Human Resources for Health

Human Resources for Health Country Profile Ethiopia

Human Resources for Health Country Profile Human Resources for Health Country Profile Ethiopia AHWO, June 2010

Human Resources for Health Country Profile Acknowledgements The country profile study on human resources for health is an effort to respond to different needs for updating information on the health workforce of each country, as well as the need to update the African Health Workforce Observatory. We should like to express our gratitude to all those who have contributed to the update of the country health workforce profile of Ethiopia from data collection through to the synthesis of this report. The WHO Country Office in Ethiopia is grateful to Mr Wondwossen Temiess for his technical support in developing the country profile update. Special thanks also go to the regions, districts and training institutions across the country, which demonstrated their readiness to assist by participating in the data collection and sharing of information. We also wish to express our gratitude to Dr. Fatoumata Nafo-Traoré, WHO Representative in Ethiopia, to Dr Gebrekidan Mesfin of the Health Systems and Services cluster at the WHO Regional Office for Africa, and to other colleagues in various divisions of the WHO country office and Regional Office for Africa who contributed to the development of this workforce profile.

Contents CONTENT... 4 Introduction... 10 Purpose... 11 Methodology... 11 Scope of the HRH profile... 12 1. Country context... 13 1.1 Geography and demography... 13 1.2 Economic context... 15 1.3 Political context... 15 1.4 Health status... 16 2. Country health system... 18 2.1 Governance... 18 2.2 Service provision... 18 2.3 Health care financing... 19 2.4 Health information system... 20 3. Health workforce situation... 21 3.1 Health workers stock and trends... 21 3.2 Distribution of health workers by category/cadre... 23 3.2.1 Gender distribution by health occupation/cadre... 24 3.2.2 Age distribution by occupation/cadre... 25 3.2.3 Region/province/district distribution by occupation/cadre... 27 3.2.4 Urban/rural distribution by occupation/cadre... 27 3.2.5 Distribution by occupation/cadre... 28 3.2.6 Health workers by years of experience... 29 4. HRH Production... 31 4.1 Pre-service education... 31 4.2 In-service and continuing education... 37 4.3 Health workforce requirements... 38 CONTENT 4

Acronyms BPR CHA CSA EFY FHAPCO FMoH GDP GHWA GNI GP HEW HRH HSDP HEP MDGs MOE FMoH NGO PASDEP PHC PLWHA RHB SNNPR TGE WHO WISN Business Process Re-engineering Community Health Agent Central Statistical Agency Ethiopian Fiscal Year Federal HIV/AIDS Prevention and Control Office Federal Ministry of Health of Ethiopia Gross Domestic Product Global Health Workforce Alliance Gross National Income General Practitioner Health Extension Worker Human Resources for Health Health Sector Development Programme Health Extension Programme Millennium Development Goals Ministry of Education Ministry of Health Nongovernmental organization Plan for Accelerated and Sustained Development to Eradicate Poverty Primary health care People Living With HIV/AIDS Regional Health Bureau Southern Nations, Nationalities and Peoples Region Transitional Government of Ethiopia World Health Organization Workload indicators of staffing need 5

Tables Table 1.1 Population distribution by sex and age in millions, Ethiopia 2009... 14 Table 1.2 Population distribution by region and place of residence, Ethiopia (2007 census)... 14 Table 1.3 Economic indicators... 15 Table 1.4 Main causes of morbidity and mortality, 2009... 16 Table 1.5 Health indicators, 2009... 17 Table 2.1 Distribution of health facilities by ownership, 2009... 19 Table 2.2 Health care expenditure, 2009... 20 Table 3.1 Background characteristics of the health workforce, 2009... 21 Table 3.2 Health worker/population ratios at national level... 22 Table 3.3 Health worker density by region... 23 Table 3.4 Distribution of health workers, 2004-2009... 24 Table 3.5 Gender distribution by health occupation/cadre... 25 Table 3.6 Health workers by age group and cadre, 2009... 26 Table 3.7 Regional/district/province distribution of workers... 27 Table 3.8 Urban/rural distribution of health workers... 28 Table 3.9 Public/private for-profit/faith-based organization/private not-for-profit distribution of health workers... 29 Table 4.1 Number of training institutions by type of ownership... 32 Table 4.2 Public and private health training institutions, 2009... 32 Table 4.3 Physicians graduated and in service, and annual loss and gain... 37 Table 4.4 Projections for health workforce requirements for the coming years... 38 Table 4.5 Average staffing standard, to be filled... 39 Table 4.6 General practitioners required in the public sector and its current gap by 2009-2010... 40 6

Figures Figure 1.1 The Horn of Africa... 13 Figure 1.2 Projected population to 2015... 13 Figure 2.1 The service provision structure... 18 Figure 3.1 Health worker density per 1000 population by region, 2009... 23 Figure 3.2 Health workers by age group, 2009... 26 Figure 3.3 Years of experience of health workers by category... 30 Figure 4.1 Trends in expansion of universities in Ethiopia, 2003-2009... 31 Figure 4.2 Number of entrants and graduates per year... 34 Figure 4.3 High-level health professional graduates, 2005-2009... 35 Figure 4.4 Mid-level health professional graduates, 2004-2005 to 2008-2009... 35 Figure 4.5 Health extension worker graduates, 2004-2005 to 2008-2009... 36 Figure 4.6 Full-time teaching staff involving in training medical students, 2009... 36 7

Executive summary Human resources are the most important assets of any health system. For health institutions to function effectively and efficiently, a well trained, motivated and well functioning health workforce must be produced, deployed, maintained and appropriately utilized towards the goal of improving the health of the population. Recently, concern for human resources for health (HRH) has received increased emphasis despite years of neglect of this issue. Ethiopia, like other countries with limited resources, has been suffering from an HRH crisis. In recognition of this, Ethiopia s Federal Ministry of Health has developed an HRH strategy as a first step to addressing health workforce challenges and developing the health workforce strategy of the country. This health workforce profile is intended to describe Ethiopia s health workforce situation in terms of professional categories and skill mix. It will help to determine the HRH needs of Ethiopia and will provide information for the development of the country s health workforce strategic plan. The current profile reflects a study that was conducted nationally and almost amounted to a census of health professionals working at various levels in the health care delivery units, woreda and zone health offices, regional health bureaux, the Federal Ministry of Health and agencies located at national level. The assessment covered all levels, including public and private health care as well health management units in the country. The assessment revealed that the members of the health workforce of Ethiopia are predominantly male (83%), and that half (50%) are aged under 30 years. The median for years of experience of health workers in the country is five years, with the highest (12 years) among specialists. Health officers and nurses have an average of nine years of experience and general practitioners have a median of three years of experience. This points to the need for better retention mechanisms so that members of the health workforce and especially general practitioners will serve in the system longer. Higher levels of the health workforce (such as general practitioners and specialists) are mainly dominated by males. Of the total number of general practitioners and specialists and who are currently in service, females constitute only 17.6% of general practitioners and 17.8% of specialists. However, at lower and midlevels, females account for 49% of nurses, 71% of midwives and 99.5% of health extension workers. Motivation and encouragement may be needed at all levels to enrol females in the professional categories in order both to increase HRH overall and to improve the proportion of females in HRH. A total of 66 314 health workers are currently in service, including 30 950 health extension workers. The national health worker ratio per 1000 population is 0.84. This result is far less than the standard set by the World Health Organization of 2.3 per 1000 population. It is to be noted that unless a huge effort is made in the next five years to improve the situation, meeting the Millennium Development Goals may be very difficult. The density of health workers has also shown variation across regions with the highest in Harari region (2.8) and the lowest in Somali region (0.47). Moreover, even large regions such as Oromia, Amhara and the Southern Nations, Nationalities and Peoples Region (SNNPR) are less than the national average (2.3 per 10 000 population). However, improvement has been observed in recent years as the density has grown from 0.64 in 2003-2004 to the current 0.84 in 2008-2009 with an average annual growth rate of 0.04%. Of the total 2152 physicians and 21 488 nurses currently in service, 46% and 28% respectively are working in Addis Ababa city administration, whereas large regions such as Oromia, Amhara and the SNNPR account for only 15%, 18% and 16.7% of physicians respectively. Therefore, it is high time to consider the disparity of health workers between regions and to improve the overall health system nationally. In addition, the Somali region which has the lowest ratio of health workers to population may need special attention to improve the situation. 8

The third Health Sector Development Programme has put emphasis on increasing the number of lowlevel and mid-level health cadres to be trained and deployed in the rapidly increasing health centres and health posts. For the last five years, the total number of the health workforce in service has shown a significant increase of about 77%; from the total health workforce of 37 397 (excluding frontline health workers such as traditional birth attendants and community health agents) in 2005 to 66 314 in 2009. The number of health officers has increased from 776 to 1606 and health extension workers from 2737 in 2004 to 30 950 in 2009. During the period 2005-2009, 12 595 nurses, 5134 health officers, 2070 physicians and 31 804 health extension workers were trained and graduated, increasing the total number of health workers significantly to 66 314. However, even though various endeavours were seen at national level to improve the number of physicians in the country, what has been gained over the last five years has also been lost. This affects the health system in many ways in terms of retraining, recruitment and so on. This study has incorporated what has been gained and lost considering the time series data obtained on the last three years of production. An overall loss of 29% from what had been expected at national level is recorded by using indirect measurement for physicians. Therefore, this is an issue of concern that must be reviewed critically at policy and programme level so that we can answer why, when and where regarding the attrition of health workers. Further study is needed to substantiate the findings. The health and education sector strategic plans promote the expansion of health science and medical schools in both the public and private sectors. Ten years ago there were only a few public medical schools and health science colleges in the country. The government of Ethiopia has put great emphasis on the expansion of health service training institutions in order to increase the number of health workers to meet the needs of the ever-growing population of the country. As part of the privatization policy and public-private partnerships, many initiatives have also been undertaken in the past five or six years to expand health services in the public and private sectors. To this effect, the number of universities and health science colleges has grown from five in 2003 to 22 in 2009. Among these, the number of medical university schools increased from three to eight, representing the major populated regions. Furthermore, 48 (25 public and 23 private) health science schools have been expanded and are currently providing training for mid-level health professionals, having a direct impact on the overall production of health workers. This study has shed light on the overall HRH situation in Ethiopia and has indicated some recommendations. In order to achieve the Millennium Development Goals, the current health workforce needs to be increased rapidly by increasing the intake of health professionals to both the public and private health sectors. The private health sector needs to be prepared to provide a bigger proportion of the country s health care and to share the health care burden with the public sector. The issue of human resource development needs more attention at all levels so that current poor planning and implementation can be improved. Strategic information, and monitoring and evaluation of human resources also need to be improved. The current national database needs to be updated annually and should be available at all levels of the health delivery system so that the status of the health workforce is easily accessible. 9

Introduction Ethiopia is a signatory to the Millennium Development Goals (MDGs) whereby the government committed itself to significant improvement of the health of the nation by 2015. The country also signed the Alma Ata Declaration on Health for All through universal primary health care. In order to translate those commitments into action, an efficient and effective health system is required. The quality of health systems critically depends on the size, skills and commitment of the health workforce. Human resources are the most important asset of any health system. For health institutions to function effectively, human, financial and material resources must be allocated, deployed and appropriately utilized towards the goal of improving the health of the population. Studies have shown that the shortage of human resources for health (HRH) is a factor that is crippling health systems and health care, particularly in countries with limited resources. Despite this, the development of human resources has been given little attention at global and national levels until recently. As a result, developing countries have particularly suffered from high attrition rates, low health manpower production, geographical imbalance and an uneven skill mix of health workers at various levels. It is now evident that in many low- and middle-income countries, meeting key MDGs especially those relating to health requires a significant increase in the number of health workers. After thorough study and assessment of the health situation, Ethiopia s Federal Ministry of Health (FMoH) has recognized the need to address the serious health workforce shortage by implementing a national health policy and strategies within the framework of successive health sector development programmes. The government is fully committed to meeting the MDGs and tackling health workforce issues for the underserved rural areas in which 85% of the population live. The government embarked on the implementation of a health extension programme to provide a package of basic and essential promotive, preventative and curative health services, based on the principles of primary health care, targeting households in a community in order to improve the health status of families with their full participation. The current Health Sector Development Programme (HSDP) for 2005-2010 has specific goals related to HRH, such as training and deploying 30 000 health extension workers (HEWs) by 2009 to achieve a ratio of one HEW for every 2500 of the population. In addition, there has been training and deployment of an additional 5000 health officers by 2009-2010 and an increase in the annual enrolment of medical students from 250 to 1000. During the programme, remarkable and encouraging achievements have been observed which have enabled increased access, coverage and improved health care, particularly in rural areas. The encouraging achievement in implementing health extension programmes (HEPs) for 2008-2009 has been noteworthy. The target was surpassed and 30 950 HEWs were successfully deployed. This brings the total number of HEWs deployed to 100% of the total national requirement of 30 000. Despite the efforts of the Ethiopian government to train and deploy more than 30 000 HEWs in rural villages and to train more than 5000 health officers between 2005 and 2010, the shortage of and migration by high-level health workers has significantly compromised the health care delivery system, especially at higher delivery points. Further, the absence of direction and strategic planning at country level, together with the lack of strategic information and monitoring and evaluation of health manpower, has greatly compromised the implementation of health services in many ways. Hence, the FMoH is keen to obtain data on the existing health workforce in order to deliver efficient and highquality health services. It is thus important to maintain up-to-date statistics on HRH to facilitate the human resource planning in the country. Therefore, this study aims to provide an update on the profile of health workers and health training institutions nationally in order to inform the country health system and to share this information sharing with the African and global HRH observatories. 10

Purpose The main purpose of the study was to provide a comprehensive picture of the health workforce situation in the country by category, by geographical distribution, and by age and sex distribution. The HRH country profile also contributes to reinforcing the HRH information system and to making it possible to better understand the HRH situation at country and regional levels. Specific objectives of the study were: to investigate the HRH stock and trends, and the size and composition of the current health workforce in both public and private health facilities, including training institutions; to identify the gap between enrolment and graduation at public and private health professional training institutions; to provide a comprehensive picture of the health workforce information system; to determine human resources availability and requirements; to estimate and project the numbers of categories of the health workforce required in order to meet international commitments. The study has shed light on: the current composition of the health workforce and future requirements for meeting the priority goals of the health sector development strategy; the geography, demography, and economic situation of the country; the country s system of health services, and its governance and policies; a comprehensive picture of the health workforce situation in the country; HRH stock and trends by category and distribution; HRH production including pre-service and post-basic training processes. Methodology Study method and procedure The study used quantitative data collection instruments to capture quantitative information on health providers, in both the public and private sectors. Key variables included age, sex, name of health provider, professional category and education, years of experience, and year of recruitment. Data were collected from administrative records of the regional, zone, woreda and health facility levels as well as of the health training institutions in the country. Desk reviews and secondary data analysis complemented the quantitative study. Study population HRH encompasses not only those who work with individual patients in delivering primary health care or specialty advanced care, but also those members of the workforce who care for the health of the population as a whole. The study population is those professionals who are working in either public and private health facilities, at health sector administrative levels and in higher educational training institutions. Data collection procedures The generic data collection instruments obtained from the WHO sample questionnaire for health-care providers and training institutions was modified to the local context. The use of structured questionnaires, human resource and personnel documents and payroll data was reviewed. The study began with the assumption that most regions would have primary data on health professionals plus basic demographic information. However, regions did not have this, which resulted in the need for extra resources and time for data collection. 11

The data collection took place in all regions of the country. The duration of data collection ranged from 1 to 3 months (September to November 2009) according to the region. Data on the training institutions (enrolment and graduation) was collected from eight medical universities (seven public, one private) and 34 private health science colleges. A half-day orientation on data collection was given to all data collectors at regional level. Data collectors were assigned to different regions on the basis of the size and population of the region. Data were brought to the centre for data entry and analysis. Data entry and cleaning was done using Excel, and analysis was carried out with EPI-Info software. The national HRH database was created. Generally there was a good response and cooperation from regional health bureaux and health training institutions in both public and private sectors. A total of 37 354 high-, mid- and low-level health providers were captured in the database. Regional health professional profiles can be extracted from the database and can be used as the basis for establishing regional databases. All possible communications media (including e-mail, telefax and telephone) were used to validate the data collected and to correct for missing variables. Scope of the HRH profile The HRH profile provides a summary of the following elements: a comprehensive picture of the health workforce situation in Ethiopia; geography, demography, and economic situation; the health services system, its governance and policies; HRH stock and trends; HRH production, including pre-service and post-basic training processes; HRH utilization. 12

1. Country context 1.1 Geography and demography Ethiopia is situated in the Horn of Africa. The total area of the country is around 1.1 million square kilometers, and it shares borders with Djibouti, Eritrea, Kenya, Somalia and Sudan (Fig. 1.1). Figure 1.1 The Horn of Africa Ethiopia is a country with great geographical diversity, with a topography ranging from 4550 metres above sea level to 110 metres below. There are broadly three climatic zones: the Kolla or hot lowlands below approximately 1500 metres, the Weyna Dega at 1500-2400 metres, and the Dega or cool temperate highlands above 2400 metres. In general, the highlands receive more rain than the lowlands. Ethiopia is the second most populous country in Africa after Nigeria. Over the last two decades the population of Ethiopia has almost doubled. The recent (2007) census showed that the country has a population of 73.9 million (50.5% males and 49.5% females) (Table 1.1). The population has grown rapidly from 39.8 million in 1984 to 53.4 million in 1994, and to 73.9 million in 2007. At an annual growth rate of 2.6%, the total population is expected to reach 90.7 million by 2015 (Fig. 1.2). Ethiopia is a diversified country with more than 80 ethnic groups with their own languages. The two predominant religions are Christianity and Islam, with 43% of the population being Orthodox Christians, 33.9% Muslims, and 18% Protestant Christians, with the rest following a diversity of other faiths. The population of Ethiopia is young, with children under 15 years of age accounting for some 45% of the population. Children under five years make up about 15% of the population, and persons over 65 years make up 4.6%. Figure 1.2 Projected population to 2015 13

Table 1.1 Population distribution by sex and age in millions, Ethiopia 2009 Year 2007 2008 2009 2010 Age group (millions) Sex <15 15 64 64+ Total Total 33 38.3 2.3 73.8 Male 17 18.9 1.29 37.19 Female 16.21 19.36 1.03 36.6 Total 34.1 39.3 2.4 75.8 Male 17.5 19.4 1.3 38.2 Female 16.6 19.9 1.1 37.5 Total 35.0 40.3 2.5 77.8 Male 17.9 20.0 1.4 39.2 Female 17.1 20.4 1.1 38.5 Total 35.9 41.4 2.5 79.8 Male 18.4 20.5 1.4 40.3 Female 17.5 20.9 1.1 39.5 The majority of the population (84%) resides in rural areas while the remaining 12 million (16 %) live in urban areas, making Ethiopia one of the least urbanized countries in the world (Table 1.2). The average household size is 4.7 persons. Addis Ababa is the only urban centre with a population of more than a million, accounting for 24% of the total urban population and 3.7% of the total population of the country. The latest information obtained from the 2005 Demographic and Health Survey on the total fertility rate shows a slight decline from 6.4 in 2000 to 5.4 in 2005. 1 Table 1.2 Population distribution by region and place of residence, Ethiopia (2007 census) Region Urban + rural (millions) Urban (millions) Rural (millions) Projected 2009(millions) Number % Number % Number % Number Country 73.9 100 11.9 16.1 61.9 83.9 78.03 Tigray 4.3 5.8 0.84 19.5 3.47 80.5 4.54 Afar 1.4 1.9 0.18 13.4 1.22 86.6 1.46 Amhara 17.2 23.3 2.11 12.6 15.1 87.4 17.8 Oromia 27.1 36.7 3.37 12.2 23.78 87.8 28.8 Somali 4.4 6.0 0.62 13.9 3.83 86.1 4.63 Benishangul.G 0.67 0.9 0.97 13.5 0.57 86.5 0.714 SNNPR 2 15.0 20.4 1.54 10.0 13.4 90.0 15.97 Gambela 0.3 0.4 0.077 25.2 0.229 74.8 0.334 Harari 0.18 0.2 0.099 50.5 0.084 49.5 0.193 Addis Ababa 2.73 3.7 2.72 100 0 0 2.86 Dire Dawa 0.34 0.5 0.23 67.5 0.109 32.5 0.361 Special Region 0.096 0.1 0.029 56.3 0.067 43.7 0.101 1 Ethiopia: Demographic and Health Survey, 2005, accessible at http://www.measuredhs.com/pubs/pdf/fr179/fr179.pdf. 2 Southern Nations, Nationalities and Peoples Region. 14

A person s utilization of health services and acceptance of modern health services greatly depend on the person s educational level. Hence, the government of Ethiopia has made huge efforts to increase the literacy status of the population. To this effect the gross enrolment rate in primary schools at national level has increased from 68.4% in 2004 to 95% in 2008, and the rate for the girls has shown a remarkable change from 59.1% in 2004 to 90.5% in 2009. 3 1.2 Economic context The Ethiopian economy largely depends on agriculture which employs 80% of the population and accounts for about 90% of exports. 4 Furthermore, 54% of the country s gross domestic product (GDP) derives from agriculture. The country is one of the least developed in the world, with a per capita gross national income (GNI) of US$ 223 in 2008; 44.2% of the population live below the poverty line (Table 1.3). The UNDP Human Development Index (HDI) for Ethiopia stood at 0.389 in 2008. Ethiopia scores 169 out of 179 countries and remains among the world s poorest countries even if exceptional achievements in growth and basic service delivery have been noted. The policy environment created by economic reform and macroeconomic stability have helped address poverty in a comprehensive way through the Plan for Accelerated and Sustained Development to End Poverty (PASDEP), which is now giving attention to poverty-related health programme targets. The government is also committed to meeting targets set by global initiatives, notably the MDGs and the recommendations of the WHO Commission on Macroeconomics and Health (CMH) which aimed at strengthening the link between improved health and economic development. 5 Table 1.3 Economic indicators Indicators 2006 2007 2008 2009 GDP (exchange rate) 8.7 9.2 10.0 12.6 GDP (real growth rate) 11.4 11.5 11.6 GDP per capita 190 205 223 223 National debt (billion ETB) a 2.3 2.8 2.8 NA Inflation rate NA NA 13% NA % budget spent on health (billion ETB) a 5.4 4.9 4.8 Poverty line 44 NA NA NA a Ethiopian birr. 1.3 Political context Ethiopia is a federal democratic republic with a parliamentarian system. The members of the House of Representatives are elected from the regions, zones, woredas (districts) and kebeles, and the members of the House of Federation are designated by their respective regions. The highest governing body of each regional national state is the regional council, which has elected members and is headed by a 3 Ministry of Education. Education Statistics Annual Abstract, 2007-2008. 4 Central Statistical Agency, 2000. 5 UNDP 2008 statistical update, December 18, 2008. Ministry of Finance and Economic Development Annual Report, 2008. 15

president nominated by the party that holds the majority of seats. The regional president is assisted by heads of various regional bureaux, including the regional health bureau. Administratively Ethiopia consists of nine regions Afar, Amhara, Benshangul-Gumuz, Gambella, Harari, Oromia, Somali, Tigray and the Southern Nations, Nationalities and Peoples Region (SNNPR) and two administrative councils (Addis Ababa and Dire Dawa). Each regional state is subdivided into zones and woredas. Each region has its own parliament and is responsible for legislative and administrative functions except for foreign affairs and defence. With the aim of promoting decentralization and meaningful participation of the population in local development activities, public service delivery including health care has to a large extent fallen under the control of the regions. Due to the government s commitment to further decentralize decision-making power, woredas are currently the basic units of planning and political administration. The woreda is the basic administrative unit and has an administrative council composed of elected members. The woredas are further divided into kebeles that represent urbandwellers associations in towns and peasant associations in rural villages. Decision-making processes in the development and implementation of the health system are shared between the FMoH, the regional health bureaux (RHBs) and the woreda health offices. As a result of recent policy measures taken by the government, the FMoH and the RHBs function more with regard to policy matters and technical support, while the woreda health offices are required to play the pivotal roles of managing and coordinating the operation of the primary health care services at woreda level. 1.4 Health status The Ethiopian population faces high rates of morbidity and mortality mainly resulting from a high prevalence of communicable infections (Table 1.4). About 75% of the population suffers from some type of communicable disease and malnutrition, which are potentially preventable. Life expectancy (50.9 for male and 53.5 for female) has remained low for many years (Table 1.5). The infant mortality rate is estimated at 77 per 1000 live births, under-five mortality is estimated at 119 per 1000 live births, and the maternal mortality ratio is 673 per 100 000 live births. 6 Since being first reported in 1984, HIV/AIDS has become one of the most important public health problems in the country, affecting a large segment of the urban population and continuing to expand in rural areas. Based on a single point estimation and projections, the estimated national HIV prevalence for 2009 was 2.3% (7.8% for urban areas and 0.8% for rural areas). Currently, more than one million people live with HIV in Ethiopia, including 289 000 HIV patients who need antiretroviral (ARV) treatment, and 886 000 children have lost one or two of their parents due to AIDS. According to a recent update by the Federal HIV/AIDS Prevention and Control Office (FHAPCO), more than 50% (167 000) of those in need of ARV therapy are receiving treatment. 7 The health and health-related indicators of the FMoH indicate that malaria, helminths and tuberculosis are the three top causes of outpatient visits to the health institutions. The leading causes of disease and death are malaria, bronchopneumonia and tuberculosis. Widespread poverty, along with generally low income levels, low educational levels (especially among women), inadequate access to clean water and sanitation facilities, and poor access to health services, have contributed to the high burden of ill-health in the country. 8 Table 1.4 Main causes of morbidity and mortality, 2009 6 Central Statistical Agency, 2006 7 Federal HIV/AIDS Prevention and Control Office monthly antiretroviral therapy (ART) report, September 2009. 8 Health and health-related indictors 2005-2006 and 2007-2008. 16

Main causes of morbidity * Value Main causes of mortality Value (%) (%) Malaria 12.0 All types of malaria 21.8 Acute respiratory Infection 6.8 Tuberculosis of respiratory system 10.2 Helminths 4.5 Bronchopneumonia 6.6 Gastritis and duodinitis 4.5 Primary atypical, other and unspecified 5.4 pneumonia Bronchopneumonia 3.8 Gastritis enteritis and colitis 4.1 Primary atypical, other and unspecified 3.2 Hypertension without mention of heart 3.0 pneumonia Infection of skin and subcutaneous 3.2 Other meningitis (except meningococcal) 2.7 tissue All other diseases of genitor-urinary 2.6 Labour pneumonia 2.5 system Otitis media and mastoiditis 2.6 Tetanus 2.4 All other infection and parasitic diseases 2.5 Intestinal obstruction without Hernia 2.3 Table 1.5 Health indicators, 2009 a Demographic and Health Survey, 2005. Indicators Both sexes Male Female Source and year Life expectancy 54 years 50.9 53.5 CSA, 1998; HSSP, 2004-2005 years years Crude mortality rate 50/1000 NA NA Health indicator 2007-2008 Under-5 mortality rate 123/1000 live births NA NA CSA, 2006; HSSP, 20042005 Maternal mortality ratio 673/100 000 live NA NA CSA, 2006; HSSP, 2004-2005 births HIV/AIDS prevalence 2.3% NA NA FHAPCO single point estimate, 2007 rate Malaria prevalence NA NA Tuberculosis detection rate 34% NA NA 2008-2009 annual performance report Tuberculosis cure rate 67% NA NA 2008 2009 annual performance report Tuberculosis treatment 84% NA NA Health indicator 2007-20088 success rate % safe water access 86.2 urban, 53.9 rural NA NA Health indicator 2007-2008 (average 59.5) Total fertility rate 5.4 NA NA DHS, 2005 a 17

2. Country health system 2.1 Governance At the time of establishment of the Transitional Government of Ethiopia (TGE) in 1991, only 43% of the population had physical access to modern health services. Health posts and the community health agent (CHA) system had almost totally collapsed. To mitigate this situation, the TGE issued a health policy that reflected a commitment to, and direction towards, decentralization and democratization with a focus on the preventive and promotive components of health care as well as the development of an equitable and acceptable standard of health services for all segments of the population. 9 In response to the prevailing and newly emerging health problems, the government of Ethiopia has set up the HSDP which incorporates a 20-year health development strategy through a series of five-year rolling programmes. Eight major area is addressed through these programmes, namely: (i) health service delivery and quality of care; (ii) health facilities construction and rehabilitation; (iii) human resource development; (iv) strengthening pharmaceutical services; (v) information, education and communication (IEC); (vi) health care financing; (vii) health management and information systems; and (viii) monitoring and evaluation. The first two phases were implemented and some encouraging results were registered. The potential health service coverage of public health facilities, for example, grew from 59.1% in 2001-2002 to 72.1% in 2004-2005. Currently, HSDP III covering the period 2005-2006 G.C 2009-2010 is now in its last year of implementation. It focuses on poverty-related health conditions, communicable diseases such as HIV, malaria and diarrhoea, and health problems that affect mothers and children, with particular attention to rural areas. The implementation frame worked in four core strategies: the Health Service Extension Programme (HSEP), the accelerated expansion of primary health care coverage, a health-care financing strategy, and the Health Sector Human Resource Development Plan. 10 2.2 Service provision The government of Ethiopia has adopted a strategy of integrated health services centered on primary health care. The six-tier system encompassing health posts, health stations, health centres, rural hospitals and referral hospitals was replaced by four-tier system. The four-tier system consists of primary health care units (a health centre with five satellite health posts), primary hospitals, general hospitals, and specialized referral hospitals with catchment population of 25 000, 100 000, 1 000 000 and 5 000 000 respectively (Fig 2.1). Health care is delivered mainly by the government. However, the private sector and voluntary organizations also play a significant role in general health care delivery. There are some 149 hospitals (82 FMoH, 67 NGOs), 1343 health centres (1332 FMoH, 11 NGOs), 1788 health Specialized Hospital 5 million General Hospital 1 million Primary Hospital 100,000 PHCU (1 HC + 5 Health posts) 25,000 Figure 2.1 The service provision structure 9 Transitional Government of Ethiopia, 1993 Health Policy. 10 Health Sector Development Programme III, FMoH. 18

stations/clinics (1717 FMoH, 271 NGOs) and 12 488 health posts in the country. 11 The national health policy emphasizes the importance of achieving access to a basic package of quality primary health care services for all segments of the population via a decentralized state system of governance. Table 2.1 Distribution of health facilities by ownership, 2009 Health facilities Public Private Total Hospitals 82 67 149 Health centres 1332 11 1343 Health stations and NHC/clinics 1517 1788 3305 Health posts 12 488 -- 12 488 The growing size and scope of the private health sector, both for-profit and not-for-profit, offers an opportunity to enhance health service coverage and utilization. The HSDP has explicitly recognized the complementarities between the two sub-sectors by articulating a strategy to promote the private sector in health-care delivery. At present, the private sector and voluntary organizations also play a significant role in general health care delivery. Efforts have been made to increase health service expansion: currently 149 public and private hospitals, 1343 health centres, 3305 health stations/clinics and 12 488 health posts are providing health services at various levels of the country (Table 2.1). Despite the fact that most of the population live in rural areas, the distribution of both public and private health facilities is skewed towards the urban areas (FMoH, 2009). The FMoH is responding to this recognized need through two major initiatives in the context of the HSDP. 2.3 Health care financing The health services in Ethiopia are financed from four main sources: government (federal and regional); multilateral and bilateral donors (grants and loans); nongovernmental organizations (NGOs), both international and local; private contributions (e.g. out-of-pocket spending). The government finances the health sector through the annual budget process. At federal level, the health sector is financed through the FMoH. At regional level, regional governments provide block grants to woredas and the major resource allocation decision is made at woreda level. Specifically, woredas are responsible for administering PHCUs (health centres and health posts) which are the immediate providers of services to communities. Resources from donors normally flow through three channels. Channel 1 is budget support and flows through the consolidated budget of the Ministry of Finance and Economic Development. Channel 2 consists of programme funds that go through the FMoH and/or the RHBs. Channel 3 is project support, where the donor administers and spends the resources (Table 2.2). NGOs provide another source of health-sector funds. Health NGOs operate mainly through project support and they provide services at a small number of mission hospitals and health centres or clinics. Private contributions to NGO care come both from out-of-pocket payments and through private-sector investments in health services such as private hospitals, clinics and pharmacies. 12 11 Health and health-related indicators, 2007-2008. 12 Third National Health Account (NHA), 2004-2005. 19

According to the 3 rd National Health Account (NHA) conducted in 2004-2005, national health expenditure grew by more than 53%, from 2.9 billion birr (US$356 million) to 4.5 billion birr (US$522 million) between 1999-2000 and 2004-2005. Per capita expenditure on health grew from US$5.60 in 1999-2000 to US$7.14 in 2004-2005. While these increases show that the government is on track toward its HSDP III target of a per capita expenditure of US$9.60 by 2008-2009, they also show that appreciable additional resource mobilization is needed to achieve the US$15.41 per capita required to reach the MDG targets or the US$34 per capita needed to reach the WHO target. Moreover, health expenditure constituted only 5% of GDP in the period. This share is small even by the standards of some Eastern and Southern African countries. 13 Table 2.2 Health care expenditure, 2009 Financing sources US$ Per capita (US$) % of total health expenditure Government 145 501 590.74 1.99 28% Households 160 042 854.70 2.19 31% Other sources 192 293 175.25 2.63 37% Public enterprises 13 796 059.21 0.19 3% Private employers 6 129 755.76 0.08 1% Other private funds 3 966 145.77 0.05 1% Total 521 729 581.43 7.14 100% 2.4 Health information system Ethiopia had a health information system in which morbidity and mortality statistics could be captured and used at national level. As the previous system was tedious and required so many variables to be collected, with the new reform of Business Process Re-engineering (BPR) the health management information system has been reformed with a big reduction in data collection tools and limited variables at regional and national levels. The variables to be collected have been reduced from 209 to 109 by the new reform. One of the strategic changes made is standardization with one data source, one channel and one reporting system, as opposed to the previous fragmented vertical system for different health programmes. The new design is currently in its pilot implementation phase. Some 700 data clerks who are trained in computer use will be hired to perform the statistical data collection. So far, 28 monitoring and evaluation experts have been trained at masters level at Jimma University and have graduated and have been assigned to different regions. At various administrative levels including national, regional, woreda and health facility levels there are clerks who compile morbidity and mortality statistics. Each year a health indicator is produced at national level, and regions also produce their own annual performance monitoring reports. At FMoH level the system is computerized for data clerks and managers, but this is not the case in all regions. The statistics compiled also include HRH data, though not in a comprehensive manner. Special attention is required at both regional and national levels to create an up-to-date HRH information system. Furthermore, the health management information system scale-up appears to be limited, particularly in big regions with limited resources for hiring the health information technicians required to initiate the implementation. 13 Third National Health Account (NHA), 2004-2005. 20

3. Health workforce situation The HRH profile study was conducted nationally with the representation of all regions from September to December 2009. A total of 37 353 low-, mid- and high-level health care providers were included from both public and private health facilities (not including HEWs). The study included health care professionals who are working at different administrative levels FMoH, regional health bureaux, woreda health offices and health facilities (Table 3.1). More than half of the health providers were male and the majority were young (less than 30 years) with a mean age of 25 years. Almost all (95%) of mid- and high-level health care providers working at facility level are included in the study. Table 3.1 Background characteristics of the health workforce, 2009 21 Variables N = 37 353 % Sex distribution Male 20 353 55.6 Female 16 234 44.4 Age group in years <20 111 0.4 20-29 15 140 51.6 30-39 7992 27.2 40-49 4466 15.2 50-59 1571 5.4 60+ 80 0.3 Total 29 360 100.0 Facility operator Public 35 190 94.3 Private 2138 5.7 Region Tigray 5265 14.1 Afar 349 0.9 Amhara 7406 19.8 Oromia 8137 21.8 Somali 1093 2.9 Benishangul 854 2.3 SNNPR 6539 17.5 Gambela 161 0.4 Harari 554 1.5 Diredawa 602 1.6 Addis Ababa 6394 17.1 NB: The total number for age is not the same as the total study group captured due to missing variables for age. 3.1 Health workers stock and trends As table 3.2 indicates, the total health workforce currently in service in the country is 66 314 persons (including HEWs). This means there are health workforce densities of about 0.027, 0.018 and 0.26 per 1000 population for physicians, midwives and nurses respectively. Furthermore, the study also shows that there are only about eight physicians, nurses and midwives per 10 000 population, which is fewer that the recommended 23 per 10 000 population the estimated average density of health workers to

population that is needed to achieve adequate coverage rates for selected primary health care interventions, as prioritized by the MDGs. Nevertheless, the present study revealed that the health worker density in Ethiopia in general has shown an increasing trend from 0.64 14 in 2003-2004 to 0.84 in 2008-2009 (Table 3.2). Table 3.2 Health worker/population ratios at national level 2003-2004 2009 Health occupational category Number Health workers per 1000 population Number Health workers per 1000 population Physician (general practitioner, specialist) 1996 0.0281 2152 0.0272 Specialist 775 0.0109 1001 0.0126 Health officer 683 0.0096 1606 0.0205 Pharmacist 172 0.0024 632 0.0081 Pharmacy technician 1171 0.0165 2029 0.0258 Nurse (all types) 14 269 0.2009 20 109 0.2576 Midwife 1274 0.017 1379 0.0176 Laboratory technician 2403 0.0338 1957 0.0249 Laboratory technologist NA NA 866 0.0110 Environmental health professional 1169 0.0164 1246 0.0159 Radiographer 300 0.0042 169 0.0021 Health assistant 6628 0.0933 1486 0.0189 Frontline health worker 15 752 0.2217 0.0000 Health extension worker - 0.0000 30950 0.3943 Other (health educator, physiotherapist, X- - - ray technician, dental technician, biologist) 1733 0.0221 TOTAL 45 817 0.6447 66 314 0.8444 NB: See definition of each occupational category in Annexes 1 and 2. The ratio of health workers per 1000 population, which at national level is 0.84, showed disparity in different parts of the country, ranging from the lowest (0.49) in Somali region to the highest (2.8) in Harari region (Fig. 3.1, Table 3.3). Four regions with less than four million population altogether have a ratio above 1.6. However, regions with more than 95% of the country s population have less than the national ratio of health workers to population. The health worker density of Oromia, Amhara and SNNPR is 0.73, 0.74 and 0.86 respectively. Unless huge efforts are made to improve health system strengthening in these regions in the next five years, meeting the MDGs may be unrealistic. In addition, the Somali region which has the lowest (0.47) health worker ratio to population may need special attention to improve the situation. 14 Health and health-related indicators, 2003-2004. 22

Figure 3.1 Health worker density per 1000 population by region, 2009 3 2.5 2 1.5 1 0.5 0 Somali Afar Oromia Amhara SNNPR Tigray Benishang HW density (HW/1000 pop) Dire Dawa Gambela Addis Harari Country Table 3.3 Health worker density by region Region Population (1000s) Density of health workers per 1000 population Health workers Tigray 4540 5339 1.176 Afar 1460 723 0.495 Amhara 17 800 13 730 0.771 Oromia 28 800 21 125 0.734 Somali 4630 2188 0.473 Benishangul.G 714 1170 1.639 SNNPR 15 970 13 859 0.868 Gambela 334 618 1.850 Harari 193 555 2.876 Addis Ababa 2860 6386 2.233 Dire Dawa 361 621 1.720 Country 78 030 66 314 0.849 3.2 Distribution of health workers by category/cadre HSDP III has put emphasis on increasing the number of low- and mid-level health cadres to be trained and deployed in the rapidly increasing health centres and health posts. For the last five years, the total 23

number of the health workforce in service has shown a significant increase of about 77% from 37 397 (excluding frontline health workers such as TBAs and CHAs) in 2005 to 66 314 in 2009. In particular, the number of health officers has increased from 776 to 1606, and HEWs have increased from 2737 in 2004 to 30 950 in 2009. Despite the increase in low- and mid-level health workers, the number of physicians and midwives (Table 3.4) has shown little increase over the last five years. 15 Table 3.4 Distribution of health workers, 2004-2009 Health occupational category 2004-2005 2005-2006 2006-2007 2007-2008 2009 Physicians 2453 2115 1806 2,085 2152 Health officers 776 715 792 1242 1606 Nurses 17 300 16 656 17 134 15 521 20 109 Midwives 1509 1189 1012 1244 1379 Pharmacists 191 162 178 413 632 Pharmacy technicians 1428 1812 1023 3013 2029 Laboratory technologists - - 172-866 Laboratory technicians 2837 1935 1644 2843 1957 Environmental health workers 1312 1239 1109 1657 1246 Radiographers 491 283 87 217 169 Health assistants 6363 4800 3184 2140 1486 Health extension workers 2737 8901 17 653 24 571 30 950 Other (social workers, X-ray technicians, dental technicians, health - 1637 156-1733 educators, biologists etc) TOTAL 37 397 41 444 45 950 54 946 66 314 Year 3.2.1 Gender distribution by health occupation/cadre Table 3.5 shows the distribution of the health workforce by category, disaggregated by gender. Highlevel health workers such as general practitioners and specialists are predominantly male. Out of the total of 1101 general practitioners and 1001 specialists presented by gender and currently in service, females make up only 17.6 % and 17.8% respectively. However, at low- and mid-levels of the health workforce, 49% of nurses, 71% of midwives and 99% of HEWs are female (Table 3.5). 15 Health and health-related indicators, 2004-2005, 2007-2008. 24

Table 3.5 Gender distribution by health occupation/cadre Health occupational category Gender Total Female Female % General practitioner 1101 194 17.6 Specialist 987 174 17.8 Health officer 1575 376 23.9 Pharmacist 621 178 28.7 Pharmacy technician 1960 733 37.4 Nurse (BSc degree) 1700 718 42.2 Midwife 1350 961 71.2 Clinical nurse 16 404 8264 50.4 Psychiatric nurse 68 31 45.6 Anaesthetic nurse 174 65 37.4 Public health nurse 951 336 35.3 Other nurse (dental, ophthalmic ORL) 386 193 50.0 Physiotherapist 149 30 20.1 Laboratory technologist 820 195 23.8 Laboratory technician 1927 676 35.1 Radiographer 160 37 23.1 X-ray technician 134 21 15.7 Environmental health professional 600 88 14.7 Environmental health worker (diploma) 639 140 21.9 Health education professional 71 14 19.7 Dental technician 33 9 27.3 Health assistant 1464 631 43.1 Health extension worker 30 950 30 950 99 Other health professional 1330 378 28.4 Total 65 554 45 393 69.2 3.2.2 Age distribution by occupation/cadre According to the civil service rules and regulations, civil servants in Ethiopia should retire by the age of 60. As Figure 3.2 and Table 3.6 show, more than half (51%) of the health workforce is young and below the age of 30 years. Only quite a small proportion (5%) is aged 50 60 years. 25

Figure 3.2 Health workers by age group, 2009 17000 15000 13000 11000 9000 7000 5000 3000 1000 15251 7992 4467 1596 < 30 30 39 40 49 50 59 60+ Table 3.6 Health workers by age group and cadre, 2009 Age group Health occupational category Total <30 30 39 40 49 50 59 60+ General practitioner 752 281 283 123 63 2 Physicians specialist 714 95 231 290 94 4 Nurse (excluding midwife) 15 967 7955 4445 2695 846 26 Midwife 1059 600 333 89 37 0 Health officer 1291 610 405 213 61 2 Dental technician 25 15 5 3 2 0 Pharmacist 530 435 76 14 5 0 Pharmacy technician 1578 1153 349 51 23 2 Laboratory worker 2191 1466 479 164 71 11 Environmental and public health worker 1030 673 263 74 20 0 Radiographer 128 56 23 30 18 1 X-ray technician 110 33 30 30 14 3 Health assistant 1275 135 416 436 265 23 Health extension worker 1563 1226 254 66 17 0 Other health professional 1171 518 400 189 60 4 Total 29 384 15 251 7992 4467 1596 78 26

