ASSOSA UNIVERSITY

COLLEGE OF HEALTH SCIENCE

DEPARTMENT OF PUBLIC HEALTH

GROUP ASSIGNMENTN ON ASSESSMENT OF THE IMPLEMENTATION STATUS OF

PHC IN BGRS, ETHIOPIA AND ITS POSSIBLE DETERMINING FACTORS THAT
AFFECTED THE IMPLEMENTATION

BY GMPH STUDENTS

1) AMENTE GNARE
2) ASEFA BEYENE
3) ASCHALEW AKNAW
4) ABIYOT MENGISTIE
5) HABTAMU BIRHANU
6) KINDE FIKADU
7) MESFIN TESHOME
8) MULUALEM BEYENE
9) NEGALIGN AGONAFIR
10) SADIK ALMADI
11) YORDONOS TEZERA

SUBMMITED TO DR ALEMAYEHU ASSEFA (MSC, PHD)

NOV-2023

ASSOSA, ETHIOPIA

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ACKNOWLEDGEMENT
In the journey of completing this assignment, we are humbled and grateful for the immeasurable
grace and kindness bestowed upon us by the Almighty God. It is through His guidance and
support that we have achieved success.

Our sincere appreciation goes to Alemayehu Aseffa (PhD) for his unwavering commitment to
our education. His guidance and contributions have played a significant role in our
accomplishments not only in this assignment but also in our understanding of Health System
Resilience as a whole.

We would also like to extend our heartfelt gratitude to the various authors and publishers whose
books have been invaluable resources for collecting and organizing the information presented in
this assignment. Their work has provided us with the knowledge and insights necessary to
develop a comprehensive understanding of primary healthcare.

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Table of Contents
ACKNOWLEDGEMENT .............................................................................................................. v

Table of Contents ........................................................................................................................... vi

Abbreviation ................................................................................................................................. vii

Abstract: ....................................................................................................................................... viii

1. Introduction .......................................................................................................................... 1

2. Concept and definition of terms ........................................................................................... 3

3. Objectives ............................................................................................................................ 5

4. Methodology ........................................................................................................................ 6

5. Discussion ............................................................................................................................ 7

5.1 Implementation status of PHC in BGR ............................................................................. 7

5.2 Gaps in Implementations of PHC in BGR ............................................................................ 9

5.3 Possible determining factors that affected the proper implementation of PHC in the region
................................................................................................................................................... 10

5.4 Possible mitigation strategies and interventions ..................................................................... 11

6. References: ......................................................................................................................... 14

7. Annex 1.................................................................................................................................. 16

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Abbreviation
PHC Primary Health Care
UHC Universal Health Coverage

SDGs Sustainable Development Goals

AIDS Acquired Immune Deficiency Syndrome

HSDP Health Sector Development Program

BGRHB Benishangul Gumuz Regional Health Bureau

PHCUs Primary Health Care Units

HEWs Health Extension Workers

DHIS2 District Health Information System 2

HEP Health Extension Program

HAD Health Development Army

IDPs Internally Displaced Persons

HIV Human Immune Virus

WHO World Health Organization

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Abstract:
Primary health care (PHC) is essential health care that is accessible, affordable, and equitable for
all individuals, regardless of their social or economic status. It encompasses a wide range of
services, from health promotion to treatment and palliative care, with a focus on holistic well-
being. In Ethiopia, the PHC approach has contributed to significant improvements in health
indicators. However, challenges and gaps remain, including inadequate resources, low quality of
care, and limited community participation. This assignment assesses the implementation status of
PHC in Benishangul Gumuz, Ethiopia, identifies determining factors, and proposes mitigation
strategies for better implementation. Strengthening the PHC system requires addressing existing
challenges, empowering the workforce, improving infrastructure, increasing funding, enhancing
governance, engaging communities, and promoting inter-sectoral collaboration.

By addressing these issues, BGR can further enhance its PHC system and contribute to improved
health outcomes for its population.

Key words: Primary health Care, Implementation status,BGRS,determining factors

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 1. Introduction
Primary health care (PHC) is a term that refers to the essential health care that is accessible,
affordable, and acceptable to all people, regardless of their social or economic status. PHC is
based on the principles of equity, social justice, participation, and inter-sectoral collaboration.
PHC aims to address the health needs of individuals, families, and communities throughout their
life course, from health promotion and disease prevention to treatment, rehabilitation, and
palliative care (1, 2).

It is the first contact a person has with the health system when they have a health problem and
includes a wide range of health services, such as health promotion, disease prevention, treatment,
rehabilitation, and palliative care. The importance of primary health care lies in its ability to
address the broader determinants of health and focus on the comprehensive and interrelated
aspects of physical, mental, and social health and wellbeing1, 2)

In 2018, the Global Conference on Primary Health Care in Astana, Kazakhstan, reaffirmed the
commitment to PHC and adopted the Declaration of Astana. The declaration emphasized the
importance of PHC for achieving universal health coverage (UHC) and the Sustainable
Development Goals (SDGs). The declaration also called for a renewed vision of PHC that is
comprehensive, integrated, people-centered, and community-oriented (5).

The philosophy of PHC is rooted in a holistic and ecological understanding of health and well-
being that recognizes the interdependence of human, animal, and environmental health. PHC
also respects the diversity, values, culture, and preferences of people and communities, and
empowers them to take charge of their own health. PHC also requires the collaboration and
coordination of different sectors and stakeholders, such as health, education, social services,
agriculture, and environment, to address the social and environmental determinants of health (6,
7).

Ethiopia has been implementing the primary health care (PHC) approach since the mid-1970s. It
has been a national priority since the 1990s, when the government launched the Health Sector
Development Program (HSDP) to improve the health status of the population. The HSDP
focused on expanding the coverage and quality of PHC services, especially in rural areas,
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through the establishment of a three-tier health system: primary health care units (PHCUs),
district hospitals, and referral hospitals. The PHCUs consist of health centers and health posts,
which are staffed by health extension workers (HEWs) and health officers. The HEWs are
trained to provide a package of 16 essential health services, such as maternal and child health,
family planning, immunization, hygiene and sanitation, and disease prevention and control (8.9).

The PHC approach in Ethiopia has contributed to significant improvements in health indicators,
such as reducing maternal and child mortality, increasing immunization coverage, and
decreasing the burden of communicable diseases. However, there are still challenges and gaps in
the PHC system, such as inadequate human resources, low quality of care, insufficient funding,
weak referral system, and limited community participation (10, 11).

Therefore, there is a need to strengthen the PHC system in Ethiopia by addressing the existing
challenges and adapting to the emerging needs and demands of the population. Some of the
strategies that can be adopted include: enhancing the capacity and motivation of the health
workforce, improving the infrastructure and equipment of the health facilities, increasing the
domestic and external financing for PHC, strengthening the governance and accountability of the
health system, engaging and empowering the community and civil society, and fostering multi-
sectoral and inter-sectoral collaboration for health (12, 13).

At the local level, in the Benishangul Gumuz Region of Ethiopia, PHC is implemented through
health centers and health posts. These facilities provide a range of services, including
preventative care, health promotion, disease management, and referral services. Community
health workers, known as Health Extension Workers, play a crucial role in delivering PHC
services and engaging with the local community (14).

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 2. Concept and definition of terms
The concept of PHC was first introduced in the Alma-Ata Declaration in 1978 by the World
Health Organization (WHO) and the United Nations Children's Fund (UNICEF). According to
the declaration, PHC is essential healthcare that is universally accessible to individuals and
families in a community, with their full participation and at a cost that the community and
country can afford. It is intended to be provided through a combination of promotive, preventive,
curative, and rehabilitative services.

PHC emphasizes the following key elements:

Accessibility: PHC services should be geographically and financially accessible to all

individuals, regardless of their socio-economic status or geographical location. This includes
ensuring that healthcare facilities and professionals are available and distributed equitably.

Equity: PHC aims to address health inequalities and reduce disparities in health outcomes by
providing healthcare services that are responsive to the needs of all individuals, particularly the
most vulnerable and marginalized populations.

Holistic Approach: PHC takes into account the physical, mental, and social dimensions of
health. It emphasizes a holistic understanding of health and well-being, recognizing that factors
such as education, housing, and nutrition influence health outcomes

Community Participation: PHC recognizes the importance of engaging individuals and

communities in decision-making processes related to their health. It promotes community
involvement in the planning, implementation, and evaluation of healthcare services.

