1. Health Financing
Quarterly Newsletter. Volume 2 No. 4. July 2015
HSFR/HFG Ends Second
SuccessfulYear,Will Build
on Achievements inYear 3
Leulseged Ageze, HSFR/HFG Chief of Party/Project Director, says
the project had a great year that , collaborating with its partners,
had achieved successes in working towards putting better health
system in place
The HSFR/HFG Project in Ethiopia recently ended its second year
(July 1, 2014–June 30, 2015) with achievements in its major pro-
gram areas, health care financing (HCF) and health insurance initi-
atives. Activities included building the capacities of frontline person-
nel in implementing HCF reforms and community-based health
insurance (CBHI).
Health Financing (HF), the project’s quarterly newsletter, recently
asked Leulseged Ageze, HSFR/HFG Chief of Party/Project Director,
to highlight project achievements and challenges last year and to
identify focus areas for the coming year. The answers have been
edited for length.
What was the focus of the project in the past
fiscal year?
The project has supported the wide range of health finance
and governance reforms that the Ethiopian FMOH [Federal
Ministry of Health] continues to initiate and implement. We
built on previous years’ achievements in consolidating the
first generation of health care financing reforms throughout
the country. However, the major focus has been preparation
for universal health coverage through financial risk protection.
IN THIS ISSUE
Dr. Ariel Pablos-Mendez Praises Ethiopia’s
CBHI Program …. Page 4
Health Care Financing Updates …. Page 5
Community Based Health Insurance
Updates …… Page 6
Social Health Insurance
Updates ..… Page 10

2. Our approach in the progression from first to the second gener-
ation reforms was balanced and systematic. As part of the con-
solidation of first generation reforms, health facilities that per-
formed well and demonstrated the capacity to run these re-
forms without any or with only minimal project support were
selected, recognized, and graduated from our support. For
health facilities and regions that embarked on these reforms
more recently, including Afar, Gambella, and Somali regions, we
focused on building reform implementation capacity.
Our HCF team worked very closely with the FMOH Medical
Services Directorate on implementation of HCF reforms in fed-
eral referral and teaching hospitals. The necessary legal, organi-
zational, and operational frameworks have been put in place.
Some of these hospitals have already begun implementing differ-
ent reform components.
With regard to the second generation reforms, we have been
supporting the government in expansion of CBHI and making
the necessary preparation for launching SHI [social health insur-
ance]. We finalized CBHI pilot evaluation through reiterative
validation and review of the draft report with Breakthrough
International Consultancy, the firm that led the evaluation, and
the EHIA [Ethiopian Health Insurance Agency]. We finalized,
printed, and disseminated the report. The report is an invaluable
source of evidence for different policy and program initiatives.
Based on the recommendation of the CBHI pilot evaluation
report and through consultation with EHIA, FMOH, and other
key stakeholders, we drafted the CBHI scale-up strategy that has
the target of covering 80 percent of woredas and up to 80 per-
cent of eligible households by 2020. While we are working on
finalization of the scale-up strategy, CBHI expansion is underway
in 185 woredas, more than our initial plan of 161.
We have been supporting EHIA in its preparations for launching
SHI in the current fiscal year. In this regard, we updated the
financial sustainability analysis by taking into account more up-to
-date socio-economic data and other policy variables.
We provided different capacity building and have seconded full-
time staff to the agency, both at central office and in selected
branch offices.
In addition to successful execution of our routine project activi-
ties, we were privileged to take part in key policy processes that
have paramount importance for the Ethiopian health sector in
general and health financing in particular. We took part in con-
sultations about and development of Ethiopia’s health policy,
specifically, the Health Care Financing Strategy and Health Sec-
tor Transformation Plan (HSTP). We were one of the key play-
ers on the Health, Clean and Safe Hospitals initiative at central and re-
gional levels. We are glad to work with Ras Desta Damitew Hospital as
sponsors and key partners. We are always grateful to FMOH, EHIA, and
RHBs [Regional Health Bureaus] for these opportunities and for their
continued confidence and trust in our team.
How do you assess the project’s performance
during the past year?
As I mentioned above, HSFR/HFG had another great year. First genera-
tion reforms are better institutionalized in all health centers and hospi-
tals throughout the country. Our support to the FMOH in institutional-
izing HCF reforms in federal referral and teaching hospitals makes imple-
mentation of these reforms across the country more complete.
Our capacity-building efforts through training of health facility govern-
ance, management, and finance teams continued with a focus on new
health facilities and newer regions. We trained around 445 persons (343
men and 102 women) on HCF reform implementation and an additional
155 persons (117 men and 38 women) on financial management. We
have also been strengthening accountability through institutionalization
of regular auditing of health facility finances – we trained 28 auditors.
We supported strengthening of health facility governance and we
trained 977 health facility governing board members on HCF reform
components, on their duties and responsibilities, as well as on their
working relations with health facility management. All preparatory steps
have been taken to provide legal and operational basis to implement
HCF reforms in federal and teaching hospitals.
