Health Information Network and Tele-health centers support

This is a continuing activity from FY07. In this continuing activity, Tulane University (TUTAPE) supports the

Ethiopian Ministry of Health (MOH) to establish health information networks and telehealth centers. In FY07,

a National Computer Resources Mapping Survey, which will map out all districts where the Government of

Ethiopia's high-speed communications network exists, human resource capacity, and hardware and

software resources will be finalized. This information identifies the Information and Communication

Technology (ICT) infrastructure and resources for use of telemedicine and distance-learning technologies

that will directly support improved care and treatment throughout the health network. In continuation of this

activity, in FY08, the facility mapping survey will be linked to this activity (ID10371, ID10510).

In FYO7, TUTAPE, in collaboration with US Army Telemedicine and Advanced Technologies Research

Center (TATRC), supported the expansion of tele-medicine and information sharing by establishing network

systems in nine institutions: MOH, the Federal HIV/AIDS Prevention and Control Office, the Ethiopian

Health and Nutrition Research Institute, the Drug Administration and Control Authority, ALERT, and

Defense, Jimma, Mekele, and Debub Universities. These included PEPFAR-supported, technology-assisted

learning centers.

In FY08 support will continue and additional technology-assisted learning centers will be established at 20

ART-providing hospitals and two additional universities (Gondar and Harmayia). Depending on connectivity

at each site, all the centers will have capacity to support 30 users (for the additional universities) at one time

in state-of-the-art, technology-assisted learning centers that include video-conferencing. These centers will

enable the institutions to access resources for telemedicine and tele-education. Related hardware and

software will be procured, and training will be provided to enhance the use of these resources. The national

fiber-optic network, currently under construction, will be tapped. In FY07, TUTAPE completed an initial

assessment to form the HealthNet, a virtual network which uses available technologies to connect health

institutions throughout Ethiopia.

In FY08, TUTAPE will conduct assessment, evaluation, and deployment of appropriate and cutting-edge

technologies for telemedicine and information-sharing. In FY08, TUTAPE will support and strengthen the

HealthNet through capacity building and technical assistance. This will enable the hospital sites to have an

active connection with nearby hospitals/universities, creating the opportunity for telemedicine, tele-

education, and a virtual referral system.

In FY07, based on the assessment conducted on regional health bureau (RHB) ICT capacity, TUTAPE has

enabled video-conferencing at RHB to strengthen information-sharing between MOH and ART data-

reporting systems at all levels. This has directly supported the MOH's identified need for expansion of

efficient telecommunications within regions, with the aim of improving data flow linkages with the data

warehouse activity.

In FY08, TUTAPE will also address gaps identified by the National Computer Resources Mapping survey on

connectivity of MOH with RHB and health facilities. This activity will leverage Global Fund for AIDS, Malaria,

and Tuberculosis resources for hardware distribution for RHB, districts, and health facilities and will

supplement any additional gaps identified in the survey.

Development of Healthcare Data warehousing and Electronic Medical Record System

These are two continuing activities (ID 5724 and ID1095) from FY07. In FY06, the National Computer

Resources Mapping Survey mapped the districts where the Government of Ethiopia's (GOE) high-speed

communications network (funded by the World Bank) exists, their human resource capacity, hardware, and

software resources. The information gathered has identified available information and communication

technology (ICT) infrastructure and resources for the implementation of the data warehouse and electronic

medical records (EMR).

There are two sub-activities:

1) Development of an EMR system to support HIV/AIDS care and treatment. In FY07, this was expanded to

include other activities at health facilities, including health management information systems (HMIS).

2) Design and development of a data warehouse for the Ethiopian Federal Ministry of Health (MOH) and

regional health bureaus (RHB) that included strengthening the geographic information system (GIS) and

spatial analysis in health.

The MOH is expanding ART services rapidly and needs a robust patient information system that improves

care and programming. The MOH, facing the challenge of improving the quality of ART services while also

rapidly scaling up capacity, is trying to ensure that ART patients are not lost to follow-up and their medical

information is not lost as they visit various clinics over time and distance. The relatively new technology of

EMR is a complement to the national HMIS, which can record and track the provision of quality medical

service at the individual client level. Using EMR, it becomes possible to record and track each individual's

care, as well as collective or aggregate patient information for HMIS purposes. For clinics using an EMR

system, many HMIS indicators can be produced automatically, without further burden to staff. The system is

needed to assure continuity of patient care over time and place, and across types of service and levels of

care. It enables: standardization and collection of health information data for decision-making; timely data-

capture at a point of care; and data access and reuse at a subsequent point of service, hence improving

care quality and reducing costs of repeated tests. Furthermore, it can report in "real-time" indicators such as

patient count by sex and age categories, geographic distributions, longitudinal cohort data, health

demographics, and adherence and cost statistics, which are accurate, valid, reliable, and timely. It also

helps in preventing duplication of patient counts and linking of patient information to currently separate

‘vertical' paper systems such as tuberculosis (TB), HIV/ART, antenatal clinics (ANC), PMTCT, voluntary

counseling and testing (VCT), and sexually transmitted infections (STI)—thus improving the efficiency of

decision-making. Electronic data reduces human error and the burden of manual aggregation for HMIS

reporting.

In FY07, EMR implementation began in 35 ART networks; in FY08, it will expand to include 50 networks.

The system will cover all patients enrolled in comprehensive ART services, as well as mothers attending

ANC and receiving PMTCT, and spouses seeking VCT. The inclusion of ANC services is to reduce the

possible stigmatization of the smart card that might occur if EMR is used only for those patients who are

taking ART. Further TB, family planning, outpatient departments, laboratory departments, in-patient

department modules will be included. The program expansion will require investment in hardware, including:

computers and monitors; uninterruptible power supplies; printers (for all 50 networks); and consumables,

including paper, toner, and cards. Adaptation of the software will continue and will draw technical assistance

(TA) from other countries implementing such a system. Related costs include: recruitment and salaries for

new software programmers, salaries for data clerks; training on use of the system, and a series of staff

sensitization interventions at facilities selected for implementation. The data flow between the EMR system

at facilities and the HMIS system at the facility, district, and regional levels will also continue to be

implemented. Ongoing support will continue to all sites. Seconded staff to MOH will be a continuing

component, including capacity building at MOH for development and expansion of EMR in the country.

The data warehouse is a central data repository that collects, integrates, and stores national data with the

aim of producing accurate and timely health information which will support evidence-informed data analysis

and reporting on HIV/AIDS care, treatment, and prevention. Relevant sources for the data warehouse

include the national monitoring and evaluation (M&E) program reports, population-based surveys, non-

identifiable aggregated data from EMR, and data from routine national HMIS reporting.

In FY07, a data warehouse architecture system study was completed and assistance was provided to

redesign the MOH website that links to the data warehouse for data mining, analysis, and reporting. This

activity was also extended to regional health bureaus (RHB). MOH and RHB staff were trained to maintain

the website. In FY08, MOH and RHB will continue to receive TA on the development of electronic data

warehouse systems, using the latest technology available and integrating HMIS, including the HIV/AIDS

information system, surveillance, surveys and other related data sources. This system also includes routine

and survey information on HIV/AIDS and other related diseases from various government organizations,

nongovernmental organizations, research institutions, and the private health sector. This activity also

includes integrating the national information and communication technology resource-mapping database,

CostET, and district-based planning application database with the MOH intranet. In FY08, support will

include human resource capacity building, hardware acquisition, and software licensing and application

development to strengthen the data warehouse. In support of this activity, mapping and unique identification

of all health institutions will be conducted as outlined in "The Signature Domain and Geographic

Coordinates: A Standardized Approach for Uniquely Identifying a Health Facility". This will be in

collaboration with the MOH, the Ethiopian Central Statistical Agency, and the National Mapping Authority.

The support includes strengthening GIS capacity through human resource capacity building, hardware

acquisition, and software licensing. In FY08, all information and communication technologies activities will

have continued trainings as part of capacity building.

National Monitoring and Evaluation System Strengthening and Capacity-Building

Development of Ethiopia's National HIV/AIDS Monitoring and Evaluation (M&E) system is a sub-set of the

comprehensive Health Management Information System (HMIS) strategy and master plan being developed

by the Federal Ministry of Health (MOH). M&E is an increasingly important subject in present-day Ethiopia,

as it has made great strides in implementing the Third One—One National M&E System with the support of

Tulane University Technical Assistance Program Ethiopia (TUTAPE). To this end, Ethiopia has redesigned

its M&E/HMIS system, which includes all HIV/AIDS indicators.

