ETHIOPIA’S INFORMATION REVOLUTION

Using digitalization to improve the health system

BACKGROUND
DIGITAL HEALTH SERIES
In 2015, Ethiopia’s Ministry of Health (MoH) introduced the Information
Public health systems increasingly
Revolution in the country’s Health Sector Transformation Plan. The
use digital technologies to
Information Revolution prioritizes two pillars of actionable and measurable
improve decision-making, planning,
interventions (Figure 1) to develop better, more accessible health services,
implementation, and evaluation of
strengthen health systems, and improve health outcomes.
health services. The rapid
pace of digital innovation provides The initiative focuses on digital transformation of the country’s health system in
ongoing opportunities for service of the goal to “ensure high quality, equitable, sustainable, adaptive, and
governments and their partners to efficient health services to meet the health needs of a changing population” (IR
advance the accountability, Roadmap).
affordability, accessibility, and
reliability of high-quality health
FIGURE 1. COMPONENTS OF THE INFORMATION REVOLUTION, AS SHARED IN
services. The Practice Spotlights THE FIVE YEAR PROGRESS REPORT
Digital Health series supports
USAID’s Vision for Health System
Strengthening 2030 and Vision for
Action in Digital Health by
exploring the ways in which digital
transformation can contribute to
countries’ health system
strengthening efforts.

Source: JSI (2021)

HEALTH SYSTEMS STRENGTHENING PRACTICE SPOTLIGHT 1

 CONTRIBUTION ANALYSIS FOR HEALTH SYSTEM STRENGTHENING MEL

capture data independently, with no way to share data

“[The Information Revolution] entails a radical shift from
across these systems. This limited the usefulness of data
traditional ways of data utilization to a systematic information and created an administrative burden for health
management approach powered by corresponding levels of workers and health system managers.
technology... it is also about bringing fundamental cultural and
When designing the Information Revolution, the MoH
attitudinal change regarding perceived value and practical use and its partners focused on a whole-system approach
of information.” (Health Sector Transformation Plan, 2015) that would improve data systems and increase
knowledge and skills to support data-led action. The
Information Revolution Roadmap (2016) outlines
specific activities, objectives, pillars, and focus areas.
Through the Information Revolution, Ethiopia’s MoH, Notably, the two main pillars span both the
donors, and other stakeholders aimed to improve digitalization of priority health information systems (HIS)
health services by facilitating better availability, quality, and the cultural transformation needed to instill data
and use of health data. At all levels of the country’s use across the health system.
health system, there was demand for actionable data,
and improvements in available technologies made it While the initial five-year period of the Information
possible to meet this demand. Revolution concluded in 2020, the work remains a
priority under the second Health Sector Transformation
The country had also experienced the challenges Plan (HSTP-2). The MoH and its partners have
presented by fragmented, unscaled digital health pilots identified additional focus areas for the country and
and information systems. Multiple, siloed systems would have begun work on the next five years of activities.

KEY DEFINITIONS

Digital Health is the intersection of digital technologies with health, health care, and society to enhance the efficiency
and quality of health care delivery and make medicine more personalized and precise. Digital health is the systematic
application of information and communications technologies, computer science, and the data they generate, to support
informed decision-making and engagement by individuals, the health workforce, and health systems to strengthen
resilience to disease and improve health and wellness for all.

Digital Transformation or Digitalization refers to the use of digital technologies at scale designed to modify or create
new organizational processes, culture, and client experiences, creating new value-producing opportunities. Digitalization
therefore encompasses a technical process (i.e., digitization) but goes further by requiring an organizational and cultural
evolution to be effectively implemented.

Health System Strengthening (HSS) comprises the strategies, responses, and activities that ensure the resilience of
health systems and advance preventative, promotive, and curative care. USAID’s Vision for Health System Strengthening
2030 defines three intermediate outcomes of HSS efforts: equity, quality, and resource optimization.

HEALTH SYSTEMS STRENGTHENING PRACTICE SPOTLIGHT 2

 ETHIOPIA’S INFORMATION REVOLUTION

INTERVENTIONS “The decision-making and problem-solving behavior of

Information Revolution Pillar 1: Cultural information users can heavily influence the ultimate use of
Transformation for Health Data Use data for service delivery improvements.” (Information
Activities under Pillar 1 focused on building a strong, Revolution booklet)
country-wide culture of data use—the bridge between
health data and health service improvement. The
availability of high-quality, timely data does not in itself
improve health outcomes. Rather, health impact and practices described below are drawn from the activities
health system strengthening occur when data are used from the Information Revolution and were highlighted
to inform decisions and identify opportunities for during stakeholder interviews. The activities were
improvement. The translation of data into insights and implemented concurrently.
actions relies on individual health system managers,
Strengthen performance monitoring teams. The
health workers, and other stakeholders applying data in
Information Revolution prioritized establishing and
their daily work and strategic planning activities.
increasing the functionality of performance monitoring
The Information Revolution approaches this cultural teams at the health facilities and woreda (district) health
transformation with an eye towards the long-term offices. A 2019 assessment of 129 select health facilities
needs of the health system—recognizing that one-time showed that 91 percent of the surveyed health facilities
efforts to increase capacity or improve data use cannot had established performance monitoring teams in
provide sufficient or sustainable improvements. The accordance with national standards. Capacity-building
design of cultural transformation activities focused on efforts by the MoH and its partners have focused on
addressing several factors: the skills and tools the team members need to monitor
their programs’ performance using quality data.
• Individuals working at each level of the health
system require skill sets related to data collection, Harmonize health informatics training programs. In
analysis, and use. Capacity development activities partnership with local universities, the MoH developed
should consider how the target groups will interact a national bachelor’s-level curriculum on health
with data on a daily basis. informatics. “This effort ensures graduates are equipped
with the knowledge and skills that correspond to the
• Training and skill building must be continually demand in the health sector… and responds to the gap
reinforced. Capacity strengthening activities should of trained HIS professionals in the country.”
consider issues of health worker turnover and (Information Revolution booklet)
ongoing training needs to ensure adequate capacity
in the health system. Once approved by the Ministry of Education, the
• Data use should be integrated into both daily curriculum was provided to all universities in the
activities (including frontline care) and strategic country, eight of which have begun offering pre-service
planning. When health workers and health system health informatics programs. More universities are
managers interact with data regularly, they become expected to begin offering similar courses to meet
more comfortable with its use and increase the Ethiopia’s goal of helping 2,000 health information
demand for timely, high-quality data. technicians gain a bachelor’s degree in health
informatics.

Pillar 1: Promising practices In addition, the MoH supported the standardization of

Activities under Pillar 1 were designed to facilitate a in-service training materials for health workers, which
cultural shift toward greater data use. The promising were disseminated to all woredas and health facilities.

HEALTH SYSTEMS STRENGTHENING PRACTICE SPOTLIGHT 3

 ETHIOPIA’S INFORMATION REVOLUTION

Provide training in mentorship and supportive Plan for long-term health system capacity needs. To
supervision. The MoH established a capacity-building ensure long-term capacity strengthening for health
and mentorship program as part of the Connected informatics, the MoH developed a 10-year HIS human
Woreda Initiative. Six local universities were chosen to resource development roadmap (2020–2030). The
support pre- and in-service training, onsite coaching, roadmap identifies current and future human resourcing
supportive supervision, and other capacity strengthening needs to support Information Revolution activities.
activities for health workers and health system managers
at the woreda and health facility levels. As of December Information Revolution Pillar 2:
2020, the program is active in 181 health centers, 36
hospitals, and 38 woreda health offices.
Digitalization and Scale-up of Priority HIS
Ethiopia’s Information Revolution was, in part, a
Support implementation research and learning response to fragmentation in the country’s digital health
centers. The Information Revolution also emphasized ecosystem. At the national level, two independent data
using data and evidence to support ongoing systems created challenges for widespread data
performance improvement of the health system. The integration and use. Data often remained at the
use of implementation research was prioritized as one subnational level, so standardization of data capture and
way to document and assess data use activities. For data sharing was needed.
example, this publication evaluates the implementation
status of a Health Management Information System. Demand for national health data has increased both
internally (to plan and monitor health services), and
To create implementation research teams, the MoH externally (to measure progress against the Sustainable
brought together 30 individuals from local universities, Development Goals and other global health goals). To
regional health bureaus, and selected woredas for an meet these demands, health information systems must
implementation research capacity-building workshop. be able to reliably report data that are high-quality,
Research teams then identified study topics, including timely, and complete. The Information Revolution’s
data use incentives, performance monitoring, effective digitalization pillar was designed to improve the digital
mentorship models, and HIS governance. The research infrastructure needed for data collection, processing,
findings will be used to identify best practices to scale and reporting—to make data more reliable and
and inform health system policies and standard available.
operating procedures.

The MoH also established a national digital health “The national health information system [was] lagging behind
innovation and learning center at St. Peter’s
in generating information needed to measure and respond to
Comprehensive Hospital. The center encourages
health inequities and their key determinants.” (Information
“collaborative problem solving, innovation,
experiment/testing, and learning space related to Revolution Roadmap)
different digital health systems” (Information Revolution
booklet). It also provides technical support for digital
health practitioners working to address longstanding
barriers to implementation. Three other topical Strengthening both individual information systems and
academies were also established: a DHIS2 academy at the overarching digital health ecosystem directly
Gondar University, an Electronic Community Health contributes to other health system strengthening efforts.
Information System (eCHIS) