ETHIOPIA HEALTH PRIVATE SECTOR ASSESSMENT - Global Financing Facility

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ETHIOPIA HEALTH PRIVATE SECTOR ASSESSMENTOctober 2019

TABLE OF CONTENTSExecutive Summary1.0Background to Ethiopia Private Sector Assessment1.1.1.2.1.3.1.4.1.5.1.6.1.7.Global Finance Facility and the Private Health SectorRationale for PSATarget Audience and Use of PSAPSA MethodologyPSA Framework – A Health Market Systems ApproachLimitationsPSA Organization2.0Ethiopia Overview2.12.22.3Ethiopia Socio-Economic IndicatorsEthiopia Health Priorities and System GapsGovernment strategy to address health system challenges3.03.1.3.2.3.3.3.4.3.5.4.0Ethiopia Private Health Sector Overview4.14.24.34.44.54.6PPM for Outpatient ServicesPPM for Inpatient ServicesPPM of Family PlanningPPM of Maternal Health ServicesPPM of Childhood IllnessesPPM of HIV/AIDs and TB5.0Enabling Environment5.15.25.3Policy and regulatory reviewMarket conditions (stakeholder interviews)Public private relations (stakeholder interviews)6.0Health Financing6.1.6.2.6.3.6.4.6.5.6.6.6.7.Trends in Total Health Expenditures (THE)Sources of Health FinancePer Capita Health ExpendituresOut-of-pocket ExpendituresAllocation of General Health Spending by Type of Health ServiceTotal Health Expenditure by Health AreaHealth Financing Strategies7.0Recommendations to Engage the Private Health Sector7.17.2Strategic framework to engage the private sectorSequencing of recommendationsPrivate sector landscapePrivate sector descriptionPPM of health facilitiesPPM of human resources for healthPPM of health training institutionsPublic Private Use of Key Health Services2

AIDUSDVATWBGWHOWDIAfrican Development BankAntenatal CareClinton Health Access InitiativeEthiopian Food and Drug AgencyFamily PlanningFederal Ministry of HealthGross Domestic ProductionGlobal Financing Facility in Support of Every Woman Every ChildGlobal Funds to Fight AIDS, Tuberculosis and MalariaGovernment Health ExpendituresGrowth Transformation PlanHealth AccountsHealth Extension ProgramHigher Education Relevance and Quality AgencyHealth in AfricaHealth Human ResourcesHealth Sector Development Plan IVHealth Sector Transformation PlanInternational Bank of Reconstruction and DevelopmentInternational Development AssociationInternational Finance CorporationMillennium Development GoalsNon-communicable DiseaseNon-governmental OrganizationNational Health AccountsOral Rehydration TherapyOut-of-pocketPrivate for ProfitProcurement Fund and Supply AgencyPublic private dialoguePublic private mixPublic private partnershipReproductive HealthRegional Health BureausReproductive, maternal, newborn, child, adolescent health and nutritionPneumococcal Conjugate VaccinePrivate Sector AssessmentSub-Saharan AfricanTotal Fertility RateTotal Health ExpendituresUniversal Health CoverageUnited States Agency for International DevelopmentUnited States DollarValue Added TaxWorld Bank GroupWorld Health OrganizationWorld Development Indicators3