In the past, Ethiopia suffered from a poorly functioning, manual data collection and reporting system that

lacked standardized indicators and formats. Reports were untimely and often incomplete. While efforts to

improve this are ongoing within the MOH, the need for technical assistance and support for the new HMIS

and M&E system is evident. PEPFAR Ethiopia recognizes this need and supports in its five-year plan the

goal of the Third One—One National M&E System.

The new national HMIS, which is currently in the piloting phase, standardizes, integrates data

collection/reporting, and harmonizes the information needs of all HMIS consumers. In FY07, TUTAPE's

technical assistance to MOH extended to successfully integrating the National HIV/AIDS M&E system into

the newly developed national HMIS, leading toward national harmonization and sustainability. TUTAPE

assisted MOH to identify core health indicators, including those for HIV/AIDS and TB/HIV, for HMIS

reporting and to improve capacity to collect patient information and use the information generated to

enhance decision-making at the local level. With MOH and partners, TUTAPE revised HIV/AIDS and related

disease-reporting formats. Support also included technical assistance to the national HIV/AIDS Prevention

and Control Office (HAPCO) to develop M&E training modules for the grassroots level. This will help

HAPCO to expand comprehensive HIV/AIDS patient monitoring services to the district health centers.

In FY07, based on the design of the MOH, TUTAPE is supporting the new HMIS by developing website and

intranet tools to access data collected from several sources: HIV/AIDS service delivery, finance, human

resources, and logistics, including information from other governmental organizations and the private

sectors. HMIS data will also be harmonized with health-related and multisectoral data collected by other

organizations, such as vital-events registration, census, survey, etc. The HMIS will also establish common

data definitions and understanding on how to interpret the information.

The new M&E/HMIS reforms are directed toward ensuring data quality to strengthen local action-oriented

performance monitoring. To that end, MOH is putting into place trainings to improve M&E/HMIS tools and

methodologies, including the use of information for data and service quality improvement and evidence-

informed decision-making. In FY07, TUTAPE developed the training modules and conducted training in a

cascaded manner for the national HMIS, including data-quality assurance for decision-making associated

with performance monitoring. TUTAPE assisted the MOH in the national rollout of HMIS to 35 ART

networks and will expand that rollout to 100 in FY08. This enhances the HIV/AIDS M&E by introducing and

reinforcing structure and methods for data quality and use and performance monitoring.

In FY07, TUTAPE also introduced HIVQUAL, a service-quality improvement system for MOH and the

HIV/AIDS Prevention and Control Office (HAPCO). At the request of MOH, TUTAPE supported the initial

exchange of experiences on HIVQUAL between Ethiopia, New York, and Thailand. HIVQUAL enables the

data generated by the HMIS to be used for improvement in data and service quality. In FY07, HIVQUAL

was implemented in 35 HIV networks; in FY08, it will expand to include 100 networks. TUTAPE provides

training-of-trainers on HIVQUAL.

The MOH recognizes the need to institutionalize M&E/HMIS responsibilities in the staffing structure at all

levels. In FY07, the MOH endorsed the training of new HMIS cadres. TUTAPE will continue to support

participants from local partners for the pre-service HMIS training program to build a sustainable M&E

system that will support the newly designed HMIS. The MOH plans to train more than 2,000 HMIS cadres in

FY08. TUTAPE will expand its HMIS pre-service training from 100 in FY07 to 500 new cadres by using

technical educational and vocational training schools (TEVT) around the country. TUTAPE will renovate the

institutions as state-of-the-art, multifunctional training institutions for HMIS and other allied health

professionals.

The MOH program links integrated supportive supervision (ISS) as part and parcel of the M&E/HMIS

reform. In FY07, to strengthen the new M&E/HMIS, TUTAPE provided technical support for ISS strategy

development. This activity will continue through FY08 for concurrent implementation of ISS with HMIS in

100 districts.

In FY07, TUTAPE supported HAPCO management to bring the information monitoring and evaluation to

department level. In FY07, TUTAPE's short- and long-term consultancies, fellows, and M&E specialists

were seconded to the HAPCO M&E department and quality team. In FY07 and FY08, TUTAPE will work to

improve organizational structures by seconding staff within the Ethiopian Health and Nutrition Research

Institute (EHNRI), local hospitals, and higher learning institutions.