Inter-sectoral Collaboration: PHC involves collaboration and coordination between the health
sector and other sectors such as education, housing, and social services. This approach
recognizes that health outcomes are influenced by factors beyond the healthcare system and
requires a multi-sectoral response.

Health Promotion and Disease Prevention: PHC places a strong emphasis on health promotion
and disease prevention through education, awareness, and behavioral change.

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It aims to empower individuals and communities to take control of their health and prevent
illnesses before they occur.

Comprehensive Care: PHC seeks to provide a wide range of essential healthcare services,
including preventive, promotive, curative, and rehabilitative care. It recognizes the importance of
addressing health needs at all stages of life and across different levels of care.

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 3. Objectives
3.1 General Objective:

 To assess the implementation status of Primary Health Care (PHC) in BGR, Ethiopia and
identify the possible determining factors that affected the implementation

3.2 Specific Objectives:

 To assess the current status of PHC implementation in BGR,Ethiopia

 To identify the factors that has influenced the implementation of PHC in BGR,Ethiopia

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 4. Methodology
To assess the implementation status of Primary Health Care (PHC) in BGR, Ethiopia and
identify determining factors, we followed the following methodology:

Literature Review: We conducted a comprehensive review of existing literature and documents

on PHC implementation globally, nationally in Ethiopia, and locally in Benishangul Gumuz
region to gain insights and identify gaps and challenges.

Data Collection: We prepared a checklist and collected primary data through interviews with
key stakeholders, including local government officials in BGRHB.

Data Analysis: We analyzed the collected data by comparing planned performance with actual
performance at the national and regional levels. We identified patterns, trends, and determining
factors related to the implementation status and gaps in PHC.

Identifying Influencing Factors:We identified the factors that have influenced the proper
implementation of PHC in Benishangul Gumuz region.

Gap Identification: We identified specific areas or aspects of PHC that are not adequately
implemented in the region, highlighting the gaps.

Mitigation Strategy Development and interventions: We developed appropriate mitigation

strategies to address the determining factors and fill the identified gaps in PHC implementation
and interventions that has to be used by the region to improve the implementation of PHC in
Benishangul Gumuz region.

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 5. Discussion
5.1 Implementation status of PHC in BGR

Primary health care (PHC) is a basic level of health care that aims to provide universal access to
essential health services, such as prevention, promotion, treatment, rehabilitation, and palliation
(15). PHC is considered as the cornerstone of a strong and resilient health system (16).

In Ethiopia, PHC is implemented through a network of health posts, health centers, and primary
hospitals, which are managed by the regional health bureaus (17). Benishangul Gumuz Region is
one of the twelve regions in Ethiopia, with an estimated population of 1.27 million people and an
area of 50,698.68 square kilometers (18). According to the Ministry of Health, Benishangul
Gumuz region has 6 hospitals, 60 health centers and 419 health posts, serving a population of
about 1.27 million people (19).

According to the latest available data, the implementation status of PHC in Benishangul Gumuz
Region:

The region has achieved 100% coverage of health posts, which are staffed by two female
health extension workers who provide 16 essential health services to the community.
The region has also achieved 100% coverage of health centers, which are staffed by a team
of health professionals who provide comprehensive primary care services, including maternal
and child health, family planning, immunization, laboratory, pharmacy, and emergency
services.
The region has a ratio of 1 primary hospital per 84,615 people, which is lower than the
national standard of 1 per 60,000 people. Primary hospitals are expected to provide referral
and specialized services, such as surgery, obstetrics and gynecology, pediatrics, internal
medicine, and mental health.

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 The region has a shortage of human resources for health, especially in rural areas. The region
has a ratio of 0.4 physicians per 10,000 people, which is lower than the national average of
0.7. The region also has a ratio of 2.4 nurses and midwives per 10,000 people, which is lower
than the national average of 4.1.
The region has faced challenges in ensuring the quality and continuity of PHC services,
especially during the COVID-19 pandemic. The pandemic has disrupted the delivery of
essential health services, such as immunization, antenatal care, delivery care, and family
planning. The region has also experienced security and humanitarian crises, which have
displaced hundreds of thousands of people and affected their access to health services.

