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Ethiopia’s HRH Strategy: Will the ‘flooding’ strategy go down the drain?

By Fikru Tafesse Lamu
on March 23, 2018

With a personnel density of 0.3 doctors, nurses and midwives per 10,000 population, a figure far below the critical threshold of 23 per 10,000, Ethiopia has been categorised as one of the countries with a health workforce “crisis”. The situation is compounded by a substantial geographic maldistribution of the health workforce, as workers tend to favour the more urban parts of the country.

In response to this apparent shortage and inequitable distribution of human resources for health (HRH), the government of Ethiopia has implemented various HRH initiatives as part of successive health sector development programs since 1998. As a result, large numbers of different categories of HRH, especially community and mid-level health workforce, have been trained in the last decade, through the accelerated scaling up of education and training programs. Private-for-profit organizations have also contributed to the education and training of mainly mid-level health workforce.


Medical graduates, Bahir Dar University, Ethiopia. Source:, 2018



However, Ethiopia’s HRH strategy, commonly referred to as the “flooding” strategy, is primarily focused on the production aspect of HRH. It is aimed at rapidly increasing the number of health care workers, without giving due attention to the other equally important components of HRH development strategies. Consequently, teaching institutions have not been adequately prepared, either in terms of human resources or in terms of related infrastructure. In addition, the education and training of the health workers has not been accompanied by the meticulous regulatory and quality assurance procedures they deserve, and the overall quality of education and training is not at the optimum level. Furthermore, only marginal attention has been given to improving the prevailing poor working conditions, as well as the poor retention of the public sector workforce in the country. Instead, the government introduced the measure of withholding the diplomas and certificates of graduating health workers, particularly physicians, in order to force them to work wherever they are assigned. In my opinion, such a measure is not only unsustainable, but also counterproductive, as it demotivates health workers and negatively impacts on the performance and overall quality of health care provided to the needy population.

In its recent report, the UN High-Level Commission on Health Employment and Economic Growth recommended investing in the creation of new jobs in health and social sectors, giving more attention to women and youth, to meet the increasing demand for HRH and maximize women’s participation in the economy.  There is no question about the relevance of this recommendation for Ethiopia, given its massive youth population and the urgent need to address the huge unemployment and gender inequality. However, producing fit-for-purpose health care workers requires strategies that address the quality of education and training, so that all health workers have the skills that match the needs of the population. In addition, decent working conditions must be guaranteed, so that the health workers can work to their full potential and remain in the system.

While it is true that investments in HRH production could help address the increasing demand for HRH and create job opportunities for the ever expanding youth population in the country, the narrow focus of the Ethiopian HRH strategy clearly leaves out other key issues that influence the productivity of health workers and overall health outcomes. Not surprisingly, in a country where decisions are usually made in a top-down manner, the framing of the HRH strategy and its implementation have been very much influenced by political rationale and the urge to fulfil that commitment, rather than a concerted, well thought out strategic plan. Nonetheless, it is high time relevant stakeholders and actors become involved in shaping the strategy and undertaking related initiatives, otherwise it will be too late.


Community health worker, Ethiopia. Source: Google, 2018









For Ethiopia’s HRH strategy to be effective, the scaling up of health worker education and training must be accompanied by initiatives such as improved incentive/remuneration packages, and career development and promotion plans to retain an effective, responsive and motivated health workforce. Policies and interventions to address poor working conditions, maldistribution and inefficiencies also need to be designed and implemented to ensure retention of health workforce in underserved areas in particular, and improve their performance. At the same time, government efforts need to go beyond just having regulatory policies for ensuring the proper functioning of the regulatory and accreditation bodies and mechanisms, to improving the quality of education and training in both public and private institutions.


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