Health System Strengthening in Sub-Saharan Africa


In all countries, we will work in under-served communities; in Ethiopia, in all primary healthcare centres (PHCs) in three rural districts in the Gurage zone, SNNP region; in South Africa in an underserved district in Mpumalanga Provinces, and in 12 midwife obstetric units providing public antenatal care to Cape Town Metro; in Sierra Leone, tertiary hospitals in Freetown, and other surgical units in the W Area (Freetown Peninsula), and in Zimbabwe, 70 PHCs in Harare.


In Ethiopia, ASSET will work in three contiguous predominately rural districts (Meskan, Mareko and Sodo) of the Gurage Zone, Southern Nations, Nationalities and Peoples’ Region (SNNPR) of Ethiopia. The total population is approximately 400,000, of which around half are aged 18 years or under. Sodo has a predominately Orthodox Christian community, while Meskan and Mareko are predominately Muslim. Diverse ethnicities are represented, including Gurage, Oromo, Meskan, Mareko, Silti, Sodo, and Dobi.

The three districts are served by a total of 18 primary healthcare centres, around 100 health posts, one general hospital, one primary hospital and one NGO hospital (Mercy Project).

General hospitals (for up to one million population) are staffed by specialist doctors (obstetrician-gynaecologist, surgeon, radiologist, but not consistently), and general doctors. No anaesthetist is usually present at this level. Primary hospitals (150-200,000 pop’n)  are staffed with general practitioners (non-specialised doctors), emergency surgical officers, health officers, midwives, and nurses; health centres (25-40,000 pop’n) by health officers, nurses, and midwives; and health posts (5,000 pop’n) by health extension workers.

There is roll out of a community-based health insurance (CBHI) with annual pre-payments indemnifying against costs at the point of delivery.

South Africa

ASSET work on the maternal care platform will focus on 12 public sector Midwife Obstetric Units (MOU) in Cape Town Metropolitan Area. The same Area will most likely be the focus for the Palliative Care Integrated Primary Health Care platform.

The total population of Cape Town Metropolitan Area is four million of whom just over half are female. A quarter of the population is under the age of 15, while 6% is 65 or older. 45.4% of the population describe themselves as "Coloured", 42.7% as "White", 8.6% as "Black African", and 1.4% as "Indian or Asian". Although the literacy rate is 91%, less than half the population has completed secondary schooling. The Gini index rose from 0.59 in 2007 to 0.67 by 2011/12. Wealthy areas of Cape Town are clustered around Table Mountain and the Atlantic seaboard, and contrast with areas of the Cape Flats, such as Khayelitsha, where most residents live.

The Midwife Obstetric Units are staffed by midwives and nurses and some have on call doctors. Cape Town Metropolitan area has 158 public primary healthcare facilities. Most of these PHC facilities are staffed by nurses (and over 90% of PHC in South Africa is nurse led), with occasional visits by doctors for specific clinics.

Public healthcare in South Africa requires out-of-pocket payments, which are means tested, such that below a certain poverty threshold, there is no charge. The state contributes about 40% of all expenditure on health, for the 80% of the population that relies on public healthcare.

ASSET work on tuberculosis (TB) care (Integrated Primary Health Care platform) in South Africa will be based in the Nkomazi Local Municipality in the eastern part of the Ehlanzeni District Municipality of the Mpumalanga Province, on the southern border of the Kruger National Park. The total population is 393 030 (2011 Census), of which 98% are black African and speak SiSwati. This is a predominately rural sub-district. Children aged 1 years or under make up 35% and working age adults 60% of the population. Only 13% have completed secondary education

Nkomazi is served by 8 district hospitals, 2 TB hospitals, 2 regional hospitals and 1 tertiary hospital. Nkomazi itself has four Community Health Centres and 28 Primary Health Care Clinics. Most clinics are fixed structures in reasonable to good condition. Many have containers on the property for overflow of patients, and often TB services are conducted in containers to limit exposure of TB to patients and staff in other areas of the clinics. Very few, if any, clinics are fitted with structures to reduce risk of TB infection, including adequate ventilation, laminar flow and UV lights.

Primary healthcare and medication is free to all. For secondary level care, patients are classified and payment influenced by work and household income on a sliding scale system, although most patients are too poor to be charged for these services. Mental Health Care Users, pensioners, and those with other form of declared disabilities do not pay, as well as those with household income below a certain threshold

Sierra Leone

ASSET work on the surgical care platform in Sierra Leone will be based in the Western Area, comprising Freetown, the capital city, and adjacent rural areas. The total population is 1,493,252 (2015 census).

Surgical Care in and around Freetown is provided by Connaught Hospital (tertiary level public hospital), Wilberforce (34 Military, providing care to service personnel and their families, and to the general public), Emergency (an NGO hospital providing care for selected emergency cases), and Princess Christina Maternity Hospital (Emergency Obstetric and Neonatal Care)

For further information regarding resourcing levels, please see surgical care platform (link).

In Sierra Leone healthcare is, in principle free at the point of care for pregnant women and children under the age of 5 years. For all others there are out-of-pocket costs for all aspects of healthcare. In addition to the prescribed charges ‘volunteer’ (non-salaried) staff may require payments for aspects of routine care. Services at the Military Hospital are free for service personnel and their families, but others pay out-of-pocket charges as in other parts of the public healthcare system.



ASSET work on the Integrated Primary Health Care platform in Zimbabwe, focussing on the integrated management of non-communicable diseases comorbid with depression, will be based in Harare, Chitungwiza and Gweru. These urban sites in and around Harare, the capital city, have a total population of 2.4 million. They are served by 74 primary care clinics, of which 44 Clinics providing all services (HIV, Maternal Child Health, Communicable & Non communicable disease, immunization), and 30 Clinics provide communicable and non-communicable disease care, excluding HIV. 80% of attendees are female. The clinics are staffed by a total of 3600 nurses and 304 lay health workers. The lay health workers are responsible for delivering the Friendship Bench’ evidence-based brief psychological intervention for depression, which is currently being scaled up across the three municipalities with funding from Canada Grand Challenges.

There are out-of-pocket payments required for some primary care services and medication, although Friendship Bench, and medication for the treatment of psychiatric disorders are free. Some patients may be able to be reimbursed for out-of-pocket costs if they have occupational medical insurance