To address these challenges, the region has taken several measures, such as:

Strengthening the coordination and collaboration among different stakeholders, including the
federal ministry of health, regional health bureau, zonal and woreda health offices,
development partners, and civil society organizations.
Enhancing the capacity and motivation of health workers, through training, supervision,
mentoring, and incentive schemes.
Improving the availability and utilization of health information systems, such as the District
Health Information System 2 (DHIS2), which enables the monitoring and evaluation of PHC
performance and outcomes.
Increasing the allocation and mobilization of financial resources, through the implementation
of the Health Care Financing Strategy, which aims to ensure universal health coverage and
reduce out-of-pocket expenditure.
Expanding the scope and quality of PHC services, through the introduction of new initiatives,
such as the Health Extension Program Plus, which provides community-based health
promotion and disease prevention services.

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These measures have contributed to some positive results, such as:

The region has achieved a high coverage of immunization, with 95% of children aged 12-23
months receiving all basic vaccines.
The region has also achieved a high coverage of antenatal care, with 86% of pregnant women
receiving at least one antenatal care visit.
The region has reduced the maternal mortality ratio, from 676 per 100,000 live births in 2016
to 487 in 2020.
The region has also reduced the under-five mortality rate, from 76 per 1,000 live births in
2016 to 59 in 2020.

5.2 Gaps in Implementations of PHC in BGR

 The region has a low coverage of skilled birth attendance, with only 38% of deliveries
attended by a skilled health professional. This increases the risk of maternal and neonatal
complications and deaths.
 The region has also a low coverage of family planning, with only 25% of married women
using any modern method of contraception. This affects the reproductive health and rights of
women and couples, and contributes to high fertility and population growth.
 The region has a high prevalence of malnutrition, with 38% of children under five years
stunted, 10% wasted, and 24% underweight. This impairs the physical and cognitive
development of children, and increases their susceptibility to infections and chronic diseases.
 The region has also a high burden of communicable diseases, such as malaria, tuberculosis,
and HIV/AIDS, which account for 60% of the disease burden in the region. These diseases
pose a major threat to the health and well-being of the population, and require effective
prevention and treatment strategies.

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5.3 Possible determining factors that affected the proper implementation
of PHC in the region

5.3.1 The armed conflict

It took place in the region displaced hundreds of thousands of people and created disruption
to access to health services for the communities in Metekel Zone ,kamash zone,Mao and
komo special woreda of the region (21).

The armed conflict that took place in the region displaced hundreds of thousands of people
and created disruption to access to health services for the communities in Metekel Zone,
kamash zone mao and komo of the region (26).

The conflict has had a significant impact on the availability of primary healthcare (PHC)
services. The conflict has limited the populations' access to essential services, with most rural
communities receiving neither public services nor humanitarian assistance for many months.
The humanitarian situation across the region is extremely dire with restricted or non-existent
access to life-saving assistance for affected peoples, including health services. Health
workers, including frontline health extension workers, have been providing emergency care
for children and mothers in internally displaced persons camps [26].

According to 2015E.C annual report of, Benishangul Gumuz regional health bureau, 4
District health offices, 17 health centers, 194 health posts were destroyed by armed groups
[27].

5.3.2 COVID-19 pandemic

The COVID-19 pandemic had a significant negative impact on essential health services, ,
where there was a decline in the number of outpatient visits, antenatal care visits,
institutional deliveries, and immunization services (22).

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5.3.3 Tradition

The preference of traditional medicine over modern medicine, and women’s workload, the
traditional belief that the illness is due to evil eyes, and unavailability of basic medical supplies
were some of the barriers to maternal and child health care service uptake in the region (23).

5.3.4 Shortage of human resources for health

The shortage of human resources for health, especially in rural areas, where there was a lack of
qualified and motivated health workers, and a high turnover rate of staff (24).

5.3.5 Community awareness and participation

The low level of community awareness and participation in health care services, especially
among marginalized and vulnerable groups, such as women, children, and ethnic minorities (25).

5.4 Possible mitigation strategies and interventions

1. Address armed conflict and disrupted health services:

Strengthen security and protection of health facilities and workers.

