Annual Review - Summary Sheet
Title: Support for the Ethiopian Health Sector Development Programme
(Federal Ministry of Health Millennium Development Goals Performance Fund)
Review period: October 2013 - November 2014
Programme Value: £275 million
Review Date: November 2014
Programme
202990
End Date: March 2015
Code:
GB-1- Start Date: Oct 2011
Main Acronyms Used:
ANC
Antenatal care
BEMOC
Basic Emergency Obstetric Care
CEMOC
Comprehensive Emergency Obstetric Care
EDHS
Ethiopian Demographic and Health Survey
FMoH
Federal Ministry of Health
HMIS
Health Management and Information System
HSDP IV
Health Sector Development Plan IV
JFA
Joint Financing Agreement
MDG
Millennium Development Goals
MDGPF
Millennium Development Goals Performance Fund
PBS
Promotion of Basic Services Programme
PFSA
Pharmaceutical Fund and Supplies Agency
PNC
Postnatal Care
SBA
Skilled Birth Attendance
SPA
Service Provision Assessment
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Summary of Programme Performance
Year
Programme Score
Risk Rating
2012
A
Medium
2013
A
Medium
/High
2014
A
Medium/
High
Summary of progress and lessons learnt since last review
The Millennium Development Goals Performance Fund (MDGPF) is a multi-donor fund which is
managed by the Government of Ethiopia. DFID’s funding is used to provide essential medicines,
medical equipment, train health workers, and strengthen health systems in all regions of
Ethiopia. The provision of medical equipment and medicines is one of the key drivers for
individuals attending health centres and receiving medical care and for that reason, this review
looks at the effects this programme has had on key health indicators in Ethiopia. In this review
period the programme has supported a national reduction in the under-five mortality rate,
maternal mortality rate and stunting prevalence in under-fives. There is strong evidence that
Ethiopia’s plans and budget allocations are effective in improving health indicators, and Ethiopia
has delivered impressive progress on its Millennium Development Goals (MDGs).
DFID’s support to MDGPF continues to provide good value for money, due largely to cost
savings achieved through the bulk purchase of consumables and improvements in efficiency and
productivity. In summary, every pound DFID invests through MDGPF provides three pounds of
value (non-discounted).
In October 2011, DFID approved providing £275 million over four financial years (October 2011 – early
March 2015) to support the delivery of Ethiopia’s current five-year Health Sector Development Plan
(HSDP IV 2010 - 2015) and accelerate progress towards the health Millennium Development Goals
(MDGs). This review covers 20141, during which a total of £87m was disbursed by DFID. This included
an additional £12m against the £75m initially committed for the year.
The UK’s support to HSDP IV is channelled through the multi-donor MDGPF programme which is
administered by the Federal Ministry of Health (FMOH). The MDGPF is designed to provide harmonised
and aligned support to the FMOH and partially fill its funding gaps in implementing HSDP IV. During
2013/14, MDGPG resources have been used to procure essential medicines, vaccines, contraceptives,
medical equipment and ambulances. In addition, it has been used to pay for health system
improvements in underserved areas, including the renovation of health centre infrastructure and staff
training.
During this reporting period, the MDGPF has continued to support the delivery of HSDP IV’s ambitious
targets. Recent data shows positive trends on the following high level impact indicators:
 a reduction in the under-5 mortality rate from 88 per 1,000 live births (2011) to 68;2
 a reduction in the maternal mortality ratio from 676 per 100,000 live births (2011) to 4203;
 a reduction in the total fertility rate from 4.8 (2011) to 4.1; and
 a reduction in the stunting prevalence in children under-5s from 44% (2011) to 40%4.
1
Roughly equivalent to Ethiopian Financial Year 2006.
2
See http://www.countdown2015mnch.org/documents/2014Report/Ethiopia_Country_Profile_2014.pdf
3 Ibid
4 A breakdown of 41.1% male / 39.2% female; 45% poor / 25.7% rich. See HSDP IV Annual Report 2013/14
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The MDGPF has also made significant progress on reducing regional and gender inequalities through
primarily directing resources towards improving health indicators in the four developing regional states of
Ethiopia and targeting women and children.
Value for Money:
The programme continues to provide good value for money. Through its direct focus on procurement,
the economy of the health system overall has improved due to lower unit prices for drugs and other
consumables, bulk purchasing of equipment, improved forecasting, and reductions in wastage from
improved warehousing and transportation and logistics efficiencies.
Even with a very conservative estimate of benefits, based only on a partial calculation of those outcomes
that can be estimated, the benefit-cost ratio for this programme is 3.55 which is equivalent to ever £1
of DFID funding producing £3 of benefit (non-discounted).
Lessons learnt:
1. The new data on the high level impact indicators shows that there has been impressive
progress in the health sector, supported by MDGPF, which indicates that Ethiopia is on track to
deliver on its national targets. There is a very high likelihood that it will also deliver on the
internationally-set health MDGs5.
2. Overall there have been improvements and expansion of key maternal and child health
interventions, although some of the ambitious service coverage targets have not been met and
certain indicators, defined and measured by the FMOH, do not meet WHO recommended
measurement standards6.
3. Inequity in health has gained higher level attention, supported by the MTR findings and a
new FMOH directorate for Health Systems Special Support, which is focused on four developing
regional states. New studies are underway through UNICEF and the Bill and Melinda Gates
Foundation to better understand how to tackle inequalities in access and use of services, and the
low demand for services, particularly in the four developing regional states. FMOH seem
receptive to trialling new approaches to address these challenges and serve hard to reach mobile
populations.
4. DFID can play an important policy dialogue role on future Health financing. This is an area
where the government has recognised it needs to do more to understand the lessons from
elsewhere and revisit what future financing options are available.
5. The fund provides predictable multi-year financing to support health targets at the federal level.
Through the use of government management systems, the fund is considered good value
for money with low overhead costs.
Summary of recommendations for the next year
1. Project Completion Report - DFID support to the MDGPF ends in March 15 and the Project
Completion Report is due in June 2015. However as data for the Project Completion Report will
not be available until October 2015, it will be advisable to consider a non-costed extension until
December 2015 so that the programme continues until the PCR data is obtained. It is also
recommended that work on the follow-on programme should starts as soon as possible, in order
to help the GoE to sustain and consolidate the momentum gained during the last five years.
2. New Joint Financing Agreement (JFA) or a similar platform for multi-donor coordination –
In 2015, the MDGPF Joint Financing Agreement (JFA) is due for revision and DFID needs to
5
Ethiopia has already achieved the MDG 4 target of reducing child mortality by two-thirds between 1990 and 2015 and has
made significant progress towards the MDG 5 target by reducing the maternal mortality rate from 1,400 in 1990 to 420 per
100,000 births in 2013
6 The Service Provision Assessment (SPA), and Service Delivery Indicators (SDI) survey have been completed. Once this data
is released it should provide an update on coverage and quality of services being delivered.
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determine prior to then what kind of mechanism is preferred for the follow-on of this programme.
Revising the JFA and agreeing new terms will be an important process for DFID to engage with,
together with FMOH and other donors.
3. Equity –To attain further progress on health outcomes in the future, it will be essential to focus
on developing regional states, areas and groups with low health coverage. Mechanisms for
doing this should be assessed, including the possibility of an allocation formula. This should
include increased support to harder to reach populations such as those living in pastoralist and
remote regions, the very poor, and marginalised or vulnerable groups. The new health Business
Case design work should review the options for delivering on this.
4. Coverage and quality of services – As progress is made on coverage of services, attention
should shift to improving and monitoring the quality of key services (against WHO standards) particularly Skilled Birthing Attendance, Antenatal Care (+4 visits), and Postnatal Care. DFID
should follow up on the findings of the Service Provision Assessment (SPA) and lobby for the
HSDP 2015-20 results framework to include internationally recognised indicators for measuring
quality of services.
5. Management of Risk. Close, ongoing monitoring of all financial and procurement actions is
recommended, with specific focus on monitoring the financial and procurement decisions of the
Pharmaceutical Fund and Supplies Agency (PSFA) as this is where the majority of MDGPF funds
are used.
A more comprehensive, (MDGPF) programme-specific, risk matrix should be
developed for the next Business Case.
A. Introduction and Context (1 page)
DevTracker Link to Business Case:
DevTracker Link to Log frame:
http://iati.dfid.gov.uk/iati_documents/3717737.docx
http://iati.dfid.gov.uk/iati_documents/4546901.xls
Outline of the programme
The MDGPF is a pooled donor fund managed by the FMoH and governed by a Joint Financing
Agreement which was signed by the GoE and Development Partners in January 2012. The Fund
provides sector support to the FMOH to allow the Ministry to implement its HSDP IV and deliver progress
on the health MDGs. The MDGPF is making a significant contribution to expanding physical health
infrastructure in Ethiopia and increasing the network of Health Extension Workers (HEWs) in order to
improve the coverage of health services. A particular emphasis is placed on the priority but underfunded
areas of maternal and child health, and health system strengthening in the Developing Regional States.
In 2013/14 nearly two-thirds of the MDGPF resources were used for procuring pharmaceuticals and
medical supplies, through PSFA. Other areas of the MDGF spending include: training of health
providers and administrators; the Health Extension Programme (HEP); and improvement/renovation of
essential health infrastructure. The HEP serves as the primary vehicle for the prevention, health
promotion, behavioural change communication, and basic curative care which aims to achieve universal
coverage of primary health care.
Since the initiation of this phase of MDGPF in 2011, Ethiopia has significantly increased the number of
health facilities and providers, it has extended services to those who have not yet been reached and
contributed to an improvement in both the quality and effectiveness of health care provision.
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B: PERFORMANCE AND CONCLUSIONS (1-2 pages)
Annual outcome assessment:
The expected outcome from the MDGPF is an increased access to and improved quality of health
services. Based on the assessment of progress against the outcome milestones MDGPF is on track to
achieve its set outcomes. There is good data available which confirms that the programme has met
three out of the four outcome indicators during this review period.
Outcome Indicator 1: An increase in the Contraceptive Prevalence Rate (CPR). The contraceptive
prevalence rate has increased from 28.6% (2011) to 41.8% (2014) amongst married women and the gap
in contraceptive use between rich and poorer sections of the society has marginally declined.7 Whilst
the national contraceptive acceptance rate has not increased as much as expected, it is on the right
trajectory and has improved from 61.7% (2011) to 63% (2014) reversing the declining trend of the past
two years. The acceptance rate has also increased in the developing regions,8 but it still lags
significantly behind the national average. Overall this indicator has been met.
Outcome Indicator 2: An increase in the percentage of births delivered with skilled birthing
attendants. The percentage of births delivered by a skilled birth attendant has increased using data
from both the Health Management and Information System (HMIS) and the Ethiopian Demographic and
Health Survey (EDHS). The HMIS data shows skilled birth attendance has increased substantially from
16.6% (2011) to 40.9% (2014), with significant increases also in the developing regions. EDHS data
confirms this trend, although with an increase from 10% (2011) to 14.5% (2014) with the gap between
the rich and the poor decreasing.9 The variation between the HMIS and EDHS may be explained by the
differing methodologies between the studies – i.e. HMIS counts deliveries by HEWs as skilled deliveries
whilst EDHS excludes deliveries by HEWs. Overall this indicator has been met.
Outcome Indicator 3: An increase in the percentage of children immunized. The Children’s
Immunization Coverage amongst 1 year olds is currently 82.9%. This is an increase from last year
(77.7%) but is below the ambitious target for this period (89%). In 2011 the number of children under 23
months vaccinated for measles was 55.7% which has increased to 86.5% during this period, and is on
track to reach the 90% target for measles in coming months. Regional variations in full immunisation
coverage exist, with the highest coverage in SNNPR (96.2%) to lowest in Gambella (40.2%). Overall this
objective has been met.
Outcome Indicator 4: An increase in out-patient attendance per capita Outpatient attendance per
capita has increased from 0.3 (2011) to 0.35 (2014). Whilst this is on the right trend, the increase is well
below the desired milestone for this period (0.65). This indicator has not been met.
Overall output score and description
The overall output score for the MDG PF is an A (met targets). However, the programme could have
scored higher due to the positive performance against the outcomes and positive trajectory for meeting
the impact targets. This score is a result of a combination of factors including very ambitious targets
having been set in the HSDP-IV (and used in the DFID Logframe), and scoring not being possible for 7
indicators due to an absence of either milestones or data.
7
In 2011 The Contraceptive Prevalence rate was 48% rich / 13% poor amongst married women. It is now 60% rich / 27% poor.
No data is available for all mothers. See Mini Ethiopian Demographic and Health Survey 2014.
8 In 2011 the Contraceptive Acceptance Rate in developing regions was : 7.1% Somali, 6.4% Afar, 13.5% Gambella, 38.9% BG. It is now 10% Somali, 27% Afar, 10% Gambella, 40% BG. See HSDP IV Annual Report 2014.
9 In 2011 the proportion of rich to poor people having births delivered with skilled birthing attendants was 26.8 (45.6% rich /
1.7% poor). In 2014 this narrowed to 10.3 (55% rich / 5.3%) poor. See Mini Ethiopian Demographic and Health Survey 2014.
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Overall conclusions across all outputs
During 2013/14 the FMOH made a focused effort to accelerate the reduction of maternal mortality,
through increased political commitments, financing and social mobilisation. The most notable success
has been on increasing the Contraceptive Prevalence Rate. While positive progress has been made on
a number of indicators at a federal level, significant differences by region, location (urban/rural) and
income group remain. The challenge areas are to continue to increase the regional coverage and quality
of health interventions.