3.2.3 Region distribution by occupation/cadre Of the total 2152 physicians and 21 488 nurses currently in service, 46% and 28% respectively are working in Addis Ababa city administration. Whereas blarge regions such as Oromia, Amhara and SNNPR account for 95% of the country s population, they have only 15%, 18% and 16.7% of physicians respectively (Table 3.7). Table 3.7 Regional distribution of workers Health occupationa l category Tigray Afar Amhara Oromia Somali Benshangul Regions SNNPR Gambela Harare Dire- Dawa Addis Ababa General 64 12 178 184 56 8 193 10 21 29 396 1151 practitioner Specialist 37 3 126 194 15 4 49 3 8 24 538 1001 Health officer 188 29 434 448 12 42 220 13 31 19 170 1606 Pharmacist 51 8 159 119 10 9 50 5 16 12 193 632 Pharmacy 241 55 603 382 27 39 395 6 22 22 237 2029 technician Nurse (all types) 2332 185 3790 5040 314 452 3980 91 276 272 3377 20 10 9 Midwife 185 212 287 45 37 316 4 29 20 244 1379 Laboratory technologist Laboratory technician Environment al health worker Health assistant Radiographe r Health extension worker Other 156 Total 58 13 213 184 12 2 97 7 6 15 259 866 173 27 534 346 46 33 372 2 41 40 343 1957 96 16 226 452 20 23 266 9 25 30 83 1246 498 0 298 93 53 13 290 4 18 27 192 1486 NA NA 25 17 3 NA 14 5 8 96 169 1259 375 6650 13 000 1100 499 7492 457 39 79 NA 30 95 0 0 282 379 475 9 125 7 18 24 5339 723 13 730 21 125 2188 1170 13 859 618 555 621 6386 See definition of each occupational category in Annexes 1 and 2 Total 258 1733 66 31 4 3.2.4 Urban/rural distribution by occupation/cadre Table 3.8 presents the health workforce categories by urban/rural density. As most mid- and high-level health professionals are located in urban areas, the health workforce density (i.e. the number of health 27

workers per 1000 population) is higher in urban areas than in rural areas. The majority of the physicians serve the urban population which is only 16% of the total population. People in urban areas thus have more benefit compared to those in rural areas in terms of access to mid- and high-level health professionals. However, quite a large health workforce of HEWs entirely serves the rural population which makes the health worker density 0.5 per rural 1000 population. Table 3.8 Urban/rural distribution of health workers Health workers per 1000 population Health occupational category Health workers (number) Urban population Rural population General practitioner 1151 0.092 0.018 Specialist 1001 0.080 0.015 Health officer 1606 0.129 0.025 Pharmacist 632 0.051 0.010 Pharmacy technician 2029 0.163 0.031 Nurse 20 109 1.6102 0.306 Midwife 1379 0.1102 0.021 Laboratory technologist 866 0.069 0.013 Laboratory technician 1957 0.157 0.030 Environmental health worker 1246 0.100 0.019 Health assistant 1486 0.119 0.023 Radiographer 169 0.014 0.003 Health extension worker 30 950 0.472 3.2.5 Distribution by occupation/cadre Private-public partnership in the health sector has a great impact in terms of achieving health services for all. The private health sector has expanded rapidly over the past 15 years in line with the government s privatization policy. Forty (27%) of all the hospitals in Ethiopia are privately owned and 1788 private for-profit clinics are currently providing health services in the country. The majority (94%) of the health workers are in the public sector. However, high-level health professionals, and particularly specialists, are often concentrated in private health facilities (Table 3.9). 28

Table 3.9 Public/private for-profit/faith-based organization/private not-for-profit distribution of health workers Health occupational category Total Public % Private % General practitioner 1151 1008 87.6 143 12.4 Internist 124 72 58.4 52 41.6 Surgeon 140 91 65.0 49 35.0 Paediatrician 92 47 51.1 45 48.9 Gynaecologist 155 83 53.5 72 46.5 Ophthalmologist 69 50 72.9 19 27.1 Orthopaedist 20 14 70.0 6 30.0 Ear, nose and throat specialist 25 9 36.0 16 64.0 Anaesthesiologist 46 33 73.5 13 26.5 Dentist 40 23 62.8 17 37.2 Radiologist 83 43 52.9 40 47.1 Neurologist 11 7 63.6 4 36.4 Dermatologist 18 8 44.4 10 55.6 Psychiatrist 25 21 88.5 4 11.5 Public health specialist (MPH, Phd) 115 111 96.5 4 3.5 Health officer 1606 1587 98.8 19 1.2 Pharmacist 632 594 94.0 38 6.0 Pharmacy technician 2029 1955 96.4 74 3.6 Nurses (all types) 21 488 20 506 95.4 982 4.6 See definition of each occupational category in Annexes 1 and 2. 3.2.6 Health workers by years of experience As mentioned above the Ethiopian health workforce is predominantly young. Figure 3.3 presents years of experience by health professional category, indicating that 50% of the health workers have a median of five years of experience. Specialists are the most experienced group with a median of 12 years of experience. Health officers and nurses have an average of nine years of experience. 29

Figure 3.3 Years of experience of health workers by category midwives Specialists 12.6 12 All Health Workers 5 8.8 Nurses 5 9.9 Health Officers 8 9.9 Laboratory Workers 3 6 Pharmacy Workers Medical Doctors (GP) 3 3 4.4 6.3 Mean Median 0 2 4 6 8 10 12 14 Years of experience 30

4. HRH Production 4.1 Pre-service education According to the current health policy, the development of the country s HRH is focused on: training of community-based and frontline workers through the team approach, developing appropriate continuing education, an attractive career structure, and remuneration and incentives for all categories of health workers. 16 The HSDP focuses on upgrading frontline cadres, low-level and mid-level health workers who are expected to staff primary health care facilities. In addition, training of high-level professionals is also to continue in accordance with population needs. The mandate for running all higher education, including that relating to health, is with the Federal Ministry of Education. The Federal Ministry of Education and regional education bureaux are responsible for the accreditation of private, degree, diploma and lower-level training institutions and programmes. Criteria set by the Federal Ministry of Education apply to student registrations in all health training institutions (public and private). The government of Ethiopia is implementing a strategy for expanding higher education as part of the Education Sector Development Programme III (ESDP-III) (2005-2006 to 2010-2011). The expansion of universities has been progressing in the past six or seven years. 17 The HSDP III promotes the expansion of health science and medical schools in both the public and private sectors. Ten years ago there were only a few public medical schools and health science colleges in the country. The government of Ethiopia has put great emphasis on the expansion of health service training institutions to meet the huge demand for health workers in view of the ever-growing population of the country (Fig. 4.1). As part of the privatization policy and public-private partnership in the health sector, many initiatives have aimed in the last five to six years to expand the health services in the public and private sectors (Table 4.1). To this effect, the number of universities and health science colleges has grown from five in 2003 to 22 in 2009. Among these, the number of medical university schools grew from three in 2003 to eight medical schools of which two are private (Hayat and Bethel) representing the major populated regions. Furthermore, 48 (25 public and 23 private) health science schools have been expanded and are currently providing training for midlevel health professionals, thus having an impact on the overall production of health workers. Figure 4.1 Trends in expansion of universities in Ethiopia, 2003-2009 27 22 17 12 7 2 20 21 22 22 9 9 5 2003 2004 2005 2006 2007 2008 2009 16 Transitional Government of Ethiopia, 1993 Health Policy. 17 Ministry of Education 2005 higher education capacity-building programme for 2005-2006 to 2009-2010. Abaseko MH. Case study. Scaling up education and training human resources for health in Ethiopia. Geneva, World Health Organization on behalf of the Global Health Workforce Alliance, 2010. 31

Table 4.1 Number of training institutions by type of ownership Type of training institution Type of ownership Total Public Private not-forprofit, Private for- FBOs profit Medicine 6 0 2 8 Dentistry 0 0 1 1 Pharmacy 0 0 0 0 Nursing and midwifery 1 0 0 1 Health sciences 24 0 23 47 Paramedical 0 0 0 0 Environnent and public heath 0 0 0 0 Total 31 0 26 57 FBO: Faith-based organization A list of the public and private health training institutions in Ethiopia can be seen in Table 4.2. Table 4.2 Public and private health training institutions, 2009 No. Public Type 1 Addis Ababa University Medical and Health Science 2 Gonder University Medical and Health Science 3 Jimma University Medical and Health Science 4 Aromaya University Medical and Health Science 5 Hawassa University Medical and Health Science 6 Mekele University Medical and Health Science 7 Bahirdar University Medical Education 8 Wollega University Health Science 9 Medawollabu University Health Science 10 Wolita Sodo University Health Science 11 Axum University Health Science 12 Jijiga University Health Science 13 Mekele Health Science College Health Science 14 Bahirdar Health Science College Health Science 15 Arbaminch Health Science College Health Science 16 Deberebrehan Health Science College Health Science 17 Debretabor Health Science College Health Science 18 Dessie Health Science College Health Science 19 Hawassa Health Science College Health Science 20 Nekemte Health Science College Health Science 21 Assela Health Science College Health Science 22 Harar Health Science College Health Science 23 Hossanna Health Science College Health Science 24 Minilik II Health Science College Health Science 25 Debretabor Health Science College Health Science 26 Goba Health Science College Health Science 27 Shashemene Health Science College Health Science 28 Mettu Health Science College Health Science 29 Borena Health Science College Health Science 32

30 Pawi Health Science College Health Science 31 Jijiga Health Science College Health Science No. Private for-profit Type 32 Medico Biomedical College Health Science 33 Tropical College of Medicine Health Science 34 Sheba Medical College Health Science 35 East Africa Health Science 36 Bethel Medical College Health Science 37 Hayat Medical College Medical 38 Africa Health Science College Health Science 39 Enat Medical College Health Science 40 Universal Medical College Health Science 41 AA Medical College Health Science 42 Unity University College Health Science 43 Betezatha Medical college Health Science 44 Centeral Medical College Health Science 45 Atalas Medical College Dental College 46 Millennium Medical College Health Science 47 Omega Medical College Health Science 48 St. Lideta Medical College Health Science 49 Kea Medical College Health Science 50 Rift Valley University College Health Science 51 Alkan Medical College Health Science 52 Farma Health Science College Health Science 53 Ayer Tena Health Science College Health Science 54 Dire Health Science College Health Science Figure 4.2 presents the enrolment rate by year and category. There are 47 health science colleges and eight medical schools captured in this study. A total of 913 specialists, 1342 health officers, 2555 physicians and 7918 nurses were enrolled in 42 public and private heath training institutions in the past five years. As indicated in the figure, the number of physicians enrolled increased significantly from 281 in 2004 to 997 in 2009 and the number of nurses enrolled went up from 728 to 1799 over the same period. However, enrolment of midwives remained low despite high public demand (Fig. 4.2). 33

Figure 4.2 Number of entrants and graduates per year 2400 Nurses GP HO Specialists Pharmacy & Phar. Tech Midwives 2000 1600 1200 800 400 0 2004/5 2005/6 2006/7 2007/8 2008/9 1799 1214 997 165 Training outputs of health training institutions The expansion of health training institutions has led to a significant increase in the production of health professionals. The data obtained from both public and private health training institutions shows that the number of medical students who have graduated has doubled over the last five years. In addition, while in 2004 no more than 333 health officers graduated, due the accelerated programme of training the number of health officers who graduated in 2009 was 1476. Over that five-year period a total of 5134 health officers graduated and were deployed to various health facilities. The number of medical doctors graduating has shown an increasing trend in 2008-2009 compared to the previous two years. 18 High-level health professional training and graduates Between 2004 and 2009 a total of 1073 physicians graduated from the seven medical schools in Ethiopia. The annual number of graduates increased from 70 in 2005 to 261 in 2009. Similarly, the number of pharmacist graduates increased over the same period (Fig. 4.3). 18 Health and health-related indicators, 2003-2004, 2007-2008. 34

Figure 4.3 High-level health professional graduates, 2005-2009 450 400 350 300 250 200 150 100 50 0 2005 2006 2007 2008 2009 Specialist Pharmacy GP Mid-level health professional training and graduates Recently the FMoH has developed a comprehensive HRH development strategy that addresses the core issue of HRH supply and demand. The HSDP III has set the target of training 5000 health officers by the end of 2009-2010 at five universities and 21 affiliated hospitals. The first and second batches of the Accelerated Health Officers Training Programme (AHOTP) have graduated (2286) where 1476 graduated in 2008-2009. Figure 4.4 presents the distribution of health officer graduates and all types of nurses over the last five years. There has been a total gain of 5134 health officers as a result of the five-year programme. Figure 4.4 Mid-level health professional graduates, 2004-2005 to 2008-2009 4800 4400 4000 3600 3200 2800 2400 2000 1600 1200 800 400 0 2004/05 2005/06 2006/07 2007/08 2008/09 All Nurses HO Laboratory Technologist 35