Our technical support was instrumental to expansion of CBHI program
to 185 new woredas, more than the originally planned 161. We provid-
ed a motorbike and a computer and printer to each CBHI scheme. This
was a huge procurement and we are very glad that these essential items
are available to the schemes. We developed the CBHI scale-up strategy
based on the lessons learned from the 13 pilot schemes. The strategy
was reviewed through stakeholders’ policy consultation workshop and
the revised version was submitted to EHIA; we expect it to be submit-
ted to and endorsed by the FMOH . We also supported recruitment
and training of 353 CBHI executive staff to new schemes. Moreover, we
trained over 8,000 kebele leaders, who are critical for effective imple-
mentation of the CBHI initiative. We also trained relevant government
staff: 571 from woredas , 401 health service providers, and 47 from
EHIA .
Furthermore, the CBHI pilot schemes evaluation revealed impressive
coverage under the pilot schemes (over 50 percent of eligible house-
holds); increased health service utilization among CBHI beneficiaries, an
average of 0.7 per beneficiary per annum visit to health providers and
2

3. 3
more than double of the 0.3 national average; and improved finan-
cial protection of members and their beneficiaries. So far, financial
protection has been provided to over 6 million Ethiopians through
the pilot and expansion CBHI schemes.
In other areas of program learning, we have been supporting
FMOH, RHBs, and EHIA on generation and use of health financing
evidence in policy decision making. Early in the year, we produced
a summary note showing that health resources are inadequate to
buy quality health, which the ministry reviewed, refined, and circu-
lated to the Ministry of Finance and Economic Development, the
Prime Minister’s Office, and parliamentarians. Finalization of the
CBHI evaluation and its policy use is another major achievement in
the year. Despite our focus on the CBHI expansion effort, we also
managed to make supervision visits to 686 health facilities (30 hos-
pitals and 646 health centers). Supervision visits were also made to
CBHI schemes; 17 visits were made to pilot schemes and 224 to
expansion schemes, which shows some schemes were visited more
than once. Such supervision events are critical to provide on-the-
spot technical support, and they also are an important source of
information for policy decision making and for gauging progress of
reforms
I think it is also worth mentioning field visits that we organized to
health facilities and CBHI schemes. This year we had more visibility
through visits by the FMOH as well as the U.S. Government and
other development partner delegations. The visits enabled us to
showcase the achievements of HCF reforms and to share lessons.
In addition to our quarterly newsletter, we produced success sto-
ries and policy briefs with wide circulation including through HFG
website. Project achievements were presented at the World
Health Systems Research Symposium and International Health
Economics Association Congress. We also supported experience
sharing and networking among regions, health facilities, and CBHI
schemes within the country.
Any challenges you would like to highlight?
Generally speaking, many of the challenges are addressed by gov-
ernment. We also have the support from our client and home
office. However, there are still some challenges, most of which are
the same ones I mentioned last year.
The first challenge is related to high government staff turnover.
We keep on observing this in health facility governing boards,
health facility management and finance staff, and CBHI executive
staff. Retaining key health facility staff is particularly challenging in
the regions that recently started HCF implementation, such as
Afar, Gambella, and Somali. Strengthening consolidation and gradu-
ation of health facilities in regions that started reform early and
thus are more advanced is a strategy that we believe will enable us
to put more effort into newer and weaker health facilities. However,
it is always difficult to sustain gains partly because of the high turno-
ver of staff and health facility board members.
Expansion of the CBHI initiative into 185 additional districts in the
past year was a huge undertaking. We also received requests for
support and have conducted some preparatory activities in Benshan-
gul-Gumuz Region and Addis Ababa City Administration to jump
start CBHI initiative. While it is good news that momentum and
interest exist, this will also be a challenge for project staff to provide
the required technical support.
Our HCF reform implementation experience, specifically, CBHI
implementation, showed that local government leadership and com-
mitment is critical to the success of these initiatives. Creating com-
mitment in new woredas and maintaining momentum in existing
ones is a huge challenge.
The CBHI pilot took place in 12 rural woredas and only one urban
center. I believe expansion of CBHI into urban settings will be a
challenge. It also will be difficult to introduce CBHI in pastoral areas,
where access to and provision of health services remains a challenge.
What will the project’s focus be in the coming
Fiscal year?
Definitely, our main focus and priority for the coming year will be
supporting implementation of CBHI in the 185 expansion woredas
and further expansion of the CBHI initiative into new woredas in the
four largest regions (Amhara, Oromia, SNNP, and Tigray) as well as
initiating CBHI in other regions such as Benshingul Gumuz and Addis
Ababa City Administration. We will work with the EHIA and RHBs
to put in place the necessary legal and operational frameworks as
well as on creating the necessary capacity.
Launching and successfully implementing SHI will also be a focus. As
a new area for the project and the country, we believe its success
will require a huge amount of staff time, external technical assistance,
and resources.
Strengthening consolidation and graduation of health facilities in the
early starter regions is a strategy that we believe will enable us to
focus our effort on the newer health facilities. The project will con-
tinue graduating health facilities from its regular support in collabora-
tion with our government counterparts. We will continue providing
training and other forms of support focusing mainly in new health
facilities, and late starter regions.
Finalizing the federal legal framework and supporting operationaliza-
tion of health finance and governance in federal hospitals will also be
a major undertaking in this fiscal year.
We will keep on working on evidence generation and knowledge

4. 4
Dr. Ariel Pablos-Mendez Praises Ethiopia’s CBHI Program
management to enhance evidence-based policy making and program
learning. We will keep on conducting periodic supportive supervi-
sion of health facilities and CBHI schemes. Efforts will also be made
to institutionalize HCF indicators and supervision instruments in
the FMOH, EHIA, and RHBs. We will support the FMOH in con-
ducting health expenditure tracking for the sixth round, and for the
first time using the System of Health Accounts 2011 framework.
This round of resource tracking will be more government led, as a
unit to institutionalize resource tracking is established in the minis-
try’s Resource Mobilization Directorate. The project will provide
technical support, while funding of training, data collection, analysis,
and report writing and dissemination is expected from the [Bill and
Melinda] Gates Foundation. The FMOH is also soliciting funding
from other sources, to conduct full-fledged health services utiliza-
tion and expenditure surveys of households and people living with
HIV.
In conclusion, how do you see your overall performance
and collaboration with different stakeholders?
Overall, we had another great year of success and remarkable
achievements. I would like to take this opportunity to thank the
project team and the strong backstopping support of the home
office. The overall leadership and support from our client, USAID,
was as usual superb. We also had strong collaboration and part-
nership with our government counterparts at all levels. We are
also grateful to all health sector partners that worked with us.
(Contributed by Habtamu Bogale)
Dr. Ariel Pablos-Mendez, USAID Assistant Administrator for
Global Health, and Dr. Kebede Worku, State Minister of the
Ethiopian Federal Ministry of Health, visited one of Ethiopia’s
first community-based health insurance (CBHI) schemes. Since
its establishment, the Gimbichu scheme has achieved remarkable
results, and is considered among the best-performing schemes in
terms of membership uptake and renewal, and financial sustaina-
bility. Its current enrollment ratio is at 58 percent of the total
eligible households in the district, which has an estimated popula-
tion of 108,255.
In his welcoming speech, Dr. Kebede described the efforts made
by the Government of Ethiopia to initiate CBHI in the four most
populous regions of the country – Amhara, Oromia, SNNP, and
Tigray. “We introduced CBHI in 13 districts at a pilot level four
years ago,” said Dr. Kebede. “By evaluating and monitoring our
strengths and weaknesses, we have taken the lessons from this
pilot to expand CBHI to 185 additional districts. Based on this
good experience, the Ethiopian government’s vision is to estab-
lish CBHI schemes in each of its 900-plus districts by 2020, and
to provide coverage for 80 percent of the population in the agri-
cultural and informal sectors.”
Dr. Kebede also recognized the government and people of the
United States for the continued technical and financial support of
the health insurance initiatives: “On behalf of the Ethiopian Gov-
ernment, I would like to take this opportunity to specially recog-
nize and thank the American people and government for their
continued support in initiation and implementation of Ethiopia’s
CBHI initiative.”
Dr. Pablos-Mendez addressed the gathering by reminding the audience
of his visit to Ethiopia four years ago: “As a public health professional, I
appreciate the progress the Ethiopian government has made in health
care financing reform and implementation of health insurance. Health
insurance was a new concept for the country at the time of my first
visit.” He said the government’s introduction of insurance has produced
significant achievements.
The visit enabled Dr. Pablos-Mendez to hear from local beneficiaries
about the changes they have witnessed since the establishment of CBHI
in their villages, and its impact on their lives.
Mrs. Kumele Cherenet, a community member with three children, told
the visitors about her experience with the new insurance scheme.
“Before implementation of CBHI in our village, we used to borrow up
to 1,000 Birr when we got sick and had to repay double the amount of
this loan. Now, by contributing an affordable
A warm welcome to Dr. Palos-Mendez in Gimbichu

5. 5
amount, we are getting quality health services both at the health
center and the hospital. Women in our villages have witnessed many
positive changes since the introduction of CBHI.”
Mr. Chalchisa Megersa, a farmer, said “among the villagers here,
before being CBHI members, at least one of us has sold our cattle
to solve our health-related problems. But now, thanks to CBHI,
each household can get comprehensive health care services without
the need to pay at time of seeking these services.”
Dr. Pablos-Mendez noted success of Gimbichu’s CBHI pilot scheme
demonstrates that Ethiopia will be a model country in health insur-
ance, and is moving towards achieving universal health coverage.
After hearing the testimonies of the CBHI member community rep-
resentatives, Dr. Pablos-Mendez pointed out that “residents of Gim
bichu are not only beneficiaries of CBHI, but also part of the
change that the world strives to see: equity in health by achieving
universal health coverage.” He also reassured the gathering that the
American people and government will be by their side to ensure
this change.
The visit of Dr. Pablos-Mendez was an important event for commu-
nities in Gimbichu. The public gathering was attended by more than
400 people including community representatives, and federal, re-
gional, zonal, and district governmental officials. A large number of
CBHI beneficiaries also attended. Community leaders thanked dele-
gation members for their visit, and their continued support. As a
gesture of gratitude and respect, they presented Dr. Pablos-
Mendez and other guests with gifts of traditional costumes.
The dignitaries were accompanied on the visit by senior officials
and experts from the FMOH, the Oromia Regional Health Bureau,
the Ethiopian Health Insurance Agency, and USAID Ethiopia.
Visitors wore traditional dresses and were blessed by
elders
Mrs. Kumele Che-
renet, a CBHI mem-
ber, explaining
about benefits of
CBHI for women
Health Care Financing Updates
The HSFR/HFG project collaborated with government counterparts
during the last quarter of the project year (April-June 2015) to pro-
vide training in health facility governance, health care financing (HCF)
reform implementation, and financial management throughout the
country. These trainings and other activities are critical to the con-
solidation of first generation HCF reform components including
revenue retention and utilization (RRU), health facility governance
structures, establishment of private wings, reform of fee waivers and
exempted health services, user fee settings and revision, and out-
sourcing of non-clinical services. The following articles highlight the
major HCF training conducted during the quarter.
Trainings on HCF reform implementation
In April, the project team in the central office and for Oromia, Hara-
ri, and Dire Dawa collaborated with the respective regional health
bureaus (RHBs) to provide basic and refresher trainings on HCF
reform implementation for 173 (131 men, 42 women) health facility
staff in Adama and Harar towns. HSFR/HFG also provided technical
support for the trainings.
In Adama, the Addis Ababa City Administration Health Bureau
organized the training into three rounds (April 6-8, 9-11, and 17,
20, and 21). The training covered HCF reform, CBHI, leadership
management and governance, the Clean and Safe Hospitals
(CASH) initiative, and professional ethics. Sixty-five hospital sen-
ior management staff (41 men and 24 women) attended the train-
ing.
The project team for Oromia, Harari, and Dire Dawa, in collabo-
ration with the RHBs in the three regions as well as the Clinton
Health Access Initiative (CHAI), organized HCF training for nine
new hospitals on April 15-22. The training, which took place in
Harar town, focused on HCF, Business Processing Reengineering,
Balanced Score Card, the Ethiopian Hospitals Reform Implemen-
tation Guideline, Hospital Performance Monitoring Indicators,
and the Health Development Army. A total of 108 (90 men, 18
women) personnel attended the training.

6. 6
Training on financial management
The project team in Amhara organized an eight-day (April 17-25)
financial management training for new health centers implement-
ing HCF reform. The training, which took place in Woldia town,
covered government accounting reform; gave an overview of HCF
reform including health insurance; and discussed directives for
RRU, facility governance, and implementation of the new fee waiv-
er system. Twenty-eight key finance staff (19 men and 9 women)
from health facilities in six zones of Amhara participated in the
training.
Consultative workshop to revise HCF legal
framework and operational manual
The project provided support for a consultative workshop held
June 5-8 in Adama town to discuss the findings of HCF supportive
supervision. The heads of the RHB and Bureau of Finance and
Economic Development (BoFED) made opening remarks empha-
sizing the need to increase the health sector budget and assess
trends in utilization, availability of essential drugs, client satisfac-
tion, and other aspects of health care. Subsequent to the presen-
tation, participants were divided into groups to discuss the issues
and each group presented its proposal for resolving the issue.
Participants commented and consensus was reached on the ap-
propriate way to implement HCF reform. A total of 145 partici-
pants (119 men and 26 women) attended. Workshop participants
were the head and deputy head of the Addis Health Bureau, CPSP
owners, responsible officials and experts from the BoFED, deans
of teaching hospitals, CEOs, medical directors, and directors of
Planning and Budget from one medical college, five hospitals, and
10 sub-city administrations.
Training on health facility governance
During the reporting quarter, the project trained 151 (121 men and
30 women) health facility governing board/body members drawn
from referral and teaching hospitals in Addis Ababa, hospitals in
Southern Nations, Nationalities and Peoples’ (SNNP), and new health
centers in Amhara region. The training topics included: a background
on HCF reforms, components of HCF reforms (RRU, health facility
governance, fee waivers and exempted health services, user fee set-
ting and revision, establishment of private wings in hospitals, and
outsourcing of non-clinical services), and the roles and responsibili-
ties of the facility governing board/body, management committee,
and facility finance and administration staff.
