TRACKING TRENDS IN ETHIOPIA S CIVIL SOCIETY (TECS) 1 INFORMATION BULLETIN NO. 10 On CHSOs ENGAGED IN THE HEALTH SECTOR JANUARY 2014

Transcription

1 TRACKING TRENDS IN ETHIOPIA S CIVIL SOCIETY (TECS) 1 INFORMATION BULLETIN NO. 10 On CHSOs ENGAGED IN THE HEALTH SECTOR JANUARY Background This information bulletin aims at investigating and sharing the major issues and challenges for Charities and Societies (ChSOs) engaged in provision of different health services. It is based on interviews conducted with ChSOs and a review of secondary material. The challenges faced by ChSOs working in the health sector are multifaceted and include problems of operation and association. These issues are not all new and some have been raised in different fora with the Charities and Societies Agency (the Agency) and the Government of Ethiopia by ChSOs, development partners and diplomatic missions. In the light of these representations, some efforts have been made to resolve the challenges. Nevertheless, fundamental issues resulting from the 70/30 directive remain unresolved such as the classification of specific costs as administrative, which logically should be operational. More recently, issues regarding the structure, mandate and associational rights of some ChSOs have arisen. The bulletin starts by describing the key roles of ChSOs in the health sector of Ethiopia. It then briefly describes the challenges of ChSOs in relation to the Income Generating Activities (IGA) directive, the 70/30 directive, the registration of health related professional associations, and the most current problem highlighted during licence renewal which relates to enhancing public knowledge and awareness on health matters. 2. Role of ChSOs in the Health Sector ChSOs are actively involved in many different areas of the health sector. These engagements range from the provision of health facilities, such as clinics and hospitals, to health education and the prevention of disease. The Agency s database lists 1,626 health projects as of October 2011 and since 2009 it has registered nearly 2,210 ChSOs which have managed different health projects in 35 sub-categories. 1 TECS is a project initiative of the DAG, whose purpose is to create a conducive and enabling environment through supporting research, dialogue and publication on emerging issues and trends in Ethiopian civil society sector, including those arising from the implementation of the Proclamation on Charities and Societies. The new TECS Information Bulletin series aims to bring to key emerging issues to the attention of Government, civil society and development partners. TECS Information Bulletin 10 January

2 The EU Civil Society Mapping Study of 2007 found that 330 health facilities or 7% of all health facilities in Ethiopia are managed by charities, many of which are located in remote rural areas. The same study highlighted that, in terms of finance, 52 charities alone contributed about 290 million ETB annually to the sector. This represented 9.8% of annual health expenditure. The following chart shows 19 major categories of ChSO engagements in the sector. These include 955 charities involved in fighting HIV/AIDS and nearly 400 working in health service expansion and research. It is very important to note that charities are engaged in a number of areas where the public health system has limited access, for instance, the treatment of autism, fistula and kidney diseases. Source: The Agency s database, December Major Challenges of Charities and Societies in the Health Sector 3.1. IGA and health facilities managed by charities Health facilities managed by charities are facing challenges in the application of the IGA directive. A number of charities manage health facilities of varying size and capacity providing both preventive and curative services for instance maternal and child health; immunization programs; antenatal care; maternity services, postnatal care; reproductive health and family planning and health education. The sizes of these health facilities range from small rural clinics to referral hospitals. To give one example, the Ethiopian Evangelical Church Mekane Yesus Development And Social Services Commission (EECMY-DASSC) is operating 44 health institutions including: TECS Information Bulletin 10 January

3 1 rural general hospital (Aira Hospital), 5 health centers, (2 in Oromia and 3 in SNNPR), 1 school of nursing in Oromia, 1 eye care clinic in Nekemte town, 36 major and medium clinics in different parts of Ethiopia including in Gambella and Benishangul-Gumuz regions. Funding flow estimates show that, globally, finance in the health sector through CSOs has declined from an estimated average of $64.6BN in the years between 2006 to 2010 to an estimated at $40.6 in 2011 (OECD 2011). As a result, CSOs are considering a range of ways of raising critically needed funds which include charging patients and beneficiaries fees for their services. However, the IGA directive does not currently recognise this kind of cost sharing activity and instead treats this form of raising funds as IGA for profit making purposes. The regulations governing IGA require charities to register as a business, pay business taxes and institute special management and accounting procedures that impose large additional costs. Case studies developed by TECS show that the IGA regulations currently in operation, rather than increasing income for charities and service provision would actually result in the closure of health facilities due to the additional costs associated with IGA. Following representation, the Agency has drawn up a new directive to address the issue of cost sharing. It is vital that those charities using cost sharing are consulted as this new directive is finalised to ensure rationale and workable regulations The directive to determine the administrative and operational costs of ChSOs (70/30 directive) The 70/30 directive has been a major challenge for the charities over the last years. The main areas of challenge are outlined in the following table: Table: Intervention component and description of challenge No. Intervention component Description of the challenge I. Training for front line health extension Costs such as per-diem, transport workers (HEWs), health care providers reimbursement, trainers per-diem, at government health centers and refreshment, hall rent, stationary hospitals, Training of Trainers costs are treated as administrative cost II. Clinical mentorship/coaching Cost of mentorship such as mentors professional fee, per-diem, travel costs are treated as administrative cost III. Integrated supportive supervision costs Per-diem and transport cost of integrated supportive supervision is categorized as administrative cost IV. Mobile and outreach services provision costs Costs related with mobile and outreach services are considered as administrative cost V. Periodic review meeting costs Treated as administrative costs VI. Consultancy costs for different initiatives VII. Transportation costs Considering transportation cost of TECS Information Bulletin 10 January

4 health commodities, drugs and equipment as administrative cost 3.3 The issue of licence renewal for societies in the health sector Societies in the health sector are numerous and include the Ethiopian Medical Association (EMA), Midwives Association of Ethiopia (MAE), Ethiopian Pharmaceutical Association, Ethiopian Society of Obstetrics and Gynaecology (ESOG) and the Ethiopian Paediatrics Society. These professional societies perform a variety of functions including: development and monitoring of professional educational programs, the updating of skills, professional certification and accreditation, university and college education support through curriculum review and development, research, and organizing international conferences and scientific meetings. Their activities while aimed at improving their members knowledge and skills development also have an important impact on the wider public. Additionally, through the international cooperation projects that they manage, these societies organise large scale regular health treatment campaigns such as eye operations, paediatric and cardiac surgery, diabetic treatment and a number of specialist treatments in both the capital city and the regions. These activities undoubtedly benefit a large number of patients, including thousands of children. The finance for these activities comes mainly from international donors and partner professional societies and therefore these professional societies are mainly registered as Ethiopian Resident. The latest demand from the Agency is that professional societies should be registered as Ethiopian societies, thereby limiting overseas funding to 10% of their annual income. This will therefore prevent such societies from carrying out a large number of health projects that directly benefit the public. Box: Midwives Association of Ethiopia (MAE) MAE engages in a number of midwifery related projects which include: Preparation of a Leadership and Management Manual for Nurse and Midwife Leaders in Ethiopia Preparation of Labour and Delivery Service Standard Guidelines and Clinical Audit Tools Preparation of Mother Friendly Service Guidelines for Hospitals and An Obstetric Management Protocol for Health Centres Preparation of A Maternity Waiting Home Service Standard In addition, in collaboration with the Federal Ministry of Health (FMoH) Design of a midwifery audit tool and the establishment of an Ethiopian Nurse Midwife Council Design of a midwifery audit tool and the development of a range of documents to improve the quality of Ethiopian midwifery services Support to and ensuring that midwifery regulations represent best practice and are in the long-term interests of the midwifery profession TECS Information Bulletin 10 January

5 4. Does advocacy on health issues matter? Unwanted pregnancies and unsafe abortion cause the death of thousands of women annually. In Ethiopia, it is estimated that about 10,000 women die every year as a result of unsafe abortion. A Central Statistical Authority survey shows that in 2005, for every 100,000 live births in Ethiopia, 673 mothers died because of complications of pregnancy or childbirth. In addition, every year, 9000 women suffer the condition known as fistula which is associated with childhood marriage, childhood pregnancies and female genital mutilation. These are just few examples of issues where advocacy and awareness raising are crucial to improving health and survival rates, particularly for women. The diagram below illustrates a number of other issues where advocacy is needed to improve public understanding, change attitudes, policy and practice in order to tackle the problem and improve health outcomes. The main aim of any advocacy is to tackle root causes in order to prevent a problem occurring. This may involve advocating for changes to laws, policy and practice or raising awareness to change attitudes. A starting point for advocacy is to consider the rights of the individual affected, for example, the rights of women to reproductive health, to gender equality or freedom from violence. Individual rights, acknowledged in international treaties and conventions, legitimise advocating for change. For instance, addressing maternal mortality in child birth and the problem of fistula, requires advocacy around the rights of girls to gender equality: to choose who and when they marry and when they have children, enabling them to delay pregnancy. However, in Proclamation 621/2009, advocacy focusing on rights (often termed a rights based approach) is restricted to Ethiopian charities and societies; it is illegal for Resident or Foreign Charities and Resident Societies. In addition there are very few Ethiopian charities or societies that focus on health or that have the mandate or interest to advocate on health issues. Resident organisations that do have a wealth of research, experience and practice that could contribute to improving health are prohibited from tackling the underlying causes of many health problems. Prepared by: The TECS team. For information, contact gemechu_desta@hotmail.com or anncondy@yahoo.com or gil.long@btopenworld.com; clairefhoward@gmail.com To view other TECS reports, visit - TECS sub page TECS Information Bulletin 10 January

6 TECS Information Bulletin 10 January