Building a Roadmap for Enhancing Public Sector Scaling of 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.

Ethiopia is a hive of activity regarding innovation. Recognising the important contribution of entrepreneurs in creating greater prosperity for the country’s 112 million inhabitants, the government is demonstrating its commitment to creating a more conducive and productive environment for innovation - particularly in health, where innovation is embedded as both a core value and strategic objective of its Health Sector Transformation Plan II (2020-2025). Initiatives such as the creation earlier this year of a National Health Innovation Steering Committee and the use of analytical tools such as the Health Technology Assessment are helping to build the foundations for a more efficient and impactful pathway for innovation to transform Ethiopia’s health system.

It was in this dynamic context that the Public Sector Scaling (PSS) Action Lab for East Africa convened its first meeting in Addis Ababa on 5 July 2023, bringing together actors from different parts of the Ethiopian government with others from the broader ecosystem to explore the ambitions, challenges and opportunities for scaling up innovation within the national health system. With supportive facilitation from the PSS Lab local ‘Champions’, the workshop began with a look back at some of the innovations that have been transformational within Ethiopia’s health sector to date to reflect on the experience already built up in this space. Jointly presented by Dr. Abas Hassen (CEO of the Health System Innovation & Quality Improvement team) and Dr. Bereket Zelalem Adam (National SBFR Coordinator within the same team), the innovations discussed included:

Project	Description
Ethiopia Health Extension Program (HEP)	The HEP was introduced in 2003. It is considered as a highly impactful social innovation that has transformed access to essential primary health care.
Auditable Pharmaceutical Transactions and Services (APTS)	APTS Is a local innovation in the pharmaceutical supply chain system that has been implemented nationally to improve accountability. APTS implementation has resulted in reduction of wastage rate and improvement in client satisfaction and drug availability
Non-Pneumatic Anti-Shock Garment (NASG)	NASG is a first-aid device that can reverse shock, decrease blood loss and stabilize women suffering hypovolemic shock secondary to severe obstetric hemorrhage. It was introduced in 2012-2013
Community Based Health Insurance (CBHI)	This is an innovation in health financing which was started as a pilot in 2004 in 13 woredas, and currently has 980 active schemes targeting the informal sector that are benefiting more than 12 million households. The impact of CBHI has significantly reduced Out of Pocket Expenditure for patients and led to greater health service utilization among beneficiaries while also reducing previous socio-economic disparity in health service utilization

While government leadership in aligning the contributions of different actors (both within and outside government) was a common factor influencing the success of these innovations, there remains a lot of work to be done to embed the right policies, processes and capacities within government to ensure these instances of scale-up are systematic, rather than ad hoc successes. As Dr Hassen noted, “There is currently no structured/organised system to coordinate and streamline the sourcing and scale-up of innovations in Ethiopia, which is leading to many potential lost opportunities for impact.” With so much of the sourcing and scaling process depending on partnership with other actors outside government, participants in the workshop identified a number of key priorities to ensure consistent and productive collaboration in this space, including:

• Enhancing government awareness of entrepreneurs and innovation supporters within the national (and international) ecosystem

• Expanding government engagement with innovations that are focused on new policies, processes or partnership models in addition to the more commonly prioritised technological products. The need to enhance public procurement policies and approaches was mentioned as a particular priority here. As Dr Shallo Daba (Director of the Grand Challenges Ethiopia program at the Armauer Hansen Research Institute) noted, “The current government procurement system is very challenging – it is too slow and too complex for the purpose of efficiently sourcing innovations”.

• Platforms and initiatives to help coordinate more streamlined engagement between public and private actors to build trust and increase collective impact. The urgency of addressing COVID-19 pandemic saw many partnerships form very quickly by necessity, and yet as Dr Maraki Fikre Merid (Managing Partner at CHS Advisory) noted, “During emergencies, everyone seems to work together very well, but this is not sustained once the crisis has lessened”.  

• Supporting technical capacity development within different parts of government, empowering relevant actors with the latest tools, skills and knowledge to lead and manage the processes associated with sourcing, assessing and scaling health innovations.

