Strengths, Weaknesses, Opportunities and Threats to Scaling Health Innovation in Ethiopia
This blog is part of a series developed by Results for Development sharing learning from the design and implementation of a locally-led and demand-driven Public Sector Scaling Action Lab for East Africa. We welcome comments and insights from others working to scale up innovations within government health systems.
Overview
Ethiopia, Africa’s second most populous country has achieved remarkable progress in recent years with the Government's commitment to improving healthcare access and quality for its citizens. Increased immunization coverage from 14.3% in 2000 to 44.1% in 2019, reduction in maternal mortality by 55% between 1990 and 2017, strengthened workforce in the health care are evident examples of progress made in the past. Interventions such as the Community Based Health Insurance (CBHI) in response to addressing the financial burden and disparities resulting from out-of-pocket spending on households in accessing healthcare initially from 13 to 350 Woredas (districts) reaching over 14.5 million Ethiopians are remarkable milestones.
While significant strides have been achieved in improving health delivery through innovative mechanisms, the Government recognizes and embraces collaborative approaches towards successful implementation. There’s room for deepening an ecosystem approach where expertise and specialties are drawn from diverse backgrounds such as policy, health financing, research, technology from both the private and public sector acknowledging the interconnectedness of diverse stakeholders, and a myriad of opportunities to affect health outcomes in a positive way.
The Action Lab
From an ecosystem approach, the Public Sector Scaling Action Lab (PSS Action Lab), launched in 2022 is a collaborative platform by Results for Development (R4D) with support from Grand Challenges Canada (GCC) in partnership with Global Affairs Canada (GAC). The Action Lab serves as a collaborative hub in East Africa, connecting governments, academia, researchers, health experts and practitioners, the private sector, civil society organizations, and development partners. Together, they engage in co-design, experimentation, and knowledge sharing to drive advancements in health innovation. What sets the Action Lab apart is its strong emphasis on taking action, going beyond conventional communities of practice and fostering hands-on learning experiences.
As pilot countries for the Action Lab, Kenya and Ethiopia bring their distinct dynamics and strengths to the table. This includes variances in ecosystem maturity levels and private sector engagement, as well as the structure of government at both central and subnational levels. These factors contribute to a wealth of insights and opportunities for collaboration within the region. Moreover, the experiences gained from these pilot countries hold the potential for replication in other regions of the continent. They also serve as valuable examples for health systems improvement beyond Africa. In this blog, we aim to share reflections and lessons learned from the strengths and areas of opportunity for collaborative work within the Ethiopian health system. By sharing these insights, we hope to contribute to the growth and enhancement of health systems in Ethiopia, while also inspiring and informing similar endeavors elsewhere.
Health System Highlight
The Health Sector Transformation Plan II (HSTP II) in Ethiopia outlines the Government's five-year vision, spanning from 2020/21 to 2024/25, with the aim of enhancing access to fair healthcare in order to foster a productive and prosperous country. This vision anchors five key pillars, namely:
Quality and equity of healthcare: Ensuring that healthcare services are of high quality and accessible to all individuals, regardless of their background or circumstances.
Information revolution for high-quality data: Embracing an information revolution to generate reliable and comprehensive data that can drive evidence-based decision-making and improve healthcare outcomes.
Motivated, Competent, and Compassionate (MCC) health workforce: Fostering a motivated, skilled, and empathetic healthcare workforce to deliver effective and compassionate care to the population.
Sustainable health financing: Establishing mechanisms for health financing that are sustainable and efficient, enabling the mobilization and appropriate allocation of resources.
Strengthened leadership and governance: Enhancing leadership and governance structures within the healthcare sector to provide strategic direction and ensure effective implementation of the transformation plan.
Ethiopia’s context demonstrates distinctive strengths, including:
Structured System: The provision of healthcare in Ethiopia is predominantly led by the public sector, which operates under a robust centralized structure. To put the plan into action, the Ministry of Health collaborates with Regional Health Bureaus (RHBs), Zonal Health Departments, and Woreda Health Offices at various levels. This collaborative approach ensures stakeholder involvement, inclusivity, and relevance in the implementation process. Additionally, the Partnership and Cooperation Directorate of the Ministry of Health oversees stakeholder coordination and supervises healthcare financing activities at both federal and regional levels. The Woreda Transformation Platform serves as a multi-sectoral platform that fosters collaboration in pursuit of the transformation agenda, working alongside the Ministerial Steering Committee to mobilise national-level efforts towards the shared goal of improving the health system and healthcare delivery.
Public-Private Partnerships: The HSTP II encourages multi sector collaboration to advance innovation through information health systems, digital health and workforce to increase responsiveness and resilience towards universal health coverage (UHC). The plan encompasses 14 strategic directions aimed at improving health indicators in Ethiopia, and one of these directions is enhancing private sector engagement in the health sector. To support this objective, the Investment Proclamation of Ethiopia and the National Sub-specialty Roadmap provide incentives to the pharmaceutical sector and encourage foreign investments to bolster the development of tertiary level hospitals and specialized services in both urban and regional areas of the country. Foreign investors and local private sector entities now have the opportunity to invest in the health and pharmaceutical sectors while benefiting from various incentives.
Readiness for Innovation: The National Digital Transformation and National ID initiatives, led by the Prime Minister's Office, have facilitated the implementation of a national digital ID across various sectors, including healthcare. Agriculture and supply chain innovations are currently driving the innovation landscape. In the healthcare sector, the Ministry of Health has developed a PPP policy and implementation framework, along with models and a National Specialty and Sub-specialty roadmap to encourage innovation.
Innovative Health Financing: Recognizing the financial burden and adverse impact of out-of-pocket spending on households' access to healthcare, the Ethiopian government introduced the Community-Based Health Insurance (CBHI) in 2011 as a pilot initiative initially implemented in 13 districts (woredas). This scheme was designed with different member contributions across districts, considering socio-economic factors to ensure equitable access. By 2017, the CBHI had expanded to over 350 districts, reaching approximately 14.5 million people. However, addressing the gaps in healthcare funding in Ethiopia requires a comprehensive mix of innovative funding mechanisms that are collaboratively designed with partners.
Weaknesses & Threats
Ethiopia’s private sector is still developing, especially participation in the health sector. However, there are ongoing efforts in public-private dialogue for supply chain innovations, health financing schemes, and the pharmaceutical sector. The country faces a high burden of healthcare expenditure, hindering access to quality healthcare for most of the population. Healthcare funding is sourced from various channels, including international loans and donations, the Ethiopian government, out-of-pocket payments, and others. Healthcare budget allocation remains low, with only 5.3% in 2019/20 compared to the WHO's recommended average of 7% for lower income countries.
The Ethiopian government is undergoing a slow process of economic reform and liberalization. Administrative procedures, such as customs clearance, can be complex and time-consuming. Limited access to foreign currency affects the acquisition of IT infrastructure and expertise needed for growth. The local private sector in Ethiopia, encompassing businesses, service delivery, and the pharmaceutical industry, remains small and fragmented due to financing challenges and a bureaucratic investment landscape. Public sector funding from development partners dominates, and private sector research and development lack integration for innovation.
While the privatization of Ethio telecom has spurred national innovations in telecommunications and banking, the healthcare sector lags behind. Most innovations are centralized in the urban center of Addis Ababa, with limited integration into rural or regional centers, except for some telemedicine initiatives in key public teaching hospitals with international academic institutions. Language disparities across Ethiopia's major regions and low digital literacy impede innovation growth beyond Addis Ababa.
Ethiopia grapples with a notable challenge related to incomplete and inaccurate data reporting and the need for data harmonization. Presently, the Federal Ministry of Health manages more than 75 health information systems that lack seamless integration. This leads to a considerable degree of fragmentation between the private and public sectors, especially in rural regions and beyond urban areas.
Opportunities & Strengths
Leadership and Political Will: Despite challenges in infrastructure and finance, Ethiopia's innovation ecosystem is gaining momentum, particularly in the tech sector. Platforms like Startup Ethiopia bring together government, innovators, venture capitalists, angel investors, and ecosystem actors to foster knowledge sharing, networking, showcase innovations, and spark conversations. The opening of the New Museum of Technology and AI in Addis Ababa, along with the first African-wide AI technology conference, further highlights the country's commitment to technological advancement.
Human Capital: With a large and dynamic population, Ethiopia presents ample opportunities for strengthening the innovation ecosystem. The government is actively engaged in consolidating gains from digital transformation and regionalization, learning from more mature ecosystems like Kenya.
Industrialization and Logistics Hub: Ethiopia's status as a travel hub, with Ethiopian Airlines serving as a key logistical player, facilitates regional trade and investment. The country's low power costs make it attractive for establishing manufacturing industries, particularly in sectors such as textiles.
Technology Infrastructure: Efforts are underway to expand mobile, data, and IT infrastructure, including the establishment of ICT free zones, data banks, and hubs. The assembly of smartphones locally is making them more affordable and accessible. The National Digital Transformation and National ID initiatives, led by the Prime Minister's Office, have facilitated the deployment of a national digital ID across various sectors, including health. Agriculture and supply chain innovations are currently driving innovation efforts.
Development Partner Support: Several development partners, including the Mastercard Foundation, USAID, Results for Development (R4D), GIZ, EU, and BMGF, demonstrate a significant interest in supporting and scaling funding for health innovations in Ethiopia.
In conclusion, adopting an ecosystem approach is crucial for addressing the challenges and unlocking the full potential of Ethiopia's health system. By recognizing the interconnectedness of various stakeholders, including the government, private sector, civil society, and development partners, we can foster collaboration, innovation, and sustainable solutions.
Consulting and involving all stakeholders early in the planning, implementation, and evaluation of health innovations is of utmost importance. The Action Lab, through its work with Champions and ecosystem convenings, aims to foster stakeholder engagement and inspire prioritization. By collaborating, we can strive towards achieving universal health coverage and explore pathways to scale innovative solutions that aim to improve the health outcomes in Ethiopia and inspire regional and global learnings more broadly.
Written by: Thomas Feeny, Michael Nzungi, Paulina Adjei and Anna Giulia Ponchia