TUTAPE continues to provide technical support for human capacity building for M&E at the national, sub-

national, and service-delivery levels. TUTAPE, in collaboration with Jimma University (JU), launched the

first postgraduate degree in health M&E and postgraduate diploma program in Africa. The first group of 31

students started in February 2006 and will graduate in FY07. Graduates will form the first Ethiopian M&E

network, a forum for sharing ideas and experiences, and mentor RHB, nongovernmental organizations

(NGO), faith-based organizations (FBO), and other local stakeholders. In January 2007, the second class of

38, including candidates from NGO and organizations for people living with HIV (PLWH) were enrolled. A

third cohort of 40 is expected to enroll in FY08. In FY08, institutional support to JU will continue, including

joint appointments of academics and technical assistance to create a sustainable integrated master's

program at JU. That technical assistance will support course coordinators, administrative staff, and other

aspects of the program. In addition, in FY08, JU will receive support to enroll paying international students

(including other PEPFAR countries) and host international short-courses in M&E.

In FY07 a summer institute for faculty for training and sharing experiences will be established. As JU has a

critical shortage of teaching staff, lecturers amongst the first M&E cohorts will be recruited as part of a staff-

Activity Narrative: retention mechanism. In FY08, this support will continue.

In FY08, a fellowship will be initiated for PLWH who will be trained in multi-sector HIV/AIDS program design,

implementation, and M&E. This will be linked to all activities at JU and All Africa Leprosy Rehabilitation and

Training Center (ALERT), with credit counted towards an advanced certificate/ degree. In addition, to

support the national HMIS and health systems, biostatisticians will be trained. These efforts will provide

didactic, as well as practical, experience for further career enhancement.

In FY07, short-term training programs (e.g., M&E for program improvement and use of data for decision-

making, program improvement and other related trainings) were provided to MOH/HAPCO, the Drug

Administration and Control Authority, EHNRI, RHB, the Christian Relief And Development Association, the

PLWH network, and the Central Statistical Agency to improve M&E knowledge and skills at national and

regional levels. Scientific writing workshops will be offered to larger audiences and will expand from 30

people in FY07 to include 100 in FY08. Participants will continue to be supported to publish their work in

peer-reviewed journals. In FY08 the short-term trainings, including M&E/HMIS, program, and HR

management and data use/quality, will be extended to cover regions.

In FY08, in order to reach a much larger audience of government, NGO/FBO, and community participants,

teaching materials from JU will continue to be converted into e-materials to support e-learning.

TUTAPE will conduct process evaluations of the HMIS reform, the data-quality system, the HIV/AIDS

committee at health facility, and other program evaluations as it becomes necessary in the course of

program implementation. TUTAPE continues to provide technical assistance to EHNRI for heath facility

survey, national -level surveys and health-impact evaluations.

HAPCO conducted the first round National AIDS Spending Assessment (NASA) in FY07 and TUTAPE

supported the intervention mapping component. In FY08 the intervention mapping would be updated for the

MOH/HAPCO and uploaded on to the MOH intranet TUTAPE is establishing in FY07.

In FY08, support will be provided to the Federal Ministry of Health, Program and Planning Department

(MOH/PPD), and HAPCO in costing programs, for use in program planning as well as in development of

funding proposals. Support will also be provided to finalize the inputs needed for the costing tool developed

in FY07.

TUTAPE, in FY06 and 07, provided technical assistance to MOH/HAPCO in producing the first and second

Annual HIV/AIDS M&E Reports. In FY08, technical and financial assistance will be given to MOH/HAPCO to

produce monthly, quarterly and annual M&E/HMIS updates and reports.

Human Resource Requirement for Meeting Targets by 2010

This is a continuing activity from FY07 (10510) which addresses the human-resource requirement for

meeting targets by 2010. Ethiopia is committed to the global initiative of universal access to HIV/AIDS by

2010 and Millennium Development Goals (MDG) 2015. To meet this target, MOH is implementing massive

ART scale-up. The most prominent challenge to this endeavor is a human resource shortage. In FY07,

TUTAPE supported a targeted evaluation to explore the human-resource requirements for meeting

PEPFAR goals and universal access by 2010. There are two evaluation questions: what is the gap in

human resources for meeting PEPFAR and universal access targets by 2010, and what strategies and

innovative solutions should be adopted if the country is to meet them?

Based on the evaluation, in FY08, TUTAPE will support MOH to develop a human-resource information

system and also provide technical assistance for the human-resource strategy implementation to address

the human resource requirement for PEPFAR targets and universal access for health. The database will be

updated annually by using university student going to their home districts during summer vacation. TUTAPE

will also support all regions to adopt the MOH system and populate and maintain the database.