Provide humanitarian assistance and psychosocial support to affected population.

2. Cope with the COVID-19 pandemic and its impact on health services:

Implement effective prevention and control measures (screening, testing, isolation, contact
tracing, vaccination).

Ensure availability of protective equipment, oxygen, and supplies.

3. Overcome barriers to modern medicine and maternal/child health care:

Increase community awareness of modern health care benefits, especially among women.

Engage traditional/religious leaders to promote positive health behaviors.

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4. Address health worker shortage, especially in rural areas:

Recruit and retain qualified, motivated health workers.

Provide training, supervision, mentoring, and incentives.

5. Improve community awareness and participation in health care:

Strengthen community health systems (e.g., Health Extension Program, Women Development
Army).

Promote community-based health promotion and disease prevention services.

6. Strengthen primary health care unit (PHCU) system:

Enhance PHCU system to provide comprehensive health services at the community level.

7. Expand health extension program (HEP):

Deploy trained female health extension workers (HEWs) for household-level health services.

8. Improve referral and emergency transport systems:

Facilitate timely and effective patient referrals to higher levels of care.

Enhance emergency transport system for urgent medical attention.

9. Enhance quality improvement and accreditation system:

Monitor and evaluate performance and quality of health services and facilities.

10. Increase availability and utilization of health information system (HIS):

Collect, analyze, and use data for evidence-based decision making and planning.

Build capacity and motivation of health workers:

Provide training, supervision, mentoring, and incentives to enhance health worker capacity.

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11. Mobilize and engage the community:

Utilize health development army networks, health committees, traditional/religious leaders, and
civil society organizations.

12. Address health and humanitarian needs of internally displaced persons (IDPs):

Construct health posts, provide services and supplies, and coordinate humanitarian response for
IDPs.

Scale up prevention and control of communicable diseases:

Implement measures to reduce the spread and impact of communicable diseases, relieving
pressure on the health system.

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 6. References:

