Ethiopian AIDS response as a lever to expand the health workforce & services Yibeltal Assefa Tamrat Assefa ( IAS 2010 HIV and health systems pre-conference meeting July Vienna

Outline of the presentation Background HIV/AIDS situation in Ethiopia HRH situation in Ethiopia The response Conclusion

Country background Total population 80 million Population growth 2.7% / year Rural population 83.9% Life expectancy M 53.4 F 55.4 IMR 77/1,000 LBs MMR 673/100,000 LBs Total health expenditure 4.4 % of GDP

HIV/AIDS situation in Ethiopia 2.3 % HIV prevalence (Urban 7. 7% and rural 0.9%) 1.1 million PLWHA 336,160 in need ART 125,000 new infections in 2009

HRH situation in Ethiopia Health workforce density and distribution Total 66,314 health workers (50% HEWs) 0.7 health workers/1,000 populations (2.3/1000) 1 doctor/ 43,000 population (2/10000) 37% of doctors working in Addis Ababa (3.7% pop) 1 Nurse/ 5,000 population (1/5000)

HRH situation in Ethiopia: challenges Health workforce migration (external & internal brain drain) –2002, ± 17% nurses and 30% doctors left country –72% medical students and 62% nursing students intend to migrate –Number doctors in private sector doubled between 2001 and 2009 Financing of health workforce Educational system for HRH HRH management Recognition of HRH crisis triggered by AIDS crisis

The concerted effort (Government & partners) Short term - task shifting Long term strategies Rapid increase in the # of medical schools both private and public (from 3 in 2005 to more than 10 in 2009) Rapid increase in the output of MDs, HOs & nurses Speciality trainings Master in public health & other specialties Master of Science in Emergency surgery & obstetrics HMIS diplomas Master in Hospital and health care management Development of HRD strategy Mainly supported by PEPFAR, DFID and GFATM

Trend of health workers in Ethiopia MD,HO, MWNurse, HEWs

Innovative approaches to scale up HIV/AIDS services The public health approach –Standardization and simplification –Task shifting –Decentralization –Free service at the point of delivery

Task shifting as emergency response Universal access with doctor-based model – need 2.5 x more Doctors Lag time to produce doctors 6-7 years; so, many patients would have died adequate number of nurses, 18,000 Studies in the west/north showed that mid and low level cadres can do the job

Types of task shifting in Ethiopia Type I: from doctors to health officers Type II: from doctors and health officers to nurses Type III: from nurses to community health workers such as –Health extension workers –Case managers –Community counselors Type IV: from nurses to patients: patient self- management

Number of HF providing HCT HCT services scale-up

ART scale-up, IndicatorEnd 2004End 2009 ART need242,453336,160 ART provided ,492 % coverage3.7%52% Women25%52% Children1%5% Addis Ababa75%25% AIDS mortality99,36044,751

Challenges Retention mechanisms for health workers Preventive services not well developed Retaining patients on treatment

The number of Hospitals and Health centres across the years ( ), Ethiopia Beyond the AIDS response Trends in Health service coverage indicators, ( ) Ethiopia

Conclusion Ethiopia is one of the countries with critical shortage of HRH, mainly clinicians Recognition of HRH crisis triggered by AIDS crisis AIDS intervention as a lever for HRH development The role of community health workers revitalised Despite the HRH crisis, Ethiopia is able to scale-up HIV/AIDS and other health services towards universal access through task shifting

Thank You Acknowledgements: ITM (Wim Van Damme, Luc Van Leemput, Freya Rasschaert) IAS, ICAP, GF, RF