Low-level health professional graduates (health extension workers) The health extension programme was initiated in Ethiopia in 2003 in line with the basic principle of the Alma-Ata Declaration on primary health-care services for all. The programme aims to reach all rural people with basic health services through HEWs and health posts. The government of Ethiopia set a target to train and deploy 30 000 HEWs in 15 000 kebeles and to construct 15 000 health posts in all rural kebeles by 2009. Remarkable progress has been made. As shown in Figure 4.5, over the past five years more than 30 000 HEWs have been trained and deployed in 15 000 rural kebeles. Figure 4.6 shows the number of teaching staff involved in the training. 19 So far 12 488 health posts have been constructed and are serving the rural community, achieving 83% of the target. 20 Figure 4.5 Health extension worker graduates, 2004-2005 to 2008-2009 9000 8000 7000 7136 7753 6918 7260 6000 5000 4000 3000 2000 2737 1000 0 2004/05 2005/6 2006/7 2007/8 2008/9 Figure 4.6 Full-time teaching staff involving in training medical students, 2009 300 250 200 19 Federal Ministry of Education, Educational Annual Abstract 2007-2008. 20 Annual Performance Report of HSDP-III, Ethiopian fiscal year (EFY) 2001. 36 150 264 100 50 0 171 118 130 121 Jimma AAU Gonder Hawassa Harromya Mekele Hayat 32 69

4.2 In-service and continuing education Medical universities such as Addis Ababa University, Gonder, Jimma, Hawassa, Mekele and Haromaya provide postgraduate programmes for health professionals. The major areas of study being provided in these institutions include public health, internal medicine, obstetrics & gynaecology, ophthalmology, orthopaedics, pathology, paediatrics, psychiatry, surgery, neurology, radiology, and tropical and infectious diseases. In 2007-2008 the health indicator showed that a total of 1209 health professionals had obtained second degrees. Of these, a rather small number (20) were female. Most of the courses of study chosen (94% of all 1209) were in public health. In Ethiopia, planning, coordination and quality of in-service training programmes for the main HRH categories is generally poor. There is little opportunity for young health professionals to benefit from continuing staff development. The introduction of new health worker cadres is high on the HRH agenda in Ethiopia and specific training programmes are underway to upgrade low- and mid-level professionals. HEWs are viewed as an important potential resource for the implementation of primary health care and for community development in the country. They are expected to mobilize the Ethiopian population around promotive and preventive health issues. Hence, there is a lot of enthusiasm and hope that HEWs will help ameliorate the HRH problem. So far they are seen to have played a very active role in addressing concerns related to HIV/AIDS, malaria, and tuberculosis, while their contribution to immunization and environmental health activities is immense. Ophthalmic nurses are currently being trained to perform cataract surgery. Health officers are expected to undergo specific training nationally in the near future in order to be able to perform emergency surgery, including emergency obstetric care. Annual gain and loss of physicians, 2005-2006 to 2008-2009 Despite the rapid expansion of health training institutions and the production of physicians, the gain made is offset by annual losses. An attempt was made to calculate the total gain made in the production of physicians together with the losses experienced by looking at three consecutive years from 2005-2006 to 2008-2009. The total number of physicians (general practitioners and specialists) who graduated during the period from 2005 to 2007 was 935. Based on this figure, 3050 physicians would have been expected to be in service at the end of 2008-2009. However, the number in service was 2162 (Table 4.3), thus indicating a loss of 888 physicians (29%). One can speculate on the reasons for this loss physicians not being deployed to the health service after graduation, early retirement, resignation, death, the brain drain to other countries, and other factors could be reasons for the loss. Table 4.3 Physicians graduated and in service, and annual loss and gain Year Gain (number of physicians graduated) Physicians in service Number of physicians expected to be in service Cumulative loss % loss 2005-2006 237 2115 2006-2007 368 1806 2352 546 23 2007-2008 330 2085 2720 635 23 2008-2009 2162 3050 888 29 Total 935 37

4.3 Health workforce requirements Acknowledging that the critical shortage of health workers and the huge disparity between regions are major causes of health inequity, Ethiopia has planned a massive scale-up for the expansion of health services, including a strategic plan for the development of an adequate health workforce. The plan recognizes the number of persons and the mix of skills required in view of the various health needs and determinants. To this effect, a feasible health workforce planning model is being utilized. This model is considered appropriate as it takes into consideration the health service location, the staffing level, population growth and economic growth as the bases for estimating health workforce requirements (and projecting them for the future). The projections for the health workforce requirements of Ethiopia by the year 2020 are based on the assumption of universal primary health service coverage, and hence a three-fold increase in the production of HRH by 2020 is considered (Table 4.4). It is envisioned that the projection will increase the health workforce density level from 0.8 to 1.8 per 1000 population. Table 4.4 Projections for health workforce requirements for the coming years Health occupational category 2009 2015 2020 Internist 470 738 917 Paediatrician 264 413 513 Obstetrician 366 574 714 Surgeon 522 820 1019 Orthopaedist 265 414 514 Ophthalmologist 196 306 380 Dermatologist 39 61 76 Psychiatrist 264 413 513 Radiologist 238 372 461 Ear, nose and throat specialist 127 198 246 Anaesthesiologist 114 178 222 Clinical pathologist 109 171 212 Forensic pathologist 33 51 64 Dentist 490 1259 1496 Oncologist 67 108 134 General practitioner 4562 13 238 14 384 Health Officer 2454 8964 9346 IESO 418 1916 2169 Anaesthesia professional 981 2810 3271 Professional nurse 3110 7874 8548 Comprehensive nurse 15 257 38 912 42 174 Midwife 3290 8915 9551 Pharmacist 678 1886 2200 Pharmacy technician 3585 9420 10 049 Laboratory technologist 992 2419 2851 Laboratory technician 5926 15 330 16 403 Radiographer 1071 2617 3083 Psychiatric nurse 357 899 1,057 Ophthalmic nurse 327 854 1,001 Physiotherapy professional 309 474 584 38

Dental professional 332 933 1089 Environmental health worker 246 790 911 Health education professional 246 790 911 Biomedical technician 310 888 1,032 Clinical psychologist 64 98 121 Social worker 209 733 841 Occupational health professional 246 790 911 Radio pharmacist 51 79 98 Dietician 120 185 229 HIT 2868 10 346 10 672 Health extension worker 27 220 44 861 50 756 Total 78 771 175 620 193 264 Though the country needs to develop a health facility-based staffing standard using the workload indicators of staffing need (WISN) method to serve as a guide to future country requirements, an average staffing standard is indicated in Table 4.5. Table 4.5 Average staffing standard, to be filled Health occupational category Specialized General Primary Health Health post hospital hospital hospital centre Internist 10 4 0 0 0 Paediatrician 9 3 0 0 0 Obstetrician 13 5 0 0 0 Surgeon 12 5 0 0 0 Orthopaedist 5 2 0 0 0 Ophthalmologist 4 2 0 0 0 Dermatologist 3 1 0 0 0 Psychiatrist 4 2 0 0 0 Radiologist 4 2 0 0 0 Ear, nose and throat specialist 2 1 0 0 0 Anaesthesiologist 4 2 0 0 0 Clinical pathologist 3 1 0 0 0 Forensic pathologist 2 1 0 0 0 Dentist 6 2 0 0 0 Oncologist 7 0 0 0 0 General practitioner 41 18 2 0 0 Health officer 0 0 2 2 0 IESO 4 0 0 2 0 0 Anaesthesia professional 11 7 3 0 0 Professional nurse (BSc) 32 16 3 1 0 Comprehensive nurse (level 4) 130 80 15 7 0 Midwife 11 13 4 2 0 Pharmacist 10 4 2 0 0 Pharmacy technician 15 12 3 2 0 Laboratory technologist 12 5 1 0 Laboratory technician 22 12 5 2 0 Radiographer 15 9 2 0 0 Psychiatric nurse 5 4 1 0 0 39

Health occupational category Specialized General Primary Health Health post hospital hospital hospital centre Physiotherapy professional 12 4 0 0 0 Dental professional 6 3 1 0 0 Environmental and occupational 2 2 1 0 0 health worker Biomedical technician 4 3 1 0 0 Clinical psychologist 2 1 0 0 0 Social worker 3 1 1 0 0 Radio pharmacist 6 0 0 0 0 Dietician 2 2 0 0 0 HIT 10 5 3 1 0 Hospital manager 1 1 1 0 0 Health extension worker 0 0 0 0 2 Total 440 234 53 17 2 Table 4.6 General practitioners required in the public sector and its current gap by 2009-2010 Region Current number of specialized hospitals Current number of general hospitals General practitioners required in specialized hospitals General practitioners required in general hospitals Total general practitioners required (specialized + general hospitals) General practitioners currently available Tigray 1 11 28 176 204 63 141 Afar 2 0 32 32 12 20 Amhara 3 14 84 224 308 175 133 Oromia 1 30 28 480 508 182 326 Somali 6 0 96 96 56 40 Beni 2 0 32 32 8 24 SNNPR 1 17 28 272 300 193 107 Gambela 1 0 16 16 10 6 Harari 4 0 64 64 21 43 Dire Dawa 1 0 16 16 19-3 Addis Ababa 8 5 224 80 304 269 35 Total 14 93 392 1488 1880 1008 872 Current gap Conclusion According to the assessment of the country s health workforce, a total of 66 314 health workers are currently in service including 30 950 HEWs. The national ratio of health workers per 1000 population is 0.84. This is far less than the standard set by WHO of 2.3 health workers per 1000 population. The ratio of health workers to 1000 population also shows variation across Ethiopia s regions, with the highest ratio in Harari (2.8) and the lowest in Somali (0.47). This information on the stock of health workers relative to the population shows that there is huge gap to be filled in order to reach the critical threshold that would allow the most basic levels of health care coverage to be accessible throughout the country. Table 4.6 shows the current gap with regard to general practitioners. 40

The shortage and imbalance (or maldistribution) in the supply, deployment and composition of the health workforce is an obstacle to the effectiveness of the country s core health systems and services. Even though various endeavours have been made at national level to increase the number of physicians in the country, what has been gained over the last five years has also been lost. This affects the health system in many ways, including retraining and recruitment. This study has examined time series data to identify both gains and loss over the last three years. An overall shortfall of 29% compared with the number of physicians expected to be in service was recorded by using indirect measurement of physicians at national level. This is a concern to be considered critically at policy and programme levels, perhaps reviewing the health workforce management systems in the country, in order to answer why, when and where the attrition of health workers is taking place. 41

