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Analytical summary - Service delivery

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Ethiopia has a decentralized three-tier system of primary, secondary and tertiary care (see figure). The devolution of power to regional governments has largely resulted in shifting decision-making for public service delivery from the central to regional and district levels. To improve the delivery of quality health care services, the sector has invested in the following improvements:

The Health Extension Programme is a flagship programme of the Ministry of Health. It serves as the primary vehicle for implementation of community-centred essential health care packages and as an effective referral system from the grass-roots level to broaden access to care at secondary and tertiary levels. A large Health Development Army was also initiated to expand the success of the Health Extension Programme deeper into the community to improve community ownership and scale-up best practices.

The Ethiopian three-tier health care system[3]

The health sector provides key health services and interventions free of charge, including immunization, counselling, testing and treatment of HIV/AIDS and tuberculosis, and prevention of mother-to-child transmission. These services help to improve the health status of vulnerable segments of society, including mothers and children.

The lowest level of referral system in Ethiopia is the primary health care unit, which is composed of five satellite health posts, one health centre and one primary hospital.

Each health post is staffed by two health extension workers who provide preventive, promotive and basic curative services, including early recognition and follow-up during and after treatment for mental health problems. Health posts also provide training on selected parts of the Health Extension Programme during household visits and outreach services.

Health centres are staffed by around 20 professionals and provide preventive, curative, inpatient and ambulatory services, treatment of common psychiatric disorders, and dental services.

Primary hospitals are staffed by around 53 persons and provide preventive, curative, inpatient and ambulatory services, and emergency surgical services, including caesarean section and blood transfusion. They also serve as referral centres for health centres and practical training centres for nurses and paramedical health professionals.

General hospitals are staffed by around 234 persons and provide inpatient and ambulatory services.They are also referral centres for primary hospitals and training centres for health officers, nurses, emergency surgeons and other categories of health workers.

The specialized hospital is staffed by around 440 professionals and serves as a referral centre for the general hospitals and provides inpatient services.

A Medical Service Directorate was established at the Federal Ministry of Health to create a customer-centred organization of services to support the rural, pastoral and urban Health Extension Programmes. Regulation of the health sector, such as setting standards for health facilities, licensing and inspecting health professionals, and carrying out product quality assessment and registration is carried out by the newly redesigned Food, Medicine and Health Care Administration and Control Authority.

Ethiopia has achieved a significant improvement in the health status of its citizens. The Ethiopian demographic health survey, 2011[4] shows that the infant mortality rate has decreased by 23%, from 77 deaths to 59 deaths per 1000 births, while the under-five mortality rate has decreased by 28%, from 123 deaths to 88 deaths per 1000 births, as compared with the Ethiopian demographic health survey, 2005.[5]

The Ethiopian demographic health survey, 2011[4] also shows that there has been a 16% increase in last births protected against neonatal tetanus since the Ethiopian demographic health survey, 2005. The contraceptive prevalence rate has shown substantial improvement and consequently the total fertility rate has decreased from 6.4 children per woman in 1990 to 4.8 children per woman in 2010. The primary health coverage rate has also increased from 77% in 2004–2005 to 89% in 2009–2010.[6]

While the health sector applauds these achievements, it still faces major challenges in meeting its target for some indicators; for example the tuberculosis detection rate was only 37% in 2010–2011. Also, despite a slight increase in antenatal care, the prevention of mother-to-child transmission coverage rate is low (9.3% in 2010–2011), only 10% of deliveries are attended by skilled birth attendants and the maternal and neonatal mortality rates are unacceptably high and far below target.[4]

The way forward

  • Strengthen the formal referral system between health centres and health posts, and make newly established health centres fully functional.
  • Improve the institutional capacity of health facilities to provide clean and safe delivery and meet the expected increase in service utilization as a result of the Health Development Army.
  • Improve the capacity of the Medical Service Directorate to guide and to provide supportive supervision, and improve the capacity of the Food, Medicine and Health Care Administration and Control Authority to regulate the provision of quality health services.
  • Address cultural barriers using health extension workers and the Health Development Army and provide client-friendly health services to increase service utilization at health facilities.


  1. Health Extension Programme in Ethiopia. Profile (pdf 2.10Mb). Addis Ababa, Government of Ethiopia, Ministry of Health, 2007
  2. Ethiopian Government portal
  3. Ethiopia’s fourth national health accounts, 2007/2008 (pdf 1.68Mb). Addis Ababa, Government of Ethiopia, Ministry of Health, 2010
  4. 4.0 4.1 4.2 Ethiopian demographic and health survey, 2011(pdf 683.08kb). Addis Ababa, Central Statistics Agency; Calverton Maryland, ICF Macro
  5. Ethiopian demographic and health survey, 2005 (pdf 2.02Mb). Addis Ababa, Central Statistical Agency; Calverton MA, ORC Macro
  6. Ethiopia country profile: human development indicators. United Nations Development Programme