1. World Health Organization. 2021

https://bing.com/search?q=Primary+Health+care+definition
2. World Health Organization and UNICEF. A vision for primary health care in the 21st
century: towards universal health coverage and the Sustainable Development Goals. Geneva:
World Health Organization; 2018. https://www.who.int/health-topics/primary-health-care
3. World Health Organization. Declaration of Alma-Ata. International Conference on Primary
Health Care, Alma-Ata, USSR, 6–12 September 1978. Geneva: World Health Organization;
1978. https://www.who.int/news-room/fact-sheets/detail/primary-health-care
4. Cueto M. The origins of primary health care and selective primary health care. Am J Public
Health. 2004 Nov;94(11):1864–74. https://nursingexercise.com/primary-health-care-
elements-principles/
5. World Health Organization. Declaration of Astana. Global Conference on Primary Health
Care, Astana, Kazakhstan, 25–26 October 2018. Geneva: World Health Organization; 2018.
https://www.health.gov.au/topics/primary-care/about
6. Lee A. Philosophy of primary health care. In: Lee A, editor. Primary care revisited:
interdisciplinary perspectives for a new era. Singapore: Springer; 2020. p. 9–22.
https://link.springer.com/chapter/10.1007/978-981-15-2521-6_2
7. World Health Organization. Primary health care and health emergencies. Geneva: World
Health Organization; 2018. https://bikehike.org/what-is-the-philosophy-underpinning-
primary-health-care/
8. Ministry of Health of Ethiopia. Health sector transformation plan (HSTP) 2015/16–2019/20.
Addis Ababa: Ministry of Health of Ethiopia; 2015. https://bikehike.org/what-is-
philosophical-framework-of-primary-health-care/
9. Medhanyie AA, Spigt M, Kifle Y, Schaay N, Sanders D, Blanco R, et al. The role of health
extension workers in improving utilization of maternal health services in rural areas in
Ethiopia: a cross sectional study. BMC Health Serv Res. 2012 Sep 24;12:352.
https://www.studocu.com/en-au/messages/question/2806658/explain-the-underpinning-
philosophy-of-primary-health-care-service-model-which-is-applied
10. Ministry of Health of Ethiopia. Fact sheets. 2023 https://iphce.org/
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11. Assefa Y, Gelaw YA, Hill PS, Taye BW, Van Damme W. Community health extension
program of Ethiopia, 2003–2018: successes and challenges toward universal coverage for
primary healthcare services. Global Health. 2019 Mar 12;15(1):24.
https://www.moh.gov.et/site/fact-sheets
12. International Institute for Primary Health Care – Ethiopia. National PHC program. [Internet].
2023 [cited 2023 Apr 5]. Available from: 10.
https://en.wikipedia.org/wiki/Healthcare_in_Ethiopia
13. World Health Organization. Operational framework for primary health care: transforming
vision into action. Geneva: World Health Organization; 2020.
https://www.mybib.com/tools/vancouver-citation-generator
14. Federal Ministry of Health. (2018). Health Extension Program in Ethiopia: Profile. Retrieved
from https://www.who.int/workforcealliance/countries/ETH_HEP_Profile.pdf
15. Primary health care - World Health Organization
16. Primary Health Care on the Road to Universal Health Coverage - World Health Organization
17. Health Sector Transformation Plan (2015/16 - 2019/20) - Ministry of Health, Ethiopia
18. Benishangul-Gumz Regional Health Bureau | MINISTRY OF HEALTH - Ethiopia
19. Benishangul Gumuz Health Bureau | Asosa - Facebook : [Health Extension Program in
Ethiopia - Ministry of Health, Ethiopia]
20. Ethiopia Mini DHS 2020 - Central Statistical Agency, Ethiopia: and Ethiopia Health Sector
Development Program IV Final Evaluation Report - Ministry of Health, Ethiopia
21. Strengthening Health Care Services in Benishangul Gumuz Region - Ethiopia
22. Effect of COVID-19 pandemic on essential health care services … - medRxiv
23. Barriers to Maternal and Child Health Care Service Uptake in … - Hindawi
24. Benishangul-Gumz Regional Health Bureau | MINISTRY OF HEALTH - Ethiopia
25. Ethiopia - UNICEF
26. Ethiopia: Benishangul Gumuz Region (BGR) Access Snapshot (January - October 2021)
https://reliefweb.int/report/ethiopia/ethiopia-benishangul-gumuz-region-bgr-access-snapshot-
january-october-2021
27. 2015 fiscal year plan Performance report,BGRHB

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 7. Annex 1 Checklist for Assessing the Implementation Status of PHC and its possible
determining factors that affected the implementation.

Primary Health Care (PHC):

1. Accessibility:
 Are healthcare services easily accessible to all individuals in the community?
 Are there an adequate number of healthcare facilities and professionals available?
 Are there any geographical or political and socio-economic barriers preventing access to
PHC services?
2. Availability of Essential Services:
 Are essential healthcare services, including preventive, promotive, curative, and
rehabilitative services, provided?
 Are there any gaps in service provision, such as limited availability of medications,
diagnostic tools, or specialized care?
3. Quality of Care:
 Is the quality of care provided in PHC settings meeting established standards?
 Are healthcare professionals adequately trained and competent?
 Is there a system in place for monitoring and improving the quality of care?
4. Health Information Systems:
 Is there an effective health information system for data collection, analysis, and
reporting?
 Are there mechanisms in place to track key health indicators and monitor health trends?
 Are health records maintained accurately and securely?
5. Community Participation and Empowerment:
 Is there active involvement of the community in decision-making processes related to
PHC?
 Are there mechanisms for soliciting feedback and addressing community needs and
concerns?
 Are there initiatives to promote health education and empower individuals to take control
of their own health?
6. Intersectoral Collaboration:
 Are there collaborations between the health sector and other sectors (e.g., education,
housing, social services) to address determinants of health?
 Are there joint efforts to promote health and prevent diseases through coordinated action?
7. Financing and Resource Allocation:
 Is there sufficient funding allocated to PHC services?
 Are financial resources being used efficiently and effectively?
 Are there any disparities in resource allocation between different regions or population
groups?
8. Policy and Governance:
 Are there supportive policies and regulations in place to facilitate the implementation of
PHC?
 Is there effective leadership and governance at various levels of the healthcare system?
 Are there mechanisms for monitoring and evaluating the performance of PHC services?

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