Bibliography Federal Ministry of Health of Ethiopia in collaboration with GHWA and WHO. Human resources for health education: case study on scaling up education and training for human resource for health. Addis Ababa, Federal Ministry of Health, 2009. Central Statistics Authority. Population and housing census. Addis Ababa, Central Statistics Authority, 2007. Central Statistics Authority. Ethiopia Demographic and Health Survey. Addis Ababa, Central Statistics Authority, 2005. Federal HIV/AIDS Prevention & Control Office (FHAPO). Monthly ART report as of end of September 2009. Addis Ababa, Federal HIV/AIDS Prevention & Control Office, 2009. Federal Ministry of Education. Education statistics annual abstract 2007-2008. Addis Ababa, Federal Ministry of Education, 2009. Federal Ministry of Health. Business process e-engineering. Finalized documents 2009. Addis Ababa, Federal Ministry of Health, 2009. Federal Ministry of Health. Annual performance report of HSDP III. Addis Ababa, Federal Ministry of Health, 2009. Federal Ministry of Health. Health and health-related indictors 2005-20066 and 2007-2008. Addis Ababa, Federal Ministry of Health, 2008. Federal Ministry of Education. Higher education capacity-building program for 2005-2006 to 2009-2010. Addis Ababa, Federal Ministry of Education, 2005. Federal Ministry of Health. Business process re-engineering. Health care delivery core process. Addis Ababa, Federal Ministry of Health, 2009. Federal Ministry of Health. The third national health account (NHA), 2004-2005. Addis Ababa, Federal Ministry of Health, 2005. United Nations Development Programme (UNDP). Statistical update, December 18, 2008. New York, United Nations Development Programme, 2008. Ministry of Finance and Economic Development. Annual report of 2008. Addis Ababa, Ministry of Finance and Economic Development, 2008. Federal Ministry of Health. Human resources for health strategy (draft). Ethiopia, 2009-2010. Addis Ababa, Federal Ministry of Health, 2009. 42

Annex 1. Definitions of health workforce data Health workforce: aggregated data In the aggregated data, the health workforce is grouped into the following 10 categories: Physicians Includes generalists and specialists. Nurses Includes professional nurses, auxiliary nurses, enrolled nurses and other nurses, such as dental nurses and primary care nurses. Midwives Includes professional midwives, auxiliary midwives and enrolled midwives. Traditional birth attendants, who are counted as community health workers, appear elsewhere. Dentists Includes dentists, dental assistants and dental technicians Pharmacists Includes pharmacists, pharmaceutical assistants and pharmaceutical technicians Laboratory workers Includes laboratory scientists, laboratory assistants, laboratory technicians and radiographers. Environment and public health workers Includes environmental and public health officers, sanitarians, hygienists, environmental and public health technicians, district health officers, malaria technicians, meat inspectors, public health supervisors and similar professions. Community health workers Includes traditional medicine practitioners, faith healers, assistant/community health education workers, community health officers, family health workers, lady health visitors, health extension package workers, community midwives, institution-based personal care workers and traditional birth attendants. Other health workers Includes a large number of occupations such as dieticians and nutritionists, medical assistants, occupational therapists, operators of medical and dentistry equipment, optometrists and opticians, physiotherapists, podiatrists, prosthetic/orthetic engineers, psychologists, respiratory therapists, speech pathologists, medical trainees and interns. Health management and support workers Includes general managers, statisticians, lawyers, accountants, medical secretaries, gardeners, computer technicians, ambulance staff, cleaning staff, building and engineering staff, skilled administrative staff and general support staff. 43

Annex 2. Health workforce classification mapping Occupation Generalist medical practitioners Definition Code 2211 Generalist medical practitioners (physicians) apply the principles and procedures of modern medicine in preventing, diagnosing, caring for and treating illness, disease and injury in humans and the maintenance of general health. They may supervise the implementation of care and treatment plans by other health care providers, and conduct medical education and research activities. They do not limit their practice to certain disease categories or methods of treatment, and may assume responsibility for the provision of continuing and comprehensive medical care. Examples of occupations included here Medical doctor (general), General practitioner, Family medical practitioner, Primary health care physician, District medical doctor-therapeutist, Resident medical officer specialising in general practice Notes Excluded occupations - classified elsewhere Specialist physician-2212, Paediatrician-2212, Surgeon-2212, Psychiatrist- 2212, Traditional medicine practitioner-2230, Paramedical practitioner- 2240 Additional comments Occupations included in this category require completion of a university-level degree in basic medical education plus postgraduate clinical training or equivalent for competent performance. Medical trainees who are non-university graduates should not be included here. Medical interns who have completed their university education in basic medical education and are undertaking postgraduate clinical training are included here. Although in some countries general practice and 'family medicine' may be considered as medical specializations, these occupations should always be classified here. 44

Occupation Specialist medical practitioners Nursing professionals Nursing associate professionals Definition Code 2212 Specialist medical practitioners (physicians) apply the principles and procedures of modern medicine in preventing, diagnosing, caring for and treating illness, disease and injury in humans using specialized testing, diagnostic, medical, surgical, physical and psychological techniques. They may supervise the implementation of care and treatment plans by other health care providers. They specialize in certain disease categories, types of patient or methods of treatment, and may conduct medical education and research activities in their chosen areas of specialization. 2221 Nursing professionals plan, manage, provide and evaluate nursing care services for persons in need of such care due to the effects of illness, injury, or other physical or mental impairment, or potential risks for health. They work autonomously or in teams with medical doctors and other health workers. They may supervise the implementation of nursing care plans, and conduct nursing education activities. 3221 Nursing associate professionals provide basic nursing care for people who are in need of such care due to the effects of ageing, illness, injury, or other physical or mental impairment. They implement care, treatment and referral plans established by medical, nursing and other health professionals. Examples of occupations included here Specialist physician (internal medicine), Surgeon, Anaesthetist, Cardiologist, Emergency medicine specialist, Ophthalmologist, Obstetrician, Gynaecologist, Paediatrician, Pathologist, Preventive medicine specialist, Psychiatrist, Radiologist, Resident medical officer in specialist training Professional nurse, Specialist nurse, Nurse practitioner, Clinical nurse, General nurse-midwife, Public health nurse, Nurse anaesthetist Associate professional nurse, Assistant nurse; Licensed practical nurse, Enrolled nurse Notes Excluded occupations - classified elsewhere General medical practitioner-2211, Dental practitioner-2261, Dental surgeon-2261, Physiotherapist-2264, Psychologist-2634 Professional midwife-2222, Associate professional nurse-3221, Associate professional midwife-3222, Paramedical practitioner- 2240 Professional nurse-2221, Specialist nurse-2221, Associate professional midwife-3222, Community nurse attendant-3253, Nursing aide (hospital or clinic)-5321, Nursing aide (home)-5322 Additional comments Occupations included in this category require completion of a university-level degree in basic medical education plus postgraduate clinical training in a medical specialization (except general practice) or equivalent. Medical trainees who are nonuniversity graduates should not be included here. Resident medical officers training as specialist practitioners (except general practice) are included here. Although in some countries 'stomatology' may be considered as a medical specialization, stomatologists should be included under 'Dentists'-2261. Occupations included in this category normally require completion of tertiarylevel education in theoretical and practical nursing. Nursing professionals who spend the majority of their working time in maternal and newborn health care services should be included under 'Midwifery professionals'-2222. Occupations included in this category normally require formal training in nursing services. Associate professional nurses who spend the majority of their working time in maternal and newborn health care services should be included under 'Associate professional midwives'-2223. 45

Occupation Midwifery professionals Midwifery associate professionals Paramedical practitioners Definition Code 2222 Midwifery professionals plan, manage, provide and evaluate midwifery care services before, during and after pregnancy and childbirth. They provide delivery care for reducing health risks to women and newborns, working autonomously or in teams with other health care providers. 3222 Midwifery associate professionals provide basic health care and advise before, during and after pregnancy and childbirth. They implement care, treatment and referral plans to reduce health risks to women and newborns as established by medical, midwifery and other health professionals. 2240 Paramedical practitioners (advanced practice clinicians) provide advisory, diagnostic, curative and preventive medical services in a variety of settings. They work autonomously or with limited supervision of medical doctors, and apply advanced clinical procedures for treating and preventing diseases, injuries, and other physical or mental impairments common to specific communities. Examples of occupations included here Professional midwife Associate professional midwife, Assistant midwife Clinical officer, Surgical technician, Physician assistant, Primary care paramedic, Advanced care paramedic, Feldsher Notes Excluded occupations - classified elsewhere Nursing aide-5321, Associate professional nurse-3231, Associate professional midwife-3232 Professional midwife-2222, Associate professional nurse-3221, Midwifery attendant-5321 Emergency paramedic- 3258, Medical assistant- 3256, General medical practitioner-2211, Surgeon- 2212 Additional comments Occupations included in this category normally require completion of tertiarylevel education in theoretical and practical midwifery. Occupations included in this category normally require formal training in midwifery services. Midwifery attendants with little or no formal training should be included under 'Health care assistants'- 5321. Occupations included in this category normally require completion of tertiarylevel training in theoretical and practical medical services. Workers providing services limited to emergency treatment and ambulance practice should be included under 'Ambulance workers'-3258. 46

Definition Occupation Code Dentists 2261 Dentists apply the principles and procedures of modern dentistry in diagnosing, treating and preventing diseases, injuries and abnormalities of the teeth, mouth, jaws and associated tissues. They use a broad range of specialized diagnostic, surgical and other techniques to promote and restore oral health. Dental assistants and therapists 3251 Dental assistants and therapists provide basic dental care services for the prevention and treatment of diseases and disorders of the teeth and mouth, as per care plans and procedures established by a dentist or other oral health professional. Pharmacists 2262 Pharmacists store, preserve, compound, test and dispense medicinal products. They counsel on the proper use and adverse effects of drugs and medicines following prescriptions issued by medical doctors and other health professionals. They contribute to researching, preparing, prescribing and monitoring medicinal therapies for optimizing human health. Pharmaceutical technicians and assistants 3213 Pharmaceutical technicians and assistants perform routine tasks associated with preparing and dispensing medicinal products under the supervision of a pharmacist or other health professional. Examples of occupations included here Dentist, Dental practitioner, Dental surgeon, Oral and maxillofacial surgeon, Endodontist, Orthodontist, Paedodontist, Periodontist, Prosthodontist, Stomatologist Dental assistant, Dental hygienist, Dental therapist Hospital pharmacist, Industrial pharmacist, Retail pharmacist, Dispensing chemist Pharmaceutical technician, Pharmacy assistant Notes Excluded occupations - classified elsewhere Dental prosthetic technician-3214, Dental assistant-3251, Dental hygienist-3251 Dental aide-5329, Dental mechanic-3214, Dental prosthetist-3214, Dental technician-3214, Dentist- 2261 Pharmacologist-2131, Pharmaceutical technician- 3213 Pharmacist-2262, Pharmacy aide-5329, Pharmacology technician- 3141 Additional comments Occupations included in this category normally require completion of universitylevel training in theoretical and practical dentistry or a related field. Although in some countries stomatology and 'dental, oral and maxillofacial surgery' may be considered as medical specializations, occupations in these fields should always be classified here. Occupations included in this category normally require formal training in dental hygiene, dental-assisting or a related field. Occupations included in this category normally require completion of universitylevel training in theoretical and practical pharmacy, pharmaceutical chemistry or a related field. Pharmacologists and related professionals who study living organisms are not included here (classified under Life science professionals). Occupations included in this category normally require basic medical and pharmaceutical knowledge obtained through formal training. Pharmacology technicians and related associate professionals who work with living organisms are not included here (classified under Life science technicians). 47

Occupation Environmental and occupational health and hygiene workers Physiotherapists and physiotherapy assistants Optometrists and opticians Code 2263, 3257 2264, 3255 2267, 3254 Definition Environmental and occupational health and hygiene workers plan, assess and investigate the implementation of programmes and regulations to monitor and control environmental factors that can potentially affect human health, to ensure safe and healthy working conditions, and to ensure the safety of processes for the production of goods and services. Physiotherapists and physiotherapy assistants provide physical therapeutic treatments to patients in circumstances where functional movement is threatened by injury, disease or impairment. They may apply movement, ultrasound, heating, laser and other techniques. Optometrists and opticians provide primary eye health and vision care services. Optometrists and ophthalmic opticians provide diagnosis management and treatment services for disorders of the eyes and visual system. Dispensing opticians design, fit and dispense optical lenses for the correction of reduced visual acuity. Examples of occupations included here Environmental health officer, Occupational health and safety adviser, Occupational health and safety inspector, Occupational hygienist, Radiation protection adviser, Sanitarian, Health inspector, Food sanitation and safety inspector Physiotherapist, Paediatric physical therapist, Orthopaedic physical therapist, Physiotherapist assistant, Physical rehabilitation technician, Massage therapist, Electrotherapist, Acupressure therapist, Shiatsu therapist, Hydrotherapist Optometrist, Optician, Orthoptist Notes Excluded occupations - classified elsewhere Specialist medical practitioner (public health)- 2212, Specialist nurse (public health)-2221, Occupational therapist- 2269, Environmental protection professional- 2133 Occupational therapist- 2269, Osteopath-3259, Chiropractor-3259, Podiatrist-2269 Ophthalmologist-2212 Additional comments Occupations included in this category normally require formal training in environmental public health, occupational health and safety, sanitary sciences, or a related field. Environmental protection workers who study and assess the effects on the environment of human activity are not included here (classified under Life science professionals). Occupations included in this category normally require formal training in physical rehabilitation therapy or a related field. Occupations included in this category normally require formal training in optometry, orthoptics, opticianry or a related field. 48

Occupation Medical imaging and therapeutic equipment operators Medical and pathology laboratory technicians Medical and dental prosthetic technicians Definition Code 3211 Medical imaging and therapeutic equipment technicians test and operate radiographic, ultrasound and other medical imaging equipment to produce images of body structures for the diagnosis and treatment of injury, disease and other impairments. They may administer radiation treatments to patients under the supervision of a radiologist or other health professional. 3212 Medical and pathology laboratory technicians perform clinical tests on specimens of bodily fluids and tissues in order to get information about the health of a patient or cause of death. 3214 Medical and dental prosthetic technicians design, fit, service and repair medical and dental devices and appliances following prescriptions or instructions established by a health professional. They may service a wide range of support instruments to correct physical medical or dental problems such as neck braces, orthopaedic splints, artificial limbs, hearing aids, arch supports, dentures, and dental crowns and bridges. Examples of occupations included here Medical imaging technician, Diagnostic medical radiographer, Medical radiation therapist, Magnetic resonance imaging technologist, Nuclear medicine technologist, Sonographer, Mammographer Medical laboratory technician, Medical laboratory assistant, Cytology technician, Blood bank technician, Pathology technician Medical appliance technician, Prosthetist, Orthotist, Prosthetic technician, Orthotic technician, Dental technician, Denturist Notes Excluded occupations - classified elsewhere Radiologist-2212 Pathologist-2212 Dental assistant-3251, Dispensing optician-3254 Additional comments Occupations included in this category normally require formal training in medical technology, radiology, sonography, nuclear medical technology, or a related field. Occupations included in this category normally require formal training in biomedical science, medical technology, or a related field. Technicians conducting laboratory tests on specimens from animals are not included here (classified under Veterinary technicians). Occupations included in this category normally require basic medical, dental and anatomical knowledge obtained through formal training. Technicians who construct and repair precision medical and surgical instruments based on engineering knowledge alone are not included here (classified under Science and engineering associate professionals). 49

Definition Occupation Code Community health 3253 Community health workers provide health workers education, referral and followup, case management, and basic preventive health care and home visiting services to specific communities. They provide support and assistance to individuals and families in navigating the health and social services system. Medical assistants 3256 Medical assistants perform basic clinical and administrative tasks to support patient care under the direct supervision of a medical practitioner or other health professional. Traditional and complementary medicine practitioners 2230, 3230 Traditional and complementary medicine practitioners apply procedures and practices based on the theories, beliefs and experiences indigenous to different cultures, used in the maintenance of health and in the prevention or treatment of physical and mental illnesses. Examples of occupations included here Community health worker, Community health aide, Community health promoter, Village health worker Medical assistant, Clinical assistant, Ophthalmic assistant Acupuncturist, Ayurvedic practitioner, Unani practitioner, Chinese herbal medicine practitioner, Homeopath, Naturopath, Bonesetter, Herbalist, Witch doctor, Village healer, Scraping and cupping therapist Notes Excluded occupations - classified elsewhere Nursing aide-5322, Home care aide-5322, Village healer-3230 Clinical officer-2240, Physician assistant-2240, Dental assistant-3251, Physiotherapy assistant- 3255, Medical prosthetic technician-3214, Medical imaging assistant-5321 Acupressure therapist- 3255, Shiatsu therapist- 3255, Hydrotherapist-3255, Chiropractor-3259, Osteopath-3259 Additional comments Occupations included in this category normally require formal or informal training recognized by the health and social services authorities. Providers of routine personal care services, self-defined health care providers and traditional medicine practitioners are not included here. Occupations included in this category normally require formal training in health services provision. Clinical care providers with advanced training and skills to provide independent medical diagnostic and treatment services should be classified under 'Paramedical practitioners'-2240. Occupations included in this category normally require knowledge and skills acquired from formal education, or informally through the traditions and practices of the communities where they originated. Faith healers who treat human ailments through spiritual therapies, without using herbal preparations or other physical interventions, are not included here. Occupations that rely on traditional forms of massage and the application of pressure, such as acupressure and shiatsu therapists, are classified in 'Physiotherapy technicians and assistants'-3255. 50

Occupation Other health service providers Health care assistants and other personal care workers in health services Other science professionals and technicians Code 5321, 5322, 5329 Definition This category may include a wide range of occupations connected with health service provision. Personal care workers perform routine patient care services as per care plans, practices and procedures established by a health professional. This category may include a wide range of occupations connected with physical and life sciences research and applications to solve human health problems. Examples of occupations included here Ambulance paramedic- 3258, Emergency medical technician-3258, Dieticians and nutritionists-2265, Audiologists and speech therapists-2266, Podiatrist- 2269, Occupational therapist-2269, Chiropractor-3259, Osteopath-3259, Psychologist-2634, Social workers and counsellors- 2635 Hospital orderly, Nursing aide, Patient care assistant, Dental aide, Midwifery attendant, Psychiatric aide, Medical imaging assistant, Home care aide, Pharmacy aide, Dental aide, Sterilization aide, Faith healer Pharmacologist-2131, Biologist-2131, Biotechnologist-2131, Cell geneticist-2131, Environmental protection professional-2133, Environmental research scientist-2133, Medical physicist-2111, Bacteriology technician- 3141, Pharmacology technician-3141 Notes Excluded occupations - classified elsewhere Nurse (associate professional)-3221, Nurse (professional)-2221, Community health worker- 3253 Additional comments Occupations included in this category normally require formal training in a health or social service-related field. Occupations included in this category generally do not require extensive health care knowledge or training. Personal care workers may work in a variety of settings, including private homes as well as health facilities (hospitals, medical and dental practice facilities, rehabilitation centres, and other types of residential facilities with or without on-site nursing care services). Occupations included here normally require formal training in a physical or life science-related field. 51

Occupation Health service managers Medical records and health information technicians Other health management and support workers Definition Code 1342 Health service managers plan, coordinate and supervise the provision of clinical, personal care and community health care services. 3252 Medical records and health information technicians assess, manage and implement health records processing, storage and retrieval systems in medical facilities and other health care settings to meet the legal, professional, ethical and administrative records-keeping requirements of health services delivery. This category may include a wide range of workers performing a variety of administrative, clerical, and other tasks and duties to support the provision of health services and functioning of health systems. Examples of occupations included here Health facility administrator, Medical nursing home administrator, Clinical manager, Director of nursing care, Hospital matron, Community care coordinator, Chief public health officer Medical records clerk, Medical records technician, Health information system technician, Health information clerk, Medical records analyst, Clinical coder, Disease registry technician Health policy analyst-2422, Government licensing official-3354, Aged care service manager-1343, Staff training officer-2424, Medical secretary-3344, Computer technician-3513, Data entry clerk-4132, Filing and copying clerk- 4415, Receptionist-4226, Building caretaker-5153, Cook-5120, Ambulance driver-8322 Notes Excluded occupations - classified elsewhere Aged care service manager-1343, Senior government official-1112 Medical secretary-3344, Data entry clerk-4132, Filing and copying clerk- 4415 Additional comments The main tasks and duties for jobs in this occupational category include guiding and directing the activities of organizations, departments and other workers. Education and training requirements may vary depending on the position and national context usually including some combination of formal education, on-thejob training and work experience. Occupations included in this category normally require knowledge of medical terminology, legal aspects of health information, health data standards, and computer- or paper-based data management, as obtained through formal education and/or on-the-job training. Clerks who perform general secretarial or clerical duties are not included here (classified under Clerical support workers ). 52

ANNEX 3. Mapping education and training to the international standard classification Field Definition Examples of education programmes included here Medicine Nursing and midwifery Dental studies Medical services (health sciences) Environmental, public and occupational health The study of the principles and procedures used in preventing, diagnosing, caring for and treating illness, disease and injury in humans and the maintenance of general health. The study of providing health care for people who are in need of such care due to effects of illness, injury or impairment, or potential risks for health, and assisting physicians and other health professionals to diagnose and treat patients. The study of diagnosing, treating and preventing diseases and abnormalities of the teeth and gums. It includes the study of designing, making and repairing dental prostheses and orthodontic appliances. It also includes the study of providing assistance to dentists. The study of physical disorders, treating diseases and maintaining the physical well-being of humans, using non-surgical procedures. The study of the relationships between living organisms and the environment that affect public health. Includes the study of recognizing, evaluating and controlling environmental factors associated with the workplace. Basic medical education: programmes for the training of medical doctors/physicians Paramedical programmes: training of paramedical practitioners/advanced practice clinicians (includes tertiary-level programmes not leading directly to the award of a medical research qualification) Basic nursing education: programmes for the training of nursing professionals (tertiary level) Basic midwifery education: programmes for the training of midwifery professionals (tertiary level) Assistant nursing education: programmes for the training of nursing associate professionals Assistant midwifery education: programmes for the training of midwifery associate professionals Dentistry: programmes for the training of dentists (tertiary level) Dental care services: programmes for the training of dental assistants, dental therapists, dental prosthetic technicians and related occupations (e.g. dental-assisting, dental hygiene, dental nursing, dental laboratory technology) Pharmacy: programmes for the training of pharmacists (tertiary level) Physiotherapy: programmes for the training of physiotherapists (tertiary level) Medical technology: programmes for the training of medical imaging and therapeutic equipment technicians (e.g. medical X-ray techniques, radiology, radiotherapy, sonography) Medical laboratory technology: programmes for the training of medical and pathology laboratory technicians Medical prosthetics: programmes for the training of medical prosthetic technicians Other programmes for the training of health professionals and associate professionals (e.g. emergency medical treatment, nutrition and dietetics, optometry, speech pathology) Programmes in services to the community dealing with items that affect public health (e.g. hygiene standards in food and water supply) Programmes in occupational health and safety (e.g. ergonomics, health and safety in the workplace, industrial hygiene) 53