance (CBHI) and social health insurance (SHI) for the informal and formal segments of
society, respectively.
Concepts of Primary Health Care

The term ‘Primary Health Care’ (PHC) is the name given to the essential healthcare that is
universally accessible to individuals and is acceptable to them at a cost that the country and
community can afford. Often, as in Ethiopia, this level of healthcare is free for people living in
rural areas. Primary Health Care gained the world’s attention after the 1978 International
Conference on PHC held at Alma Ata in the USSR (now called Almaty in the country that has
become Kazakhstan). Since then many countries have started to follow the approach of PHC to
reach rural communities where most of the health problems exist. PHC focuses on disease
prevention and health promotion. It is the type of healthcare delivery sometimes described as ‘by
the people, of the people and for the people.’ It involves the community in the whole process of
healthcare delivery and encourages them to maintain their own health.

The role of the Health Extension Workers and Practitioners is to work with the community and
help them acquire the knowledge and skills that enables them to ensure their own health.

Ethiopia is one of the countries in the world which has adopted PHC as a national strategy since
1976. This strategy focuses on fair access to health services by all people throughout the country,
with special emphasis on prevention and the control of common diseases, self-reliance and
community participation. Since this time the concept of Health Posts and the development of
rural health services have been further developed.

The government of that time started to construct Health Posts, train Traditional Birth Attendants
(TBA) and Community Health Agents (CHA), and assign them to Health Posts. However, this
was not sustained due to factors such as insufficient managerial support, lack of in-service
training, lack of remuneration and mainly due to centralised health service management and the
shift to vertical health programmes.

Horizontal health programmes;-

Vertical health programmes are centralised, non-integrated and disease-specific health

programmes. They are designed to tackle single diseases, such as malaria. Although vertical
programmes used to be popular, it is now widely thought that they are not very effective and may
even undermine the rest of the health services by using too many resources. In late 1997, the
Federal Ministry of Health in Ethiopia started to decentralise the health delivery system from
Regional to woreda and kebele level, while still maintaining the vertical health programme
approach. This approach has not brought the required health outcomes. A new initiative, the
Health Service Extension Programme (HSEP), was therefore launched in 2003 together with the
Health Sector Development Programme II (HSDP II).

Health Service Extension Programme

The Health Service Extension Programme, (HSEP) is an innovative, community-based

programme that was first introduced in Ethiopia in 2003. This programme was launched after
realising that the basic health services were not reaching the majority of the population.

The objective of HSEP is to improve equitable access to mainly preventive health services
through community (kebele) based services. These services all have a strong focus on health
promotion and preventive health activities, as well as increased community health involvement.
The principle behind this programme is to transfer ownership and the responsibility of
maintaining health to individual households. This programme has required a sustained political
commitment from the government and continued investment that has led to the construction of
over 14,000 Health Posts and the training of 30,000 female Health Extension Workers (two for
each Health Post) and their deployment in each village

Health Service Packages for the Health Service Extension Programme

1. Disease Prevention and Control. Under this component the most dominant
communicable diseases are addressed.

 a. TB, HIV/AIDS and other STI prevention and control.

 b. Malaria prevention and control.

 c. First aid and emergency measures.

2. Family Health Service.

 a. Maternal and child health.

  b. Family planning.

 c. Immunization.

 d. Adolescent reproductive health.

 e. Nutrition.

3. Hygiene and Environmental Sanitation.

 a. Excreta disposal.

 b. Solid and liquid waste disposal.

 c. Water supply and safety measures.

 d. Food hygiene and safety measures.

 e. Healthy home environment.

 f. Control of insects and rodents.

 g. Personal hygiene.

4. Health Education and Communication.

Organisation of health service delivery

In this section you will learn about the current organisational structure of the healthcare system.
The healthcare service has always consisted of a mixture of public, private and nongovernmental
healthcare sectors. However, for this session you will mainly focus on the public sector
organisational structure. In the mid-1990s, prior to the implementation of Health Sector
Development Programme I (HSDP I), the public healthcare system was structured into a six-tier
and four-tier healthcare system, which is organised into Primary Health Care Units (PHCUs),
District Hospitals, General Hospitals and Specialised Hospitals. The PHCU is a Health Centre
surrounded usually by five satellite Health Posts. Each Health Post serves approximately 5,000
people and the five together total 25,000 people who are looked after by each Health Centre.
Currently it was organized into three tiered health care system
 The six-tiered national health care system consists of:

 Community health services (Health Posts)

 Health stations (Clinics)
 Health centers.
 Rural hospitals.
 Regional hospitals and.
 Central referral and teaching hospitals.

The Four-tiered national health care system consists of:

 The Three-tiered national health care system consists of:

Principles of Primary Health Care (PHC)

1. Accessibility (equal distribution): this is the first and most important key to PHC.
Healthcare services must be equally shared by all the people of the community
 irrespective of their race, creed or economic status. This concept helps to shift the
accessibility of healthcare from the cities to the rural areas where the most needy and
vulnerable groups of the population live.

2. Community participation: this includes meaningful involvement of the community in

planning, implementing and maintaining their health services. Through the
involvement of the community, maximum utilisation of local resources, such as
manpower, money and materials, can be utilised to fulfill the goals of PHC.

3. Health promotion: involves all the important issues of health education, nutrition,
sanitation, maternal and child health, and prevention and control of endemic diseases.
Through health promotion individuals and families build an understanding of the
determinants of health and develop skills to improve and maintain their health and
wellbeing.

4. Appropriate technology: technology that is scientifically sound, adaptable to local

needs, and acceptable to those who apply it and for whom it is used.

5. Inter-sectoral collaboration: to be able to improve the health of local people the PHC
programme needs not only the health sector, but also the involvement of other
sectors, like agriculture, education and housing.

Elements of Primary Health Care

1. Education on health problems and how to prevent and control them.

2. Development of effective food supply and proper nutrition.

3. Maternal and child healthcare, including family planning.

4. Adequate and safe water supply and basic sanitation.

5. Immunization against major infectious diseases.

6. Local endemic diseases control.

7. Appropriate treatment of common diseases and injuries.

8. Provision of essential basic medication.