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Leadership and governance

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The leadership and governance of health systems, also called stewardship, is arguably the most complex but critical building block of any health system.[1] It is about the role of the government in health and its relation to other actors whose activities impact on health. This involves overseeing and guiding the whole health system, private as well as public, in order to protect the public interest.

It requires both political and technical action, because it involves reconciling competing demands for limited resources in changing circumstances, for example with rising expectations, more pluralistic societies, decentralization or a growing private sector. There is increased attention to corruption and calls for a more human rights based approach to health. There is no blueprint for effective health leadership and governance. While ultimately it is the responsibility of government, this does not mean all leadership and governance functions have to be carried out by central ministries of health.

Experience suggests that there are some key functions common to all health systems, irrespective of how these are organized:

  • Policy guidance: formulating sector strategies and also specific technical policies; defining goals, directions and spending priorities across services; identifying the roles of public, private and voluntary actors and the role of civil society.
  • Intelligence and oversight: ensuring generation, analysis and use of intelligence on trends and differentials in inputs, service access, coverage, safety; on responsiveness, financial protection and health outcomes, especially for vulnerable groups; on the effects of policies and reforms; on the political environment and opportunities for action; and on policy options.
  • Collaboration and coalition building: across sectors in government and with actors outside government, including civil society, to influence action on key determinants of health and access to health services; to generate support for public policies and to keep the different parts connected – so called "joined up government".
  • Regulation: designing regulations and incentives and ensuring they are fairly enforced.
  • System design: ensuring a fit between strategy and structure and reducing duplication and fragmentation.
  • Accountability: ensuring all health system actors are held publicly accountable. Transparency is required to achieve real accountability.
Leadership and governance.jpg

An increasing range of instruments and institutions exists to carry out the functions required for effective leadership and governance. Instruments include:

  • sector policies and medium-term expenditure frameworks
  • standardized benefit packages
  • resource allocation formulae
  • performance-based contracts
  • patients' charters
  • explicit government commitments to non-discrimination and public participation
  • public fee schedules.

Institutions involved may include:

  • other ministries, parliaments and their committees
  • other levels of government
  • independent statutory bodies such as professional councils, inspectorates and audit commissions
  • nongovernment organization "watch dogs" and a free media.

This section of the health system profile is structured as follows:


Analytical summary

In Ethiopia, the Federal Ministry of Health at national level and the regional health bureaus at regional level are responsible for health sector leadership. Functions of the Federal Ministry of Health are to:

  • initiate policies and laws, prepare plans, budget and implementation
  • ensure the enforcement of laws, regulations and directives of the Federal Government of Ethiopia
  • undertake studies and research
  • approve contracts and international agreements in accordance with the law
  • provide assistance and advice when necessary to regional executive organs.
The Federal Ministry of Health. Source: Ministry of Health, 2009

There are four authorized agencies dealing with the Ministry's technical themes. These autonomous agencies report to both the Federal Ministry of Health and the Ministry of Finance and Economic Development.These are:

  • The Food, Medicine and Health Service Administration and Control Agency of Ethiopia, whose mandate is to inspect and ensure quality control of drugs, facilities, professional personnel and food products (one stop service, 4 “Ps” – Product, Premises, Professional Practice and Food Products).[2]
  • The Ethiopian Health and Nutrition Research Institute, which conducts research on nutrition, traditional medicines and medical practices on causes and spread of disease, dealing with public health emergencies.[3]
  • The Pharmaceutical Fund Supply Agency, which ensures the regular adequate supply of effective, safe and affordable essential drugs, medical supplies and equipment in the public and private sector and ensures their rational use.[4]
  • The HIV/AIDS Prevention and Control Office, established in 2002,which is an executive body of the National AIDS Council at both federal and regional levels through regional offices. This agency leads the multisectoral decision-making process, which consists of the Government, nongovernmental organizations, private organizations, religious leaders, civic society representatives and people living with HIV/AIDS. Among the Government institutions involved in the HIV/AIDS Prevention and Control Office are the Ethiopian Health and Nutrition Research Institute, the Pharmaceutical Fund Supply Agency and the Food, Medicine and Health Care Administration and Control Authority of Ethiopia.[3]

Devolution of power to regional governments has shifted decision-making on public service delivery from the federal level to regional level and further down to woreda (district) level. Thus, offices at different levels, from the Federal Ministry of Health to regional health bureaus and woreda health offices, now share decision-making processes, powers, duties and responsibilities. The Federal Ministry of Health and the regional health bureaus focus more on policy matters and technical support while woreda health offices manage and coordinate the operation of the district health system under their jurisdiction.[2]

Based on the Health Sector Development Programme [2] (HSDP) process, health planning is composed of two cycles:

  • the 5-year HSDP strategic plan blueprint for all other plans;
  • the annual planning cycle that translates the 5-year HSDP into an annual plan of work entailing achievable targets, strategies and interventions under different levels of the health care system.

The planning system has created a platform for joint planning by all stakeholders at all levels of the health system, including health sector development partners. Simultaneously, a monitoring and evaluation system has been designed as part of the policy, planning and monitoring and evaluation core process and has been implemented at all levels of the health system.

To strengthen the implementation of monitoring and evaluation, a balanced scorecard directly linked to the annual plan at all levels has been selected as a planning and management framework.[4]

Based on the alignment and harmonization principle to enhance development assistance effectiveness, Ethiopia is a signatory of the International Health Partnership (IHP+) Global Compact and was the first country to develop and sign a country-based IHP+ Compact.[2]

Context and background of the health system

Ministry of health and other institutions involved in health and social services

Policy making and health planning

Regulation, monitoring and evaluation

Priorities and ways forward


Endnotes: sources, methods, abbreviations, etc.


  1. Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
  2. 2.0 2.1 2.2 2.3 Health Sector Development Programme IV, 2010/11–2014/15. Final draft (pdf 780.81kb). Addis Ababa, Government of Ethiopia, Federal Ministry of Health, 2010
  3. 3.0 3.1 Government of Ethiopia, Federal Ministry of Health
  4. 4.0 4.1 Fourth national health accounts (pdf 1.68Mb). Addis Ababa, Government of Ethiopia, Federal Ministry of Health, 2010