At output level, progress can only be scored for 7 out of the 14 indicators, due to absence of milestones
for 4 indicators and absence of data available for 3 indicators. For those indicators with no milestones,
an analysis of the trend data shows that performance has continued to improve compared to last year
and is on a positive trajectory.
Key lessons
1. Overall there have been improvements and expansion of key maternal and child health
service interventions, although some of the ambitious service coverage targets have not been
met. The challenges exist with regards to the inequities in access and use of services, with large
variations between and within regions. Two examples are provided below:
 Contraception Prevalence Rate (CPR). While positive overall progress has been made on
CPR significant gaps exists between urban (60%) and rural (39%) areas and between regions
(Addis 57%, Somali 1%), and there is still a large unmet need amongst adolescents.
 Skilled Birthing Attendance (SBA). The place of delivery and who provides assistance
during delivery varies significantly by income quintile and location. 94% of the poorest
women deliver at home and 4.5% receive care provided by skilled provider (doctor, nurse or
midwife), while 50% of the richest women deliver in public health facilities and 56% receive
care from a skilled provider. SBA ranges from a low of 15% in the Somali region to a high of
86% in Addis Ababa. The 2014 DHS found the main reasons for women not attending a
health facility for delivery were because they believed it to be ‘not necessary’ or not
customary. To address this, coffee ceremonies have been introduced at maternity wards in
health facilities, to encourage patients to feel that they are ‘at home’ and traditions are being
followed. This also provides an opportunity for patients to share knowledge and raise
awareness of health measures.
2. Coverage and quality of services. Progress has been made on service coverage but there are
still challenges around the quality of services, particularly on ANC4+, SBA and PNC, which need
to be addressed and more systematically monitored.
3. Partner Coordination. As more contributors, like the World Bank, GFATM and USAID join the
MDGPF, the coordination and alignment challenges will increase. New donors entering MDGPF
bring with them new requirements and procedures making management of the fund more
complex.
4. Risks - DFID (and other donors) policy dialogue has been focused on management of risk,
related to the areas for improvements identified in previous financial and procurement audits.
Over the last year significant action has been taken to address the identified weaknesses.
Key actions
 Equity – Close monitoring of progress is advised at regional and sub-regional levels along with a
continued push for a better analysis and understanding of the barriers to access by certain
population groups (political, social, cultural and economic). DFID, in partnership with MoH,
should endeavour to make future policy level dialogues more evidence based, through utilising
work such as the equity assessment which has recently been commissioned.
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




Quality – As progress is made on coverage of services, attention should shift to improve and
monitor the quality of services (against WHO standards), particularly on ANC4+, SBA and PNC.
Partnership – DFID should step up its partnership engagement to maintain the harmonised
working of donors around the MDGPF, and to ensure political realism around FMOH’s future
plans to shift more to Performance Based Financing.
DFID Policy Dialogue – DFID should balance its dialogue between a focus on risk management
and other technical issues such as equity, quality of services and health financing.
Risk – Actions from financial and procurement audits should be closely monitored to ensure
follow up.
Project Completion Report – DFID should start preparation for the Project Completion Report
as soon as possible. This should include a comprehensive analysis of the progress on output,
outcomes and impact data for the MDGPF.
Has the logframe been updated since the last review?
Yes it was updated since the last AR. The risk of output 4 was downgraded from medium to low, and
some indicators were dropped due to a lack of data.
No further changes are recommended prior to the Project Completion Report as the next year’s plan has
been approved and DFID’s last disbursement has already been made.
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C: DETAILED OUTPUT SCORING (1 page per output)
Output Title
Reduced fragmentation and increased efficiency of donor assistance
Output number per logframe
1
Output Score
A+
Risk:
Low
Impact weighting (%):
30
Risk revised since last AR?
No
Impact weighting % revised
since last AR?
No
Indicator(s)
Milestones
Progress
Score
1.1 Number of Donor
Partners channelling support
through the MDGPF according
to the Joint Financing
Agreement
1.2. Percentage of total
funds to the health sector at
federal level channelled
through MDGPF
An increase on the previous year
(11 committed, 6 disbursed under
the JFA)
In total 11 Donor Partners committed to
supporting MDGPF, of which 9 disbursed
funds under the JFA.10
A
A 10% increase from the previous
financial year (previously 25% of
funds disbursed to the health sector
were channelled through MDGPF.)
In this review period, 612.9 million USD was
disbursed to the health sector, of which
234.7 million USD was channelled through
MDG PF (a 76.1% increase on last year)
A++
Key Points
During this review period, total donor fund disbursement to the health sector was USD 612 million, of
which USD 234.68 million was channelled through MDGPF (38.3% of the total). This represents a
76.1% increase on last year, when USD 133.23 million was channelled through MDGPF. The large
increase in the percentage of total funds to the health sector channelled through MDGPF was largely
due to GAVI and the World Bank joining MDGPF.
11 Donor Partners committed to channelling support through MDGPF this year, of which 9 Donor
Partners disbursed those commitments under the JFA. This is due to the Italian Cooperation not
disbursing its committed funds and the World Bank not yet signing the JFA.
Summary of responses to issues raised in previous annual reviews (where relevant)
 During this review period the percentage of funds channelled through MDGPF increased by
76.1% in comparison to last year. This is a significant increase in relative share.
 DFID continues to play a strong role in promoting harmonisation of funds to the health sector,
through encouraging other Donors to commit to channel money through MDGPF and adhere to
the Joint Financing Agreement. In 2014 the EU provided funding via UNICEF to MDGPF.
GFATM is also considering channelling a proportion of its funds through MDGPF and USAID has
shown interest in doing the same.
 Out of the 11 donors in 2013/14, DFID was the largest contributor to the MDG PF (60%) with a
total contribution of 142.6m USD (above the 110.7m committed) (Figure 1). With new large
funders disbursing funds to the MDGPF DFID’s contribution has steadily decreased from nearly
80% in 2011/12 to 60% this year. As new donors enter the MDG, the FMOH has had to respond
to new demands to earmark funds, set up separate sub accounts, additional audit requirements,
and agree performance indicators. These demands will inevitably increase the complexity of the
overall coordination, management and reporting on the fund.
 The effectiveness of the HMIS system has continued to be one of the focus areas for donor
policy dialogue and was discussed during an IHP+ mission, and is being monitored on a 6
10
The WB is not a signature to the JFA but disbursed funds using a P4R mechanism, whilst the Italian Cooperation is a
signature to the JFA but did not disburse the funds committed.
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viii
monthly basis by the WB. Also, through the Promotion of Basic Services (PBS) programme, a
data quality assessment was made in health, which identified the strengths and weaknesses of
the information systems and made recommendations on how to address these.
Figure 1. MDGPF Disbursements EFY 2001-06 (source- FMOH, EFY 2006Annual performance report
Recommendations
 Strong DFID Policy dialogue and coordination amongst donors is required to maintain the
harmonised working of donors around the MDGPF. This is likely to become more complex and
increasingly challenging in future, particularly if GFATM and USAID also join. Possible future
support from the new Global Financing Facility, may also bring further changes, which will need
to be considered and addressed in the revised Joint Financing Agreement for the MDG PF.
 As MDGPF grows in size and in number of donors, DFID should consider whether there is a
need for a MDGPF Secretariat in the future to ensure full oversight of the programme.
Output Title
Pillars of the health system strengthened
Output number per Logframe
2
Output Score
A
Risk:
High
Impact weighting (%):
30
Risk revised since last AR?
No
Impact weighting % revised No
since last AR?
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ix
Indicator(s)
2.1 Per capita government
expenditure for health (USD)
2.2 Percentage of service delivery
sites with live saving Maternal / RH
medicines available
2.3 Proportion of Health Centres with
available Basic Emergency
Obstetrics and Neonatal Care
services
2.4 Proportion of hospitals with
available Comprehensive Emergency
Obstetrics and Neonatal Care
services
2.5 Proportion of Health Centres
providing Integrated Management of
Neonatal and Childhood Illnesses
Milestones
Progress
USD11
Score
An increase from the previous
financial year (previously 5.27 USD
per capita)
There is no milestone for this
period
5.96
per capita was spent
on health during this period.
A
No data is currently available.
N/A
95% of Health Centres having
available Basic Emergency
Obstetrics and Neonatal Care
services.
98% of hospitals having available
Comprehensive Emergency
Obstetrics and Neonatal Care
services.
97% of Health Centres provide
Integrated Management of Neonatal
and Childhood Illnesses
No data is currently availablePending on the release of SPA data
N/A
No data is currently available.
Pending on the release of SPA data
N/A
89% of all Health Centres provided
Integrated Management of Neonatal
and childhood illnesses.
B
Key Points
Ethiopia’s per capita national health expenditure was around 21 USD in 2011, up from 16 USD in 2007
but significantly less than the low income country average of US$31 and the WHO recommended level
of $60 by 2015.12 Although full data13 to assess the total government expenditure on health since 2011 is
not available, during this review period per capita government regional expenditure on health increased
from 5.27 USD (2012/13) to 5.96 USD (2013/14).
No data was available for the percentage of service delivery sites with Maternal medicines; the
percentage of Health Centres with Basic Emergency Obstetrics and Neonatal care services; or the
Percentage of Hospitals with Comprehensive Emergency Obstetrics and Neonatal Care services and so
these indicators could not be scored. However, significant actions have been taken during the review
period to improve these health indicators. In the future, DFID should work with the Government of
Ethiopia to improve data collection, so that progress within these indicators can be regularly captured.
In 2013/14 the number of health centres providing Integrated Management of Neonatal and childhood
illnesses (IMNCI) increased from 2,373 to 2,967. This resulted in 14% increase in the percentage of
Health Centres, from 75.5% (2012/13) to 89% (2013/14), providing these services, but was lower than
the targeted milestone.
Summary of responses to issues raised in previous annual reviews (where relevant)
 During this review period, a large proportion of the policy dialogue of the health sector and
MDGPF meetings focused on responding to the financial and procurement audits and putting in
place actions plans to monitor the follow up.
 Disaggregated data on stock outs, at lower levels, continues to be difficult to obtain and monitor.
 DFID is supporting a new programme targeting the developing regions which focuses on tackling
the demand side barriers which prevent people from accessing and using public health services.
As lessons are learnt from this programme they should be fed into MDGPF.
 The previous AR warned against the use of ambitious milestones from the HSDP. Milestones in
the next programme should be carefully considered to ensure that they are realistic.
11
Note: both the milestone and progress is calculated using per-capita regional allocation, reported in HSDP IV Annual Report
as 116.43 ETB per capita – regional allocations. (Conversion at 1 ETB = 0.0512 USD)
12
13
The per capita – national allocation as reported in HSDP IV Annual Report.
Total expenditure on health by federal and regional governments, and by Woreda, city and facility administrators
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Recommendations
 A number of outputs were not achieved due to overambitious milestones. DFID to work with the
FMOH in preparation for the Project Completion Report to obtain data for all indicators.
 DFID future policy dialogue should focus more on equity and quality of services (eg. B/CeMOC)
 Where possible, support PFSA / FMOH to provide reliable, disaggregated data on stock outs.
Output Title
Health Extension programme
Output number per Logframe
3
Output Score
A
Risk:
Medium
Impact weighting (%):
25
Risk revised since last AR?
No
Impact weighting % revised
since last AR?
No
Indicator(s)
Milestones
Progress
Score
3.1 Ratio of Health Extension Workers to
population
3.2 Focused antenatal care coverage (1+
visit) (EDHS data).
1 : 2,500
(HEW: Population)
There was no milestone
for this period.
1: 2,39514
A
N/A
3.2a Narrowing gap between rich and
the poor in focused antenatal care
coverage (1+ visit) (EDHS data).
Narrowing
gap
in
comparison
to
2011
baseline (74.9% rich /
17% poor)
76% of women receive
care at least 42 days
after delivery.
In 2011 43% of women received
antenatal care. This increased to 57.515
in 2014.
77.3% rich / 23.7% poor.16
66% of women received care at least 42
days after delivery (increase from
50.5%).
B
In 2011 6.7% of women received
postnatal care within 2 days of delivery.
This has increased to 13.2% during this
period.
N/A
3.3 Postnatal care coverage (women
who receive care at least once during
postpartum (42 days after delivery)).
(HMIS data).
3.4 Postnatal care coverage by health
provider within two days of delivery
(EDHS data).
There was no milestone
for this period
A
Key Points
The health extension programme (HEP) has been the flagship programme adopted for increasing the
coverage of maternal and child health services. HEP is an innovative community-based strategy to
deliver preventive and promotive services and selected high impact curative interventions. It brings
community participation through creation of awareness, behavioural change, and community
organization and mobilization. It also improves the utilization of health services by bridging the gap
between the community and health facilities through the deployment of Health Extension Workers
(HEW).
14
This was calculated using 35,907 HEWS against an estimated population of 86 million.
This is calculated over the previous five year period. See Ethiopia Mini-Demographic Health Survey 2014
16 See Ethiopia Mini Demographic and Health Survey
15
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xi
During this reporting period the ratio of HEW to Population met the milestone. However, the total
number of HEWs has decreased from 36,336 HEWs (2013) to 35,907 HEWs (2014) and the ratio has
increased from 1 HEW: 2334 population (2013) to 1 HEW: 2395 population (2014). This is due to an
over recruitment of HEWs during the last period, which prioritised the quantity of HEWs over the quality
of training they had been given.
Box 1: Health Extension Workers
Adverse pregnancy outcomes can be
minimised or avoided altogether if antenatal
care is received early in the pregnancy and
continued through delivery. The World Health
Organization (WHO) recommends that a
woman without complications should have at
least four antenatal visits, the first of which
should take place during the first trimester.
The 2014 DHS data shows that 57.2% of
women made one ANC visit during their
pregnancy, however just 32% percent of
women made four or more ANC visits. The
gap between rich and poor access to ANC
continues to be large with some slight
decrease in 2014. 24% of the poorest income
quintile receive ANC from a skilled provider
(doctor, nurse, midwife, auxiliary nurse),
compared to 77% from the richest quintile.
Urban rural variations are also high and urban
women make their first ANC visit more than a
month earlier (4 months) than rural women
(5.2 months).
Health Extension Workers are selected by their local
community, but must be female, at least 18 years old
and speak the local language. Females are selected
as most health education delivered by HEWs is
related to issues affecting mothers and children.
Female HEWs are therefore more likely to be
culturally accepted and trusted by communities.
The progress of HEWs in Ethiopia was reviewed in May
2013 by an independent review team on behalf of FMoH
and HSDP. They found that HEWs have significantly
increased both demand and access to Maternal, Neonatal
and Child Health Services. HEWs conduct regular
household visits to deliver 16 educational packages of
healthcare prevention and promotion of basic health
messages. This includes information on hygiene and
environmental santiation, disease prevention and control,
family health services, and basic health education.
HEWs have been instrumental in educating women on
the danger signs in pregnancy, birth preparedness,
motivating women to receive antenatal care, and
providing safe and clean deliveries at health posts.
Acceptability of HEWs by local communities have
improved, as have the skills of HEWs, the scope of their
work and their confidence in conducting tasks. This has
been aided through regular skills improvement courses
and Integrated Refresher Training.
According to the 2014 DHS data the level of postnatal care coverage is extremely low, with just 13.2
percent of women receiving postnatal care within two days (as recommended) and 81.6 percent of
women receive no postnatal check-up at all. There are large differences between DHS and HMIS data,
with DHS reporting the proportion of women receiving postnatal care at least 42 days after delivery as
17%, and HSDP EFY 2006 reporting post natal care coverage as 66.2% (up from 50.5% the previous
year). This is due to the reports using different methodology, DHS is based on results from household
surveys whilst HSDP using government records. We have previously used HSDP results and so in this
annual review, for reasons of consistency, we have continued to use HSDP data. However the large
discrepancy between the data sets has been noted and is being investigated.
Summary of responses to issues raised in previous annual reviews (where relevant)
 A MTR was conducted in 2013, to review progress against the HSDP and MDGPF. A long list of
recommendations resulted, which were discussed between the FMOH and the donors and a
reduced list of actions was agreed. This included actions to improve community ownership,
maximise resource mobilisation through improving financing and building the capacity of the
health insurance agency; improvements to the quality of service delivery in hospitals; increasing
the numbers of staff trained in Public Health Emergency Management; improving the supply of
pharmaceuticals; improving health infrastructure and access to services through producing
ambulance guidelines, maintenance plans and investment strategies; and increasing the training
and governance of staff members. These actions have been subsequently incorporated into the
consolidated plan for next year.
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xii
Recommendations
 A number of outputs were not measurable due to absence of milestones or over ambitious
milestones. The development of a follow on to this programme should have clear and pragmatic
milestones.
 DFID needs to encourage FMOH to focus from scaling up to focus on equity and quality of
services. An example is during the next HSDP (2015-20) indicators should change from
measuring one ANC visit to increase ANC4+. Attention should also shift to promoting earlier first
ANC visits and reducing differences between urban, rural populations and within regions.
Output Title
Output
Logframe
Risk:
Improved community ownership
number
per 4
Risk revised since last AR?
Low
Output Score
B
Impact weighting (%):
15
Yes.
Previously Impact weighting % revised
Medium
since last AR?
No
Indicator(s)
Milestones
Progress
Score
4.1. Total number of individuals within
the Health Development Army network
(1:5)
4.2. Percentage of health facilities with
boards where the community is
represented
There was no milestone for this
period.
2,289,741 one-to-five groups
were set up during this period.
N/A
100%
96%
B
Key Points
The implementation of the Health Development Army network was started in 2010/11 with the aim to
drive behavioural change and expand safe health practices at community level. Roll out in 2013/14 is
described as positive but there are some questions regarding its appropriateness amongst mobile,
pastoralist communities. In 2013/14 442,773 Health Development Army groups were set up with
2,289,741 one-to-five networks (i.e., one HDA per five women). Across all regions, the number of oneto-five networks established in this period were: 149,245 in Tigray, 626,953 in SNNPR, 572,802 in
Amhara, 880,975 in Oromia, 41,561 in Addis Ababa, 5,510 in Harari, 12,695 in Dire Dawa. With the
exception of Addis Ababa, this was an increase in every region.
The Health Extension Workers (HEW), supported by the Health Development Army (HDA) at community
level, have significantly increased both demand and access to Maternal and Neonatal Child Health
services. However, challenges remain regarding the skills of the HDA and appropriateness of this
approach in developing regions with dispersed pastoralist communities, where health seeking
behaviours are low.
As per the legal framework of health service delivery administration, governance and management,
health facilities shall be administered by a joint governing body established from the community, staff of
the health institutions, and representatives from other government offices. Of the 3,351 functional health
facilities (125 hospitals and 3,226 HCs), 3,103 health facilities (123 hospitals and 2,980 HCs) have
formed governing bodies, with most of them being functional in 2013/14.
The overall risk rating for this output has decreased in relation to last year. This was due to the initial
concerns that the HDA model would not gain traction being proven unfounded.
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Summary of responses to issues raised in previous annual reviews (where relevant)
 A review of HDA model was conducted which showed that at community level HEWs, supported
by the HDA, have significantly increased both demand and access to Maternal and Neonatal
Child Health services. In Tigray, the HDA has contributed towards an increase in the uptake of
maternal and neonatal health interventions and an increase in the number of deliveries at health
facilities. This was partly due to new innovative social strategies such as preparing porridge in
health facilities, organizing traditional ambulances and regular meetings with all pregnant women.
 In 2013/14, efforts have started through PBS, to begin to introduce measures to promote social
accountability in health. So far the emphasis has been on getting the processes and procedures
in place.
Recommendations
 DFID should continue to work with FMOH and the Demand Creation Programme to test and trial
new approaches to reach hard to reach and mobile populations, and improve health seeking
behaviours.
 To continue to collaborate with the Promotion of Basic Services Programme to enhance social
accountability in health and promote lessons learning and sharing of findings from these efforts.
 The risk register should be revised to include consideration that the Health Development Army
network, as it now established across Ethiopia, could be used to achieve aims other than those
specifically related to improving health, especially in the run-up to Ethiopia’s general election in
May 2015.
 In light of the point above, the overall risk rating for this output should be revised up to medium.
D: VALUE FOR MONEY & FINANCIAL PERFORMANCE (1 page)
The programme continues to provide good value for money and it has been calculated that £1 of
DFID funding achieves the equivalent of £3 of value (not discounted). This is largely due to
improvements in productivity and efficiency by PSFA. 73% of the funding DFID provides to
MDGPF is used by the PSFA which allows the organisation to purchase public health
consumables in bulk, resulting in large efficiency savings. For example, two out of the four
drugs procured through MDGPF are purchased at prices below international standards. PSFA
has also implemented a number of actions to improve efficiency gains during this period – such
as investing in cold storage (allowing for increased purchase of drugs), improving transport
times and costs, and improving health centres’ forecasting of their needs.
The assessment of value for money should always be based on the Logframe and underlying theory of
change, as the assessment requires considering the inputs, the ways efficiency can be assessed against
outputs, effectiveness against outcomes, and overall cost effectiveness against impacts. However, the
pool fund modality of this programme, as well as DFID Logframe, has some limitations. These include:
 The MDGPF is merely one source of funds to the health sector, providing inputs that are only
relevant alongside inputs from other funding sources (i.e. drugs and equipment funded through
MDGPF are of sub-optimal use without complementary inputs to improve their effective use (such
as skilled human resources and other supporting infrastructure).
 DFID Logframe only captures part of the outputs of the health sector; therefore it does not fully
represent the whole theory of change.
As a result, it is difficult to estimate efficiency measures in a robust manner, because these depend on a
good understanding of all health system outputs and the theory of change (ToC). It is recommended
that the ToC is revised in the next programme’s business case.
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xiv
Cost drivers of the MDGPF and the health sector as a whole
The MDGPF allocates expenditure across a number of areas. (See Table 1.)
Table 1 MDGPF Actual Expenditures, 2014 (EFY 2006), USD
Actual
Expenditures
Public Health Commodity
Procurement
USD
Share of total
95,380,266
73%
Health System Strengthening
4,816,878
4%
Health Service Delivery
266,254
0.2%
Maternal Health
14,729,305
11%
Child Health
6,359,392
5%
Human Resource Development
3,448,467
2.6%
Health Extension program
5,770,461
4%
Prevention & Control
670,050
1%
Miscellaneous
87,850
0%
Total MDG PF Expenditure
131,528,922
100%
o/w Maternal & Child Health
51,980,331
40%
Source: MDGPF 4th Quarterly Report 2006
It is important to note that even within some of the more general categories, funds are spent on maternal
and child health. For example, 73% of actual funds were spent on public health commodity
procurement, but 26% of these can be directly attributable to maternal and child health. Similarly, 16%
of human resource development is for Maternal and Child Health, including training of HEWs. Therefore,
although the MDGPF reports that only 20% of resources are directly related to MCH (maternal health +
child health + Health Extension programme), further analysis shows that this would be 40%.
Economy: MDGPF contribution to key health system cost drivers
Nearly 73% of the MDGPF resources were spent on drugs, equipment and medical supplies in 2013/14.
Therefore, one of the main ways that the fund contributes to the overall health system is to improve
overall economy through the focus on procurement of equipment, drugs, and other consumables.
The PSFA has, partly due to the MDGPF, been able to increase the extent to which it purchases in bulk,
thereby increasing its negotiating power to reduce unit prices in comparison to international standards.
(See Table 2.) For instance, Magnesium Sulphate and Depo Provera were obtained at prices much
lower than the international standard (with the price for the latter falling significantly from the price it paid
in 2012).
Table 2: Drug price comparisons, PSFA vs International prices, US$
Drug
Amoxicillin, 125 mg/5 ml suspension, per ml
Cotrimoxazole 250 mg/5ml suspension, per
ml
Magnesium Sulphate, 40 mg/ml, per ml
Depo prover, vial
17
PSFA Price
2012
0.44
0.078
PSFA Price
2014
0.0067
0.005
0.070
0.489
International price (seller buyer median prices)17
0.0049 - 0.0066
0.0051 - 0.0048
0.1062 - 0.1002
0.7694 - 1.3
MSH (Management Sciences for Health). 2014. Edition. (Updated annually.) Medford, Mass.: MSH.
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The PSFA has also been able to make efficiency gains in its own operations through:
 Improving the forecasting of needs of health centres in order to estimate needs over multiple
years, increasing the ability to order in bulki;
 Investing, through the funds in the MDGPF, in warehouses including cold storage to enable
proper storage of bulk purchases;
 Investing in trucks (including those with refrigeration) to reduce transportation costs;
 Improving processes for clearing customs to reduce the time from arrival at port to delivery to
health centres, as well as to ensure proper storage throughout the process;
 Investing in advanced product management systems to allow tracking of individual lots, to
minimise wastage due to expiration.
These efficiency gains result in lower overall procurement prices for the system as a whole.
Overall cost effectiveness
Given the expected achievement of the health system as a whole over the MDGPF period, it is possible
to estimate, at least partially, the overall cost effectiveness by ascribing economic value to health
outcomes and impacts. The method used here differs from that in the original business case, which
vastly under-stated the number of DALYs that could be attributed to DFID’s contribution to the MDGPF.
The targets themselves have also been revised to reflect a higher level of contribution to the total health
sector budget, which is estimated to be 20% for the MDGPF period.
The results are summarised below. For these outcomes alone, the number of DALYs is over 3.5 million,
with a value (at GNI per capita of USD 380ii) of over $1 billion.
Table 3: DALYs averted as a result of DFID’s contribution to MDGPF
Health outcomes attributable to
DFID
Number of Children vaccinated
against measles
Number of ITNs distributed
Total number of FP users
Number of Deliveries by skilled
birth attendants
Number of women receiving
antenatal visits
Number of babies breastfeed
(nutritional deficiencies averted)
Number of TB cases averted
Number of Diarrahoeal and
respiratory disease cases averted
Revised
Targets
DALYs averted
(BC approach)
DALYs Avertediii
(revised approach)
Value of DALYs
averted, USD
205,683
813,800
833,209
319
19,100
15,881
128,877
22,569
48,973,274
8,576,141
-
245,381
4,944
-
858,932
16,371
-
568,440
89,240
13,887
1,456
915,990
348,076,022
5,000,000
303,900
375,858
2,550,000
3,617,435
969,000,000
1,374,625,437
Although this is a conservative estimate of the total DALYs averted, based on only a partial calculation of
the achievements of the health system overall, it is clear that the programme offers strong overall cost
effectiveness. The benefit/cost ratio is 3.55 (non-discounted) on the basis of the value of DALYs averted
for these few interventions alone. A full valuation including all of the government health system’s outputs
as well as second-round impacts on productivity and economic growth would provide an even greater
return.
Table 4: Benefit/cost ratio calculation
Value of DALYs averted attributed to DFID MDGPF contribution, USD
DFID MDGPF contribution, USD
Benefit/cost ratio
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1,374,625,437
387,348,702
3.55
Quality of financial management
Date of last narrative financial report
Date of last audited annual statement
November, 2014
May, 2014
MDGPF funds are regularly monitored through financial and procurement audits to ensure appropriate
management of funds. These assessments found no record of fraud, but highlighted some areas which
had room for improvement. These concerns have been noted, raised and discussed through the
MDGPF meetings and action plans are now in place, which are being closely monitored through financial
audits and regular MDGPF meetings.
Financial Audit. The MDGPF received an unqualified external audit report for 2012/2013 (Ethiopian
Financial Year 2005). The report showed that all external funds had been used in accordance with the
funding agreement and complied with the national laws and regulations. However a few issues were
highlighted.
 Asset registers are not complete
 Some coding errors at regional level
 Poor financial management in a developing regional states, with request for update on what
actions are being taken to strengthen Financial Systems
 Overdue advances at Addis Abba Regional Bureau, FMOH, Axum and Addis Ababa University.
Last year, the lack of an internal audit report, contrary to the Government’s financial management rules,
was of great concern. However, the FMOH has now completed the internal audit for 2012/13 and
2013/14 which are in the process of being verified by external auditors. We will receive these reports in
February 2015.
Procurement Audit. We identified a number of concerns regarding the latest procurement audit for
2011/12. Most concerned the levels of compliance with Ethiopia’s Public Procurement Agency (PPA)
rules in the following areas: restrictive biddings; discretionary power used by the Pharmaceutical
Funding and Supply Agency (PFSA) director; multiple purchases from single suppliers; and lack of
satisfactory progress in increasing procurement transparency.
The PFSA, which falls under the FMOH, has a procurement responsibility for bulk purchases of
specialised medical commodities which is quite unique to other Government agencies and has faced
challenges adhering to general PPA rules. In recognition of this, specific actions have been taken to
replace the director of the PFSA; to suspend guidelines developed by the Agency; and to instruct them
to follow the standard Government of Ethiopian public procurement guidelines. A new high level PFSA
Board has also been set up that includes staff from the Prime Minster Office, the Ministry of Finance and
Economic Development, Public Procurement Agency and the FMOH to oversee and monitor
procurements conducted by the Pharmaceutical Funding and Supply Agency. A procurement action plan
is in place and being monitored.
Since April 2014, there have been two rounds of meetings with the Minsters of Health to assess
progress on audit recommendations. We will continue to monitor progress in this area through our
quarterly meetings with the Ministers of Health.
E: RISK (½ page)
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Overall risk rating:
changes in 2014.
Medium at Business Case approval. Last Annual Review rated Medium/High. No
Overview of programme risk
The programme’s risks are regularly assessed using the Human Development Risk Matrix which was
last updated in June 2014. This sets out delivery risk, policy and programme risks, and external risks.
The Joint Financing Agreement also contains an Action Plan with actions for strengthening financial and
procurement systems. This plan is reviewed and updated every six months. Through these two
documents, programme risks are regularly monitored. In the future, the programme could benefit from
developing a MDGPF Risk Matrix which combines these documents and allows for systematic overview
and regular monitoring of all risks (possibly jointly with other donors).
This year, the risk level of Output 4 (improved community ownership) was decreased from medium to
low due to concerns that the HDA network would not gain traction being proven unfounded. This risk
should be revised up to medium to reflect concerns that the HDA network, now that it is established,
could be used for non-health related objectives – such as to propagate election materials in the run-up to
Ethiopia’s general election in 2015. The risk register should also include consideration that progress
towards MDGs may slow in the run up to Ethiopia’s elections due to a decreased Government focus on
health priorities. Regular monitoring of the programme’s indicators is necessary in order to respond
quickly to a slow-down in improvement and to take necessary mitigating actions.
The MDGPF does not support the Government of Ethiopia’s Commune Development Programme.
However, as MDGPF resources are deployed nationwide it is likely to provide medicines, medical
equipment and possibly renovate health facilities in areas where the Commune Development
Programme is being concurrently implemented. To mitigate this risk, MDGPF only provides funding for
the renovation of existing health facilities and does not provide any funding for building new health
facilities.
Outstanding actions from risk assessment
 The next Business Case should have a programme-specific, comprehensive risk matrix and risk
register which should be monitored and updated regularly.
 The risk level of Output 4 should be increased to medium.
F: COMMERCIAL CONSIDERATIONS (½ page)
Delivery against planned timeframe
In general, all elements of MDGPF are delivering as expected regarding its timeframe, and overall
progress is on track to meet targets by 2015.
Performance of partnership (s)
During this review period, two additional donors joined the MDG PF, i.e. the World Bank through its
Programme for Results (PforR) and GAVI through its Health System Strengthening Support. However,
the World Bank is yet to sign the JFA and in the next review period DFID should work with the FMoH and
other donors to understand the reasons behind this.
Management of Assets
All MDGPF assets are governed by Ethiopia’s public financial management systems. To improve the
Public Financial Management across Ethiopia, the GoE has followed a systematic “basic first” approach.
This included streamlining the PFM cycle through developing legal frameworks, robust planning and
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budget preparation guidelines, accounting manuals and chart of accounts; moving from a single entry to
double entry accounting method to reduce data entry error; preparing training materials in cash
management, accounting, internal auditing, procurement; and gradually developing a basic
computerized accounting system.
The PFM progress made in recent years in Ethiopia has been well documented in the Public Expenditure
and Financial Accountability (PEFA) reports that have been conducted at regular intervals in 2007, 2010
and 2014. Ethiopia is currently ranked in the top five countries in the Africa region in terms of PEFA
scores.
A Fiduciary Risk Assessment (FRA) of the health sector was also conducted in 2011 and found that
whilst the environment of internal controls was strong some weaknesses in their application remained.
On the basis of the FRA recommendations, the GoE committed in the JFA to:
 make the FMoH responsible for financial management, accounting, recording and reporting
MDGPF ;
 set up a Board to govern the Pharmaceuticals Fund and Supply Agency (PFSA)
 prepare quarterly Financial and Activity Reports using a specified format which includes
information on sources and uses of funds, budgeted and actual expenditure, Bank statements
and proof of bank reconciliation, planned and achieved procurement and distribution
activities, and a six month cash flow forecast;
 regularly publish Reviews and Evaluations including an annual HSDP performance report,
HSDP mid-term evaluation and annual joint reviews; and
 regularly conduct audits, including an annual internal audit, external financial and
procurement audit, and prepare and implement an Action Plan to address audit
findings/concerns.
Despite some delays in producing the audit reports and action plans, the GoE has performed
satisfactorily on these commitments. The FMoH has used funds from the HSSP/HPF to their financial
management capacity by employing 25 additional auditors, procurement advisors and accountant staff
for their Grant Management Unit. A sector PEFA is planned for health later this year which will assess
whether the capacity of the FMoH has grown since 2011.
G: CONDITIONALITY (½ page)
Update on partnership principles (if relevant):
The 2014 Country Partnership Principles Assessment (PPA) was valid at the time of this annual review.
The 2014 assessment judged that: “Overall, we assess that the Government of Ethiopia remains
committed to the underlying principles of our partnership sufficient to continue financial aid. Our
concerns prevent us from considering a return to general budget support.”
DFID’s new PPA guidance (March 2014) recommends that offices may want to consider undertaking a
programmatic partnership principles assessment ahead of disbursements for specific programmes that
are channelled through government systems. As per the new guidance, DFID Ethiopia conducted a
Programmatic PPA for the provision of sector budget support to the MDGPF in October 2014 prior to the
£65m disbursement. Overall we concluded that the Government of Ethiopia has shown strong
commitment to improving the health and wellbeing of their citizens and that there is sufficient evidence of
the Government’s commitment to the partnership principles to allow the disbursement of financial aid to
the MDGPF.
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H: MONITORING & EVALUATION (½ page)
Log Frame
For the purposes of DFID internal AR process, DFID has selected a number of indicators from the HSDP
for monitoring performance, which are set out in a DFID specific log frame. Since the last AR in 2013
one Outcome level indicator were dropped (new acceptors for FP), plus a total of five output level
indicators have been dropped from the Log Frame. This includes two indicators on Malaria (due to
GFATM now funding these), one on the % of financial recommendations actioned, plus two related to
babies and breastfeeding. One new indicator was added to track the Percentage of service delivery sites
with live saving Maternal / RH medicines available. With four outputs, the total output level indicators is
14. The challenge is that for this AR that a total of 6 output indicators cannot be scored.
Annual Review Process
This was primarily a collaborative desk based Annual Review process, with five days inputs by Katie
Bigmore (DFID Somalia, HD Lead), seven days inputs by Emily Tofts (DFID Ethiopia, Strategic Adviser)
and five days consultancy inputs by Emily Wylde (Consultant focused on VfM). This was overseen by
Kassa Mohammed (MDGPF Lead Adviser) and quality assured by Jyoti Tewari (DFID Ethiopia, Senior
Human Development Adviser), Angela Spilsbury (DFID Ethiopia HD Team Adviser), and DFID OpEx
Team.
The review involved consultation with FMOH as well as with other donors (Netherlands) and a half day
field trip to Oromia region to visit Mikewa Health Center and Wara Health Post, to consult with woreda
and kebele level health staff and to better understand the work of the HEW and HDA.
Evidence and evaluation
The data used this review has been taken from the Health Sector Development IV (HSDP IV) Annual
Performance Report, 2013/14; the Ethiopia Demographic Health Survey 2011, Ethiopia Mini
Demographic and Health Survey 2014; the MDG PF Quarterly Financial and Activity Report for the
quarter ended July 7, 2014; PBS draft Annual Review 2014, HSSP draft Annual Review 2014, PBS 11th
Joint Review & Implementation Review Report October 2014, Woreda and city administrations bench
marking survey August 2013.
Monitoring progress throughout the review period
The MDGPF uses Government of Ethiopian systems and procedures for planning, budgeting,
disbursement, financial management, procurements of goods and reporting. This is regulated by a Joint
Financing Agreement which defines the responsibilities of partners and how the fund should be
governed.
The MDGPF is overseen by a Joint Core Coordinating Committee which meets every two weeks and
comprises members from GoE and DPs. In addition DFID participated in the Annual Review Field
Mission, which examines progress in the various regions and also focuses on key thematic areas. This
process feeds into the annual review of the health sector, where outputs and outcome targets and
progress are reviewed by the FMoH, Regional Health Bureaux and Development Partners. This includes
a review of the contribution of the MDG PF to health sector targets.
These sector review processes are supported by the Health Strategic Support Programme (TA fund),
which is also DFID supported. Additional review and evaluation data is commissioned and obtained
through the Health TA fund which conducted a series of analytical, diagnostic and surveys during the
year.
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Progress reports are sent to Development Partners on a quarterly basis and contain information on
activities and outputs. The quality and timeliness of the quarterly reports and annual reports have
improved during this year. Since April 2014, we have had two rounds of meetings with the Minsters of
Health to assess progress on audit recommendations. We will continue to monitor progress in this area
through our quarterly meetings with the Ministers of Health.
Beneficiary feedback
There was no beneficiary feedback sought specific to the MDG fund, nor were there any specific
activities that MDGPF supported to assess client satisfaction. There are however other initiatives which
have sought feedback from citizens on health services, such as social accountability component through
PBS, and citizens benchmarking surveys.
The woreda and city administrations bench marking survey (August 2013) involved a two strand review
in health which looked at both the availability of equipment, refrigeration and medicines at health
facilities, and also involved focus Group Discussions (FGD) with citizens. The data generated through
FGD and Citizen Report Card results showed that health services are regarded by citizens as one of the
better and improving services in their areas. There are complaints by 13% of citizens that facilities do not
have all the necessary supplies. The request is for there to be clear standards of what services can be
expected at different levels of facilities health posts. Urban residents were found to be much more critical
when it comes to perceived responsiveness of health services than residents in woredas.
Beneficiary feedback was also obtained through the PBS 11th Joint Review, Implementation and
Supervision Mission which this year focused on Citizen’s Engagement in Tigray National Regional State
(October 2014). The review looked at a number of areas including financial transparency, accountability,
grievance redress and social accountability (SA). The findings on SA is that a lot has been done to
provide training, establish the tools and processes to promote voice and participation. Community
members report progress through the creation of a more structured forum for dialogue between citizens
service providers and local providers that has improved the participation of the poorest of the poor and
vulnerable groups (eg disabled, people with HIV, women, children/youth and the elderly) in problem
identification, prioritization, planning, implementation.
i
For example, for several MDGPF activities, the purchase of drugs was set up as one large order, with delivery to be taken over
three years, thanks to the ability to make advance estimations of medium-term needs.
ii
World Bank, PPP, Atlas method for 2012
iii
Brenzel (1993) Selecting an Essential Package of Health Services Using Cost Effective Analysis. World Bank and Harvard
Public School of Health.
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