Table 1. Number of Health Facilities Governing Board/Body Mem-
bers Trained on Facility Governance
Note: HC=health center
Region # Participants # Facilities
Men Women Total
Amhara 28 0 28
14 new HCs
Central 13 15 28 5 hospitals
SNNP 80 15 95 24 hospitals
Total 121 30 151
The report from community-based health insurance
(CBHI) implementing regions indicates that as of June 30,
2015, 1,374,325 households (1,077,301paying and 297,024
non-paying) were enrolled in the schemes both in pilot
and expansion woredas.
The overall enrollment rate is 33.1 percent (45.9 percent
in pilot and 31.8 percent in expansion woredas) of eligible
households. The schemes generated 196,234,599.27 Birr
(41,831,485.69 Birr in pilot woredas and 154,403,111.58
Birr in expansion woredas) from members’ contributions
Community-Based Health Insurance Updates
(i.e., excluding general and targeted subsidies). In pilot
woredas, 909,214 visits were made to health facilities
(792,789 in health centers and 116,425 in hospitals) from
April 2011 through June 2014. During 2014/15, 431,659
visits were made in health facilities (359,867 in health cen-
ters and 71,792 in hospitals). Of these visits, 86 percent
were made to health centers, 14 percent to hospitals.

7. 7
CBHI schemes in expansion woredas enroll
around1.2 million households; collect 154.4 mil-
lion Birr in premiums
There are 123 CBHI expansion woredas in Amhara and Oromia (64
in Amhara and 59 in Oromia); 75 of them (49 in Amhara and 26 in
Oromia) have officially established CBHI schemes. (An “officially
established” scheme is one that has begun enrolling members and
collecting premium payments and is reimbursing contracted health
care providers for providing services to scheme beneficiaries.)
There are 1,199,739 households (932,185 paying and 267,554 non-
paying) enrolled in these regions. The total amount collected in
premiums is 154,403,113 Birr.
Of the 64 expansion woredas in Amhara region, 49 have officially
established schemes. Table 2 summarizes the numbers of Amhara
households enrolled in a CBHI expansion scheme. Of the total
1,177,325 eligible households in the region’s expansion woredas,
304,380 paying households were enrolled in 2013/14 and 267,176
paying households were enrolled in 2014/15 for a total of 571,556
paying household enrollments. In addition, 84,255 indigent house-
holds were enrolled, for a grand total of 655,811 member house-
holds over the two years.
The two-year average enrollment rate in the 49 schemes was 33.4
percent of eligible households. The highest enrollment rate was
reported in South Wollo zone (45 percent), followed by Oromia
zone (42.2 percent) and West Gojjam (38.6 percent). Over the two
years, the schemes generated a total of 94,911,006.00 Birr.
A total of 130,835 Amhara households renewed their membership
in 2014/15. The highest household membership renewal was in
West Gojjam, South Wollo, and South Gondar, the least in Wag
Himra and North Gondar.
Table 2: Household Enrollment in Schemes and Amount of Premi-
um Collected in CBHI Expansion Woredas of Amhara Region Dis-
aggregated by Zone. 2013/14-2014/15
In Oromia region, all 59 CBHI expansion woredas started
member enrollment and contribution collection in the final
quarter of 2013/14. Of these, 26 have established CBHI
schemes. Only 12 schemes (three each in North Shoa and
West Shoa, two in West Arsi, and one each in East Shoa, Arsi,
West Arsi, and East Harargie) reported the number of paying
and indigent households and the contribution collected. The 59
expansion woredas have enrolled 543,928 households (360,629
paying and 183,299 indigent) (Table 3). The highest enrollment
rate is in Finfine Special Zone (50.6 percent) followed by North
Shoa (42.8 percent), Guji (37.0 percent), and Arsi (36.3 per-
cent). The schemes generated 59,492,107.58 Birr from member
contributions.
Table 3: Household Enrollment in Scheme and Amount of Premium
Collected in CBHI Expansion Woredas of Oromia Region Disaggregat-
ed by Zone
Health service utilization by beneficiaries of
CBHI expansion schemes
In Amhara’s 64 CBHI expansion woredas, 35 schemes reported
that beneficiaries made 664,463 visits to contracted health facil-
ities (615,396 to health centers and 49,067 to hospitals) and the
schemes reimbursed 27,841,728.80 Birr to those facilities in
2014/15. Over the time that these schemes have been operat-
ing, their beneficiaries have made a total of 792,413 visits
(737,245 to health centers and 55,168 to hospitals) and the
schemes have reimbursed 32,158,948.81 Birr to the providers.
Note: HH– household

8. 8
In Oromia region, 18 of the 26 established schemes start-
ed providing health care services in 2014/15. Ten schemes
reported on the number of beneficiary visits in the year
(81,271 visits, 75,156 of which were to health centers,
6,115 to hospitals). Nine reported on reimbursements,
which totaled 3,689,415.08 Birr.