EXECUTIVE SUMMARYBackgroundThe Global Financing Facility (GFF) in Support of Every Woman Every Child is a country driven partnership thataims to accelerate efforts to end preventable maternal, newborn, child and adolescent deaths and improve thehealth and quality of life of women, adolescents and children. The GFF is supporting the Ethiopian FederalMinistry of Health (MOH)’s efforts to collaborate with the private sector as a strategy to address health prioritiesand system gaps confronting the Ethiopian health sector. GFF agreed to support the MOH to conduct a privatesector assessment (PSA) as a first step in a longer process to engage the private health sector. A PSA can play aninstrumental role in generating sound data on the private health sector to guide MOH policy and planning andcreate a “road map” to harness private sector resources.MethodologyThe PSA team used a three-step process to carry out the assessment: Plan Analyze Recommend. In theplan phase, the PSA team engaged in a series of conversations with MOH to help shape the direction of the PSAaccording to national priorities and gaps and identify key public and private stakeholders as key informants.During the analyze phase, the team reviewed published and gray literature; conducted secondary analysis ofpast surveys including the past Ethiopia Demographic and HealthHealth Market Systems Approachsurveys and Ethiopia Health Accounts; and supplemented themwith stakeholder interviews. The team used an iterative processto triangulate the data from the three sources and vet thefindings with MOH leadership. Moreover, the team used ahealth market systems approach (see box) to interpret the dataand shape the recommendations. In the recommend phase, thePSA team presented actionable strategies to be vetted withMOH and private sector leaders, eventually creating thefoundation for private sector engagement strategy and actionplan. Key limitations of the PSA include: the time constraint, theinability to interview larger number of stakeholders such asthose outside of Addis Ababa; and data gaps and challengesrelated to private sector data that must be interpreted withcaution.Ethiopian Health Sector LandscapeThe PSA offers a new landscape of the health sector to demonstrate the wide range of actors – both domesticand international as well as state and non-state – that play an active role in health. Although not exhaustive, thenew health sector landscape offers a more complex and nuanced perspective of the full range of actors thatneed to be involved when designing policies and plans to improve health. Key discoveries include: Although the MOH is the lead government agency responsible for health policies and regulation, there areother government entities, like the Ministry of Finance and the Prime Minister’s Office that play animportant role in health. Development Partners are a key player in health contributing an estimated 33% of total health expenditures. The private sector goes beyond health services and is engaged in a wide range of activities including medicaltraining, commodity manufacturing and distribution, etc. that can be leveraged to complement MOH’sinitiatives in health.4

Health consumers are an important stakeholder in health and are engaged during strategic and annualplanning processes.Ethiopian Health Sector LandscapePUBLIC SECTORPRIVATE HEALTH SECTORPrivate not-for-profit sectorOffice Prime MinisterEthiopian Privatization AgencyPPPGeneralDirectorateCORAHFederal Ministry of Health (FMOH)Community Based HealthAssociationsProfessional HealthAssociationsEthiopia HealthcareFederationEMA, EPHA, PHA, Clinic Associations(3), MAPPE, Nurse, Midwifery, Lab andPharmacists AssociationsFederal AgenciesAHRI, EFDA, EHIA, EPHI, EPSA,FHAPCO, NBBSLocal GovernmentRegional Health Bureaus(Zone & Woreda health offices)Ethiopian Chamber ofCommerceENAHPA, North America Health ProfessionalAssociation, Ethiopia American Doctors Group,Ethiopia Diaspora AssociationManufacturers, Importers,DistributorsPrivate for-profit sectorHERQAEthiopian InvestmentCommission CommerceDiaspora AssociationsIndustry AssociationsDevelopment Partners in HealthBMGF, CIDA, CHAI, CRDA, DFID, EU,GFF, GAVI, Global Fund, Irish AID, ItalianCooperation, JICA, Nordic DevelopmentAssociation, Pathfinder, Save the Children,SIDA, Carter Center, PEPFAR/USAIDPackard Foundation, GAVI, IFC/WorldBankDiagnostics/EquipmentLaboratories, ImagingServices, Radiology,Medical EquipmentHealth FinancingMedical Insurance,Debt/Equity InstitutionsHealth FacilitiesPharma SectorClinics (primary, medium,specialty); Centers;Hospitals (primary,general and specialized)Manufacturers,Importers, Wholesalers,Distributors, Pharmacies,Drug Stores and VendorsIndustryOther relatedindustryWorkplace programs,health insurance, CSRInformal SectorTeaching Hospitals and MedicalUniversities3,000 total – 70% localAMREF, RED CROSS, MSF, MSH, MSI,CURE Hospital, Kenema Pharmacies(Non-licensed, untrained providers)Ministry of Sciences andHigher Education (MOSHE)Local / International NGOsCabinetPPP-H NodeMinistry of Finance (MOF)FBOsCatholics, Orthodox, Adventist,ProtestantTraditional MedicinesPractitionersPrime MinisterSocial Affairs StandingCommitteeIT and other supportservicesHealth Consumers and Advocacy GroupsCivil Society Organizations (CSOs) representing health, gender, equity and poverty issuesEthiopian Private Health Sector at a Glance The private health sector owns and manages a wide range of health facilities offering diverse health servicesand products. The private health sector is present across all levels of care in Ethiopia, ranging from primary level facilitiessuch as private pharmacies and drug stores, non-government health facilities and civil society organizations,and primary clinics/medium clinics; to secondary level facilities including private for profit specialty clinics; totertiary level facilities like non-government and private for profit hospitals and specialty centers. The Ethiopian private for-profit sector serves mostly the high- and middle-income groups in both urban andrural areas while the non-government organizations and charities, together with MOH, serve the workingpoor and poorer income groups mainly in rural areas. The private sector also serves the poor while the MOH heavily subsidizes the middle-and upper-incomegroups who can afford to pay for healthcare in the private sector. The Ethiopian private sector is relatively small and fragmented (approximately 20% of total market share)compared to other countries in the region (e.g. 46% in DRC and about 65% of all health facilities in Kenya aremanaged by Private sector).5