• Recognising that innovation is a means to achieving better outcomes, rather than an end in itself, and securing more stable and long-term streams of financing from within and outside government to ensure innovation is embedded into the way government operates, rather than a ‘boutique’ operation on the side.

• Developing / adapting contextually-relevant tools and frameworks that help to track the progress of innovations taken up within the public sector, and using data from regular monitoring and evaluation to flexibly iterate on the process as it unfolds (or as Kidist Tesfaye, CEO of YeneHealth phrased it, “Let us innovate as we navigate through each point in the process”.

It was noted by the PSS Action Lab team that all of the priorities identified above were aligned to the different stages of the ‘Mountain Model’ being used by governments in other countries (such as Kenya and Tanzania) to systematise the demand-driven scale-up of innovations within their health system. Enabling the sharing of strategic and implementation-related lessons from across these countries in support of Ethiopia’s journey through the six stages below would therefore be very beneficial.

Mountain Model Stage	Government Leadership	Ecosystem Support
Articulate Demand	Conduct an inclusive process of consultation with government (national/regional), frontline workers and community members to identify gaps and inefficiencies within the health system where innovation is needed.	It is beneficial for an actor with local knowledge / expertise outside the public sector (e.g. academia) to be a neutral partner in facilitating the government consultation process.
Scan, Assess & Select Innovations	Agree assessment criteria to help identify appropriate innovation(s) that have the potential to address priority gaps/inefficiencies.	In response to government demand, curate and showcase different kinds of innovative solutions for public sector actors at various levels to consider.
Identify Scaling Pathway	Analyze factors such as cost, time, impact and sustainability to agree an appropriate pathway(s) for scale-up.	Provide support to innovators to ensure that relevant datasets are available to support accurate decision-making around efficient scaling pathways.
Attract / Reallocate Scaling Resources	Secure political commitment and resources from internal and/or external stakeholders to support scale-up of the chosen innovation(s).	Contribute different kinds of financial and non-financial support to government to help support the initial phases of scaling, which government can then gradually absorb as scaling matures.
Implement, Learn & Iterate	Design and implement an appropriate strategy to monitor scaling progress and inform potential modifications in light of the changing system environment.	Provide technical assistance to governments in funding / co-designing appropriate MEAL tools and techniques for government to use, while supporting innovators to be flexible in the scale-up of their solution.
Institutionalize	Systematize the sourcing and scale-up of innovation within government policies, planning cycles and continuous improvement initiatives.	Provide targeted capacity development support aligned with government-defined priorities, and consider longer-term public-private partnerships for conducting responsibilities that might be more effectively ‘outsourced’.

In the final session of the workshop, participants brainstormed areas for government and ecosystem actors to support achievement of the priorities they had collectively identified above. Specifically, the Government invited members of the PSS Action Lab and other workshop participants to immediately feed into its current development of ‘National Health System Innovation Guidelines’, which are being designed to help establish dedicated structures, responsibilities and processes supportive of innovation scale-up within different parts of the Ministry of Health. To further develop the technical capacities of those staff members so they can feel confident in playing their part along the scaling process, a special iteration of the IDIA Managing Innovation for Impact training course targeting public sector teams and other key actors within the Ethiopian innovation ecosystem is also being planned with support from the Bill & Melinda Gates Foundation. Finally, the PSS Lab will continue to act as a conduit between Ethiopia and other countries in East Africa as they move through the process of embedding innovation within their health systems, including exploring the relevance of new tools such as the Innovation Investment Cases being tested with county governments in Kenya.

As the workshop concluded, participants were enthused by the opportunities and momentum that was gathering around innovation in Ethiopia, and the clear commitment from the national Government to drive it forward for the benefit of the health system and indeed, other services. The future of public sector innovation in Ethiopia is exciting, and at the PSS Lab we’re delighted to be part of helping progress that journey.

With thanks to all of our workshop participants

Authored by: Michael Nzungi and Anna Giulia Ponchia