Original CBHI pilot schemes enroll
766,516 members, collect ETB 41.8 mil-
lion Birr in premiums
The CBHI program in Ethiopia started in April 2011 with
13 pilot schemes in Amhara, Oromia, SNNP, and Tigray
regions. These 13 original schemes had enrolled 766,516
households by the end of June 2015. Of these 17,033
households (12,748 paying and 4,285 non-paying) were
new in 2014/15; in the same year, 95,727 households re-
newed their membership. The schemes generated
24,858,068.58 Birr in contributions from new and renew-
ing members in the year. Since the establishment, the
schemes enrolled 174,586 households (145,116 paying and
29,470 non-paying) and generated 41,831,485.69 Birr from
new and renewing member contributions. The average
household enrollment rate is 45.9 percent; the highest
enrollment rate is reported in Tehuledere (85.5 percent),
followed by Gimbichu (65.2 percent), Kilte Awlaelo (57
percent), and South Achefer (55.7 percent) (Table 4).
The three schemes in Amhara enrolled 2,986 new paying
households in 2014/15. They also enrolled six non-paying
(indigent) households; however, they lost 62 non-paying
households in Fogera Woreda, for a net loss of 56. A total
of 27,910 households (11,936 in Tehuledere, 11,464 in
South Achefer, and 4,510 in Fogera) renewed their mem-
bership in the year. The schemes generated 4,504,626.00
Birr. The average enrollment rate in the region was 50.4
percent, the highest being in Tehuledere (85.5 percent)
and the lowest in Fogera (31.9 percent).
The four schemes in Oromia enrolled 11,472 new house-
holds (7,339 paying and 4,133 non-paying) and 20,958
households renewed their membership. The regional en-
rollment rate is 41.9 percent of eligible households, the
highest being 65.2 percent in Gimbichu.
The three pilot schemes in SNNP region enrolled 21,356
households (20,139 paying and 1,217 non-paying) and gen-
erated 3,521,776.08 Birr from April 2011 through June 2015. The schemes
enrolled only 321 new households (113 new paying households and 208
non-paying) in 2014/15; 36,596 households renewed their membership.
From April 2011 through June 2015, the schemes generated 4,600,598.37
Birr; 1,078,822.29 Birr were generated in 2014/15. Currently, the overall
household enrollment rate in pilot woredas in the region is 45.3 percent;
the highest is in Damboya (45.5 percent), but the rate is about the same for
all three schemes.
The three schemes in Tigray enrolled 2,310 new households (477 in Ah-
ferom, 666 in Kilte Awlaelo, and 1,167 in Tahitay Adiabo); the number of
non-paying households remained the same in all the three pilot woredas.
The schemes mobilized 7,529,641.00 Birr from April 2011 through June
2015; of this 1,701,408.00 Birr came during the reporting year. The total
household enrollment rate in the region is 46.9 percent, the highest being
recorded in Kilte Awlaelo (57.0 percent).
Table 4: Number of Households Enrolled in the Original Pilot Schemes, Number of
Beneficiaries, and Contribution Collected Disaggregated by Region and Woreda
Service provision in the original pilot woredas
In 2014/15, CBHI beneficiaries made 431,659 visits (359,867 to health cen-
ters and 71,792 to hospitals) and reimbursed 17,524,989.78 Birr to health
facilities in the four pilot woredas.
Since 2011, Amhara region has ranked first among the four schemes, in
terms of both total number of visits made and amount reimbursed to health
facilities. In 2014/15, 173,896 visits were made to health facilities (157,486
(86 percent) to health centers and 16,410 (14 percent) to hospitals) and
7,148,193.94 Birr was reimbursed; this represents nearly 37 percent of the

9. 9
total reimbursed between 2011 and 2015.
Since April 2011, when the three Amhara CBHI schemes started
providing protection to beneficiaries, 600,111 visits (556,071 in
health centers and 44,040 in hospitals) have been made to contract-
ed health facilities and the schemes have reimbursed the health facili-
ties 20,203,116.85 Birr for services provided.
In Oromia, 77,019 visits (43,166 in health centers and 33,853 in hos-
pitals) were made and the four schemes reimbursed 3,722,023.93
Birr to health facilities in 2014/15. Since April 2011, 217,039 visits
(133,331 in health centers and 83,708 in hospitals) have been made
and schemes have reimbursed the health facilities 8,796,371.00 Birr.
In SNNP region, 92,842 visits (80,856 in health centers and 11,986 in
hospitals) were made and the schemes reimbursed 2,680,440.01 Birr
in 2014/15. Since April 2011, 285,969 visits (256,127 in health cen-
ters and 29,842 in hospitals) have been made and 7,988,314.26 Birr
reimbursed.
In Tigray region, 87,902 visits (78,359 in health centers and 9,543 in
hospitals) were made, and schemes reimbursed 3,974,331.90 Birr in
2014/15. From April 2011 through June 2015, a total of 183,970
visits were made in health facilities (207,127 in health centers and
30,627 in hospitals) and schemes reimbursed 10,507,881.62 Birr.
Workshop on CBHI Scale-up Strategy
HSFR/HFG in collaboration with the Ethiopia Health Insurance Agen-
cy (EHIA) organized a CBHI Scale-up Strategy Consultation Work-
shop. On the first day of the workshop, held June 2-3, 2015 at the
Capital Hotel in Addis Ababa, project staff made three presentations:
Highlights of CBHI pilot evaluation findings and policy recommenda-
tions, by Abebe Alebachew of the consultant firm Breakthrough
International Consultancy, who led the evaluation; HCF reforms in
Ethiopia by Leulseged Ageze, Project Chief of Party; and CBHI con-
cept and global experience, by Hailu Zelelew, a Senior Associate/
Scientist at Abt who is also technical director of HSFR/HFG project .
Jean Damascene Butera, an international consultant working with
HSFR/HFG project, presented highlights of the scale-up strategy. On
the second day, workshop participants critically reviewed the CBHI
scale-up strategy. Based on their institutional affiliation and ex-
pertise/experience, participants were assigned to one of five working
groups: 1) Vision, mission, objectives, guiding principles, scale-up
approach, and road map; 2) strengthening CBHI legal framework and
institutional structure; 3) CBHI financing mechanisms and strength-
ening management systems; 4) strengthening partnerships with
health care providers and strengthening communication and commu-
nity mobilization; and 5) monitoring and evaluation and the CBHI
management information system. Each group reported back in a
plenary
session
on
major issues identified and recommended a course of action. The
project team revised the draft CBHI scale-up strategy based on
these inputs.
The 72 workshop participants (65 men and 7 women) were from
the FMOH, EHIA central and branch offices, Ministry of Labor and
Social Affairs, and RHBs, and were selected CBHI executive staff
and woreda administrators. The workshop was covered by public
and private media outlets, such as the Ethiopian Broadcasting Cor-
poration (EBC), Sheger FM, Radio Fana with its regional links, and
the widely circulated public newsletters Addis Zemen, The Ethiopi-
an Herald, and Addis Lisan.
Training on CBHI
During HSFR/HFG Year II, the project, in collaboration with RHBs
and EHIA branch offices, provided refresher training on CBHI
program implementation and the CBHI Financial Administration
and Management Systems (FAMS). It also conducted training for
health care providers and an orientation for EHIA branch offices in
four regions (Amhara, Oromia, SNNP and Tigray). Overall, the
project trained 8,666 personnel ( 8,030 kebele leaders, 571 per-
sons drawn from woredas, kebeles, and health centers, 353 CBHI
executive staff (286 orientation on CBHI program and 67 on CBHI
FAMS), 401 health care providers, and 47 EHIA branch offices staff.
Above: Leulseged Ageze, Chief of Party, HSFR/HFG Project
addressing the participants. Below partial view of participants,
workshop on CBHI Scale-up strategy

10. 10
Training for CBHI executive staff in pilot and
expansion woredas
As discussed above, the project trained a total of 286
CBHI executive staff (198 in Amhara, 35 in SNNP,
and 53 in Tigray region) in Year II.
The project team in Amhara region organized a three-
days training for CBHI executive staff of the 25 new
woredas preparing to implement the CBHI program.
The training was held in three sites, Kemissie, Wore-
ta, and Dangila. The training topics included: concepts
and basic principles of CBHI, CBHI regional directive,
CBHI FAMS, and medical audits. A total of 198 CBHI
executive staff (170 men and 28 women) attended the
training.
The project team in SNNP region organized a two-
day training for newly recruited CBHI executive staff
of both pilot and expansion CBHI schemes. During
the training, held in Hossana town, the project team
made presentations on topics that included concepts
of health insurance (community-based and social
health insurance), FAMS, managing contracts with
health providers, database management, and staff
roles and responsibilities. The presentations were
followed by practical exercises and questions and an-
swers. A total of 35 persons (27 men and 8 women)
attended the training.
The project team in Tigray region in collaboration
with Health Insurance and Monitoring and Evaluation
(M&E) teams from the central office organized a four-
day training in Wukro town for CBHI executive staff
from both pilot and expansion woredas. Training top-
ics included: concepts and principles of CBHI, when
and how to establish scheme (registration, contribu-
tion collection, ID card preparation and distribution),
effective ways of implementing CBHI program and
lessons from other regions, M&E (basic concepts, indi-
cators and targets, data collection tools, and data
quality assessment), and CBHI FAMS including the
prerequisite for financial auditing of schemes. The project
staff and RHB accountant served as trainers. At the end of
the training, participants said that the training enabled
them to comprehend procedures and approaches in the
implementation of the CBHI program. They also prom-
ised to organize sensitization and mobilization activities
and to facilitate establishment of schemes in their
woredas. Attending were 53 CBHI executive staff (33
men and 20 women): 18 woreda health office curative and
rehabilitative core process staff who serve as CBHI coor-
dinators; 17 CBHI IT staff; and 18 scheme accountants.
Social Health Insurance Update
Review of implementation manual
HSFR/HFG in collaboration with the Ethiopia Health In-
surance Agency (EHIA) organized a one-day consultative
meeting between EHIA central office staff and branch
managers and project staff to review the social health in-
surance (SHI) implementation manual. The meeting, which
took place on May 15, 2015 in Adama , was attended by
26 persons (22 men and 4 women).
The meeting was chaired by Mr. Mulat Tegegne, EHIA
Acting Deputy Director. The project team made a
presentation on the manual’s major topics, which was
followed by discussion. Participants forwarded comments
about how to improve member registration formats, con-
tents of the member ID card, systems for collecting con-
tributions, implementation of different provider payment
mechanisms, and data management and reporting on
member profiles and health service utilization.
The HSFR/HFG Health Insurance team is incorporating
comments and suggestions into the manual, and working
closely with EHIA staff to facilitate endorsement of the
document. Once it is endorsed, the project will print and
distribute the manual to all branch offices and organize
training on it.

11. 11
HSFR/HFG Staff Donates Potted
Plants to Ras Desta Hospital
For the Ethiopian New Year, HSFR/HFG staffs have do-
nated 64 pots of plants to Ras Desta Memorial Hospital, a
well-known public health facility in Addis Ababa city.
HSFR/HFG staff made the gift in recognition of the facility
being a pioneer in implementing health care financing
reforms, and a long-time partner of the project, initially
collaborating with the USAID HSFR project and over the
past two years with HSFR/HFG. The project also is over-
seeing Ras Desta’s implementation of the FMOH’s new
Clean and Safe Hospitals (CASH) initiative.
Central office project staff collect funds to purchase the
plants and deliver them to the hospital. The staff mem-
bers were received by Ato Tilahun Desta, Ras Desta’s
Disease Prevention and Health Promotion process own-
er, who expressed appreciation on behalf of the facility
and its staff. He said the gift exemplifies the project staff’s
relentless effort in providing support in all areas to make
the hospital a better place.
HSFR/HFG project staff delivering/arranging potted plants at
Ras Desta Memorial Hospital

12. Expanding Access. Improving Health.
Health Sector Financing Reform/ Health Finance and Govern-
ance (HSFR/HFG) project is a continuation of Health Sector
Financing Reform (HSFR) Project which has been working to
support the implementation of the Health Sector Financing
Reform and the Health Insurance Programs at the national,
regional, zonal, woreda and health facility levels.
The overall goal of HSFR/HFG project is
 to help the government consolidate and scale up the vari-
ous components of HCF reform,
 to increase utilization of health services by further im-
proving their quality and reducing financial barriers that
impede access to them through scaling up risk-sharing
mechanisms (insurance), promoting community participa-
tion to ensure accountability, and supporting the genera-
tion of evidence for program learning and decision mak-
ing.
Implemented by Abt Associates Inc.
In collaboration with
Broad Branch Associates, Development Alternatives Inc.,
Futures Institute, John Hopkins Bloomberg School of Public
Health, Results for Development, RTI international and Train-
ing Resources Group Inc.
Address
Central Office
Mexico Square , TadesseTefera Buliding 2nd
floor, In Front
of Hotel D’Afrique
Tel: 251 115 501 049, Fax: 251 115 501 556,
P.O.Box 42521, Addis Ababa, Ethiopia
Regional Offices
Hawassa regional Office
Covers SNNPR & Gambella Regions
Areb Sefer, Ali Shemsan Building, 3rd
floor
Tel: 251 (046) 221 5003/4854, Fax: 251 (046) 220 4332
P.O. Box 1133, Hawassa
Bahir Dar Regional Office
Covers Amhara & Benishangul GumuzRegions
Kebele 13 House # 179 Around A.D.M School
Tel: (251) 582-262-970/71, Fax: (251) 582-262-69
P.o.Box: 2316, Bahir Dar
Tigray Regional office
In front of Ethio Telecom, semen region, Nilex Plaza
building, 3rd
floor,
Tel: 251(344)413479, Fax:251(334)413479, Mekelle
Oromia Project Office
Project Office for Oromia, Harari and Dire Dawa regions
(co-located with central office)
Health Sector Financing Reform/ Health
Finance and Governance (HSFR/HFG) project
Health Financing is Produced by Health Sector Financing Reform/Health
Finance & Governance (HSFR/HFG) Project in Ethiopia
Content & Design: Bethlehem Negash, Editing: Linda Moll
For comments contribution and suggestion
Write: bnegash@hsfreth.org
Tel: 251 115 501 049, Fax: 251 115 501 556, P.O.Box 42521,
Addis Ababa, Ethiopia