TUTAPE is leading the human resource for the Technical Working Group (TWG), and this data base will be

used by the TWG to monitor human-resource dynamics and analyze the trend over time.

The national ART implementation guidelines propose that teams of two doctors, one nurse, one counselor,

one pharmacist, one lab technician, one administrator, and one data clerk are needed to manage ART

services at a facility. These health care workers will be the population of interest.

The Ethiopian minister of health requested in a meeting to the Ambassador and the PEPFAR coordinator

that PEPFAR makes funds available to this activity as it is a top priority for the Government of Ethiopia

represented by the Ministry of Health.

The Presidents Emergency Plan for AIDS Relief (PEPFAR) recognizing the severe HRH crisis in Sub-

Saharan Africa has led the initiative to address the international HRH crisis.

Ethiopia is committed to the global initiative of Universal Access to HIV/AIDS by 2010 and Millennium

Development Goals (MDG) by 2015 with the support of initiatives like

PEPFAR. To meet this target, FMOH is implementing a massive ART scale up of which the most prominent

challenge is the human resource shortage. The densities of health workers per population remain among

the lowest in the world, and inadequate to reach health status goals of the Health Sector Strategic Plan.

With 0.3 physicians and 2.05 nurses per 10,000 population, Ethiopia ranks in the lowest HRH density

quintile of African nations and far below WHO estimate of 2.1 minimum workforce required per 10,000

population. To assess the current HRH situation, an assessment has been undertaken with an adapted tool

developed by WHO, initially by consultants from Harvard in 2003 and as a first step of the HRH Business

Process Re-engineering (BPR) in 2006. George Washington University has also conducted a multi-country

study that included Ethiopia to identify legal and policy bottlenecks for task shifting for HIV/AIDS services.

The findings from these assessments, as could be anticipated, suggest that the key problems are shortage

of health professionals, poor performance, inequitable distribution of the available health workforce among

regions and health facilities. The FMOH and the Ministry of Education have limited technical capacity to

coordinate, supervise and evaluate basic health training programs resulting in poor quality of training for the

main HRH categories. Furthermore, medical education curricula are not aligned with current and future

health system needs and health policy. There is a lack of standardized accreditation and national

examination for licensing. This is compounded by poor planning, coordination & quality of in-service training

programs (mostly donor driven training activities) and little opportunity for young health professionals to

benefit from continuing staff development. Health professionals have low levels of remuneration and lack

conducive working conditions which correlates to the poor general performance of the available health

professionals, manifested as poor handling of patients, absenteeism and shirking of duties, pilfering of

drugs and materials and internal or external migration.

Recognizing the shortcoming of the system the FMOH has embarked on a Civil Service reform along the

lines of business process reengineering (BPR) to revamp the health system. This is pursued along seven

interrelated core themes: access and quality, financial utilization, health management information system,

logistics, emergency response and human resources for health (HRH).

Though HRH core process was initiated in 2005 it has not been progressing as anticipated. Initially an HRH

Observatory and BPR team was established but the process

was delayed for various reasons and as a result disbanded by FMOH.

The FMOH high level management, cognizant of the urgency of the HRH situation in the country and in an

attempt to find a workable solution has identified Tulane University as

its lead partner to develop the country's HRD strategy and implementation plan up to 2020.

Tulane, as part of its PEPFAR funded activities develops human resources and expertise for Monitoring and

Evaluation and had completed a national assessment and strategy

of the health sector HRD for HMIS. Moreover, Tulane in FYO7 through PEPFAR/CDC funding is working to

address the Human requirements for Meeting targets by 2010

which would enable to answer two evaluation questions and as a result develop a HRIS database. These

activities position Tulane with the expertise and know-how to provide

the FMOH with the technical expertise it needs.

Tulane has assumed the responsibility of leading the FMOH HRH strategy and implementation with

PEPFAR support. Tulane's technical assistance will include but are not limited to alternative methods for

estimating detailed densities of health workforce over time; education, training and skill development;

analysis of policy, legal and financial framework; assessment of political feasibility of different reform

options; sequencing of investment options in HRH and develop monitoring and evaluation activities needed

to support the above areas. Tulane will also develop human resource management capacity of the FMOH

as well as develop the necessary tools including software and applications.

This request is for a new funding to support these activities and to mobilize national and international

experts in various aspects of human resources development including experts in health policy, law, costing,

workforce forecasting, management and education to support this effort. At the request of the Ministry,

Tulane will second HR experts.