Ethiopian Mixed Health Delivery SystemThe Ethiopia health sector is a mixed delivery health system composed of adiverse range of actors across the public and private sectors. A mixed healthsystem is defined as a system in which publicly financed government healthdelivery co-exists with privately financed (mostly through out-of-pocketpayments) market delivery (Nishtar, 2002). Below are key statistics on thepublic-private mix of key components of the Ethiopian health sector.Public-Private Mix of Health Infrastructure. The total number of publichealth facilities in Ethiopia has increased significantly between 2008 to 2017.Most the growth has been mainly in public health facilities. During the sametime period, the private health sector expanded its health infrastructure butnot at the same rate as the public sector. Of the more than 28,000 health facilities in Ethiopia, the public sector owns 3out of 4 (MOH 73% compared to private for-profit and not-for-profit facilitiescombined- 27%). Growth in private sector health infrastructure has concentrated in primaryclinics, medium clinics as well as retail pharmacies, drug stores and drugvendors. Distribution of both public and private health facilities is inequitable – themajority of public and private health facilities are concentrated in Oromia,South and Amhara regions.Ethiopia has a nascent pharmaceutical and manufacturing industry withgrowing private sector capacity. In 2016/17, the private sector owned all (75) manufacturing companies ofwhich 11 are large scale. There is a growing – albeit small – number of private importers andwholesalers (384 and 489, respectively). Compared to potential demand given the population size and growth inincome, Ethiopia has a small retail pharmacy market – only 3,327 retailpharmacies and 4,476 drug shops.The public sectorowns and managesmost health facilitiesin Ethiopia – 3 out of4.Distribution of bothpublic and privatehealth facilities isinequitable,concentrated inOromia, South andAmhara regions.The private healthsector plays asignificant role in thepharmaceuticalsector and ownsmost pharmaciesand labs. Yet theretail pharmacysector is smallcompared topotential demand.Public-Private Mix of Human Resources in Health (HRH). There is limiteddata on HRH across both sectors. The data gap is more acute in the privatesector - the MOH has not produced a report on private sector HRH since 2009but is now trying to address this gap with new initiatives to include privatesector HRH in a revised HRH development strategy. Moreover, there is a highpercentage of under-reporting of private sector HRH due to the uncertain policyon dual practice and private wings as well as an important number of unlicensedhealth professionals produced largely by their reluctance to do the mandatoryservice time when assigned to rural areas that are not well-equipped. In manyinstances, these young professionals work informally in the private sector.Regulatory barriers also exist in absorption of privately trained HRH into publicsector. Nevertheless, a staffing pattern between the sector has emerged frompast data that is also confirmed with stakeholder interviews: The public sector employs the largest portion of HRH – almost 94%.Private sector playsa major role intraining of healthprofessionals butthere are challengesin licensing theseinstitutes andcertifying theirgraduates.6

The public sector employs the majority of all health cadres,particularly general practitioners and nurses. The private sector employs many specialists.Public-Private Mix of Medical Training. The number andscope of private medical training institutes is unknown; few arelicensed, and data collected is incomplete. The national regulatorybody – Higher Education Relevance and Quality Agency – hasstruggled to keep pace with the recent and rapid expansion ofprivately-owned private medical training institutes in Ethiopia.Recent data shows: The private sector operates and manages nearly half of allmedical training institutions although HERQA struggles tomonitor the institutes’ curriculum quality and graduate levels. The private medical training institutes focused mainly ontraining nurses, midwifes and allied health professionals.Public-Private Mix of Health Services. Examining healthconsumers’ health seeking behavior is an approach to estimatedemand for private health sector. Despite the extraordinaryamount of data available on the Ethiopian health sector, there areinconsistent definitions of the private health sector nor do MOHreports disaggregate the data by source (between public andprivate and within private, private for profit, non-governmentorganizations and faith-based organizations), making it difficult toestimate use of private health services. Despite the datalimitations, demand for health services is on the rise - from 45% in2008/09 to 62% in the 2014. The rapidly growing demand forhealth services underscores the challenges the MOH confrontsand will continue to confront in trying to deliver accessible andquality health services without making an active effort inengaging the private health sector. Outpatient and inpatient services: The public sector is the mostimportant health care provider in Ethiopia: 3 out 4 outpatientvisits and 4 out of 5 inpatient visits take place in a public facility.When examining the type of private facility visited for inpatientservices, private and non-government clinics are the main typeof facility (86%) followed by hospital (9%) and pharmacies (5%).As expected, the highest income groups (Q4 and Q5) usesprivate and non-government healthcare providers at a higherrate (27% and 3%, respectively) compared to lowest incomegroup (Q1 - 21% and Q2-2%) for out-patient services.Nevertheless, use of private healthcare and non-governmentproviders is at comparable levels across all income groups,The public sector inEthiopia is the mostimportant health careprovider: 3 out 4outpatient visits and 4 outof 5 inpatient visits takeplace in a public facility.The private health sectorserves all income groups– including the poor. Ahigher (27%) portion ofwealthy consumers seekan outpatient consultcompared to the poor(21%).Approximately the samelevel of wealthy and poor(1 out of 5) seek inpatientcare in a private facility.The governmentsubsidizes a significantportion of healthconsumers who can affordto pay for healthcare inthe private sector.7

varying between 20% to 30%. Government health facilitiesheavily subsidize the highest income groups (Q3-80% and Q468%).There is the same health seeking pattern for inpatient services.Most Ethiopians seek inpatient services at a governmentfacility (71%) compared to a private one (for-profit 21% andnon-government 5%). Of the 26% of health consumers whoseek inpatient services with a private healthcare provider, mostare admitted at a private (for-profit and non-governmentorganization) clinic (64%) and hospital (36%).When examining use of private sector facilities for inpatientcare, the highest income group uses for-profit and nongovernment health facilities at a similar rate as the poorestincome group (21% and 18%, respectively). Indeed, use ofprivate facilities for inpatient services is at comparable rate forall income groups, varying between 16% to 27%. Governmenthealth facilities heavily subsidize the higher and highest incomegroups (Q3-71% and Q4-63%), almost at the same rate as thepoorest (77%), even though higher income groups can afford toseek and pay for care for hospital care in the private sector. Family Planning Services: Most Ethiopian women (84%) obtaintheir FP method in government facility while only 14% get theirmethod in a private one. Of the women who obtained theirmodern FP method in a private facility, most (61%) attainedthe FP method in a clinic, followed by pharmacy (20%) andnon-government facility (14%).The family planning market is appropriately segmented: morethan one quarter (26%) of married women from the wealthiestincome group (Q5) obtain their family planning method at aprivate facility while the public sector predominately serveslower income groups (Q1 and Q2 at approximately 92%). It isinteresting to note that the private health sector also servesthe poor– albeit at much lower rates that higher incomegroups (Q1 at 7%, Q2 at 4% and Q3 at 9%). Of note is the levelof government subsidization of the wealthier income groups(Q4 at 91% and Q5 at 71%) who can afford to obtain theirfamily planning services with a private health care provider. Maternal health services: The private health sector delivers thefull range of maternal health services: ante-natal care (ANC),delivery and post-partum.ANC: A low percentage (32%) of pregnant women completedthe required four or more ANC visits yet this is a markedimprovement from earlier rates (19%). One of out of tenwomen received their ANC with a private provider. Thesewomen visited a private hospital (36%), non-governmentfacility (28%) or private clinic (36%).When analyzing selectmaternal and child healthservices, the public sectoris still the most significanthealthcare provider.On average, one out offour receive theirmaternal and child healthcare in a private facility.The rate is higher fordiarrhea and/or fever:one out of three childrenare treated by a privateproviderOf those who see aprivate provider, pregnantwomen seek maternalcare mostly at privatehospitals while motherswith sick children seektreatment from frontlineproviders – pharmacistsand drug sellers.The private sector servesall income groupsincluding the poor. Thepoor rely more on publicservices compared to thewealthy.8

As to be expected, more wealthy women seek care in a private facilityapproximately compared to poorer women. Approximately 15% ofwomen from the wealthiest income group (Q5) obtain their ANC care ata private facility while the public sector predominately serves lowerincome groups (Q1 and Q2 at approximately 95%). It is interesting tonote that the private health sector also serves the poor– albeit at muchlower rates that higher income groups (Q1 Q2 and Q3 at around 3%).Delivery: According to the DHS 2016 data, only 26% of live births inEthiopia were delivered by a skilled provider. This low portion of skilleddeliveries explains why maternal mortality persists at 421 deaths per100,000 live birth. Of the 26% of women who delivered in a facility, themajority delivered in a public one no matter the income group. The oneout of five pregnant women who in a private facility went to a privatehospital (68%), non-government facility (24%) and private clinic (12%).Lower income mothers relied more on a public facility (Q1-75%, Q281% and Q3-78%). A much smaller percentage of women from theseincome groups delivered in a private one (less than 5%). A largerpercentage of wealthier mothers (Q4-12% and Q5-14%) delivered in aprivate facility. The private health sector is an untapped resource toincrease the number of skilled deliveries. Child health services: Ethiopia has made major strides in reducing theinfant and childhood mortality rates. Indeed, Ethiopia has achieved itsMillennium Development Goal (MDG) to reduce the mortality rate forchildren under the age of five.But the FMOH subsidizes asignificant proportion ofwealthier households whocan afford to pay forservices in the privatesector.Moving wealthier incomehouseholds to a privateprovider could free upscarce public resources toincrease access for thepoor.Diarrhea: Compared to other priority health services, there is greateruse of the private sector to treat a child’s diarrhea. Approximately one third (30%) of children receivedtreatment at a private facility. Still, the public sector is the most important provider for diarrhea.All income groups seek treatment for a child’s diarrhea in a private facility, ranging from 25% in the lowerincome groups to as high as 40% in the highest. Treatment of diarrhea is an area in which the private sectorcan play a major role through local manufacturing of and expanded access ORT through private channels.Fever/cough: Among children with fever, more than one third (33%) sought care with a private provider whilethe other two almost thirds (63%) visited a public provider. Once again, all income groups seek treatment of achild with fever. Moreover, the higher income groups treated their sick child with fever at a private facility(approximately 43%) as those with a sick child with diarrhea. The MOH could save resources by encouragingthose who can afford to pay to seek treatment with a private provider.9

Examples of Public Private Partnerships in Ethiopia. The MOHhas a growing – albeit limited – experience in partnerships with theprivate health sector. The partnerships range from health servicedelivery, to management contracts, to outsourcing of non-clinicalservices. Stakeholder interviews show that: Most of the partnerships are ad hoc, informal and often based onpersonal relationships between the public and private sectorpartners. Faith-based organizations have long-standing servicedelivery partnerships with the MOH, but it is still mostly informalwith a majority having no contract or MOU in place. And severalnon-government and civil society organizations have partnershipswith the MOH to implement projects through informal agreements. There is an increasing number of partnerships with the for-profitFMOH has a growing –albeit limited –experience inpartnerships with theprivate health sector toaddress these healthpriorities.sector to deliver TB, HIV and FP and more recently laboratoryservices. It is important to note that these recent partnerships aredonor driven through specific health projects. There are barriers to expanding the number and type of public-private partnerships. MOH lacks the tools and capacity to executepartnerships, compounded by scarce and incomplete data onprivate sector size and capacity, insufficient number of MOH staffwith the skills to design and manage complex PPPs, and no strategylinking partnership to HSTP priorities.The general policyframework shows agrowing governmentand FMOH interest inworking with the privatehealth sector. It is difficult to partner with private health sector. Althoughincreasingly organizing into professional and trade associations, theprivate sector is still fragmented and does not speak with “acommon voice”; quality is inconsistent in private health sector; andnegative perceptions and lack of trust linger between the twosectors.Enabling Environment for the Private SectorOpportunitiesA review of the general policy framework shows a growing governmentas well as MOH interest in working with the private health sector. Thefirst national health policy in 1993 mentioned the role of the privatehealth sector. HSDP I-II Plans did not recognize a private sector role inhealth. HSDP IV and the HSTP 2015-2020, however, increasinglyacknowledged the private health sector. Moreover, the 2015 HealthFinancing Strategy initiated private wings in public hospitals and otherprivate sector projects. Subsequently, all plans - HSDP IV and HSTP plans referenced the need to engage the private sector in health.The FMOH’s attitudetowards the private forprofit sector, haschanged in the last fiveyears.The overall policyenvironment supportsprivate sectorengagement and publicprivate partnerships.The MOH’s attitude towards the private sector, mostly private forprofit sector, has changed in the last five years. The MOH aligned itselfwith the GOE’s perspective on private sector after the 2015 Growthand Transformation Plan. The 2015 HSTP identified specificopportunities to partner with the private health sector. Moreover, the MOH develop a PPP Strategic Framework10

aligned to the 2017 MOFEC PPP Proclamation that paved the way for more coordinated efforts and initiatives inengaging the private sector in health.ChallengesDespite the favorable policy environment, there are severalbarriers preventing the private health sector from playing a larger,positive role in the Ethiopian health sector. Fortunately, there areseveral MOH initiatives underway to address several of them. No overarching private sector engagement strategy. Instead,there are ad hoc, diverse and at times, overlapping strategies toengage the private sector across the different MOH departments.Moreover, these strategies recommend engaging the privatehealth sector but offer few details or implementation plans tooperationalize the sector engagement. No common vision of key challenges in the health sector. Thepublic sector focused on challenges related to population’sinterests – access, quality, equity – while the private sectorfocused on the barriers as a healthcare business. The one areathat both sectors agreed on is human resources for health (HRH)stating there is a shortage of trained and skilled healthprofessionals in the sector. Data on the private sector data is highly unreliable. Factorscontributing to poor data quality include: i) inconsistentdefinition of “private” across ministry reports and acrossreporting time periods, ii) Challenges in implementation andinterpretation of the 2012 facility standards; iii) data is notcentralized with uneven reporting from the regional healthbureaus and woreda health offices; iv) data is incomplete on keysegments of the private sector – particularly the private supplychain actors; and iv) data is out-of-date with gaps on privatesector HRH since 2009. Moreover, the private sector routinelyunderreports because of various reasons that are mostly to dowith building trust and dialogue. MOH. Weak (but improving) regulatory framework andimplementation. The overall regulatory framework is out-of-dateand contains many barriers to growing and harnessing theprivate health sector. Contributing factors include challenges inpolitical commitment and decision-making as well as policy gapsin the areas of facility licensing, HRH certification and licensing,dual practice, private medical training institutes accreditation,and PPP authority and capacity. There are, however, severalregulatory review processes underway to address some but notall barriers. Poor market conditions limit private health sector opportunities.In addition to delivering health services, private providers arealso businesses. They face the same challenges that otherbusinesses do when operating in the Ethiopian economy. The keyMarket conditions presentthe biggest constraint toprivate sector growth andlimits their ability topartner with the FMOH.There are limited economicand financial incentives toattract and retain privatehealth businesses.There is still distrustbetween the public andprivate health sectors, butthe suspicion is breakingdown.Both sectors have limitedexperience in public privatedialogue but a strongcommitment to strengthencommunication andimprove relations.The FMOH has severalinitiatives underway toaddress the policyconstraints and marketconditions as well asimprove public privateengagement11

market barriers health businesses confront include: i) limited access to capital creates barrier to market entry,dampens growth and limits expansion of existing businesses; ii) high cost to purchase key inputs to complywith quality standards; iii) no tax “relief” for private healthcare businesses delivering healthcare to the poor;iv) land and rent costs are significant barriers to entry to market as well as expansion; vi) unlevel playing fieldand competition with public health sector, and vii) lack of trained and skilled health professionals as well as thesalaries representing an expensive input cost. Limited government incentives to attract more private sector providers. The MOH has limited financial andeconomic incentives in place, such as services contracts, voucher payments for priority health services andnational health insurance to name a few. The MOH, however, is slowly rolling out these types of incentives butthe private sector would like government to scale up and expand them. Lack of trust due to limited engagement but promising initiatives. Both public and private stakeholdersinterviewed expressed a strong desire to move beyond mistrust and suspicion and to improve the relations butthere are several barriers: i) limited capacity of existing mechanism(s) as a platform for public private dialogue;ii) private sector consultation is irregular

1.0 Background to Ethiopia Private Sector Assessment 1.1. Global Finance Facility and the Private Health Sector 1.2. Rationale for PSA 1.3. Target Audience and Use of PSA 1.4. PSA Methodology 1.5. PSA Framework - A Health Market Systems Approach 1.6. Limitations 1.7. PSA Organization 2.0 Ethiopia Overview 2.1 Ethiopia Socio-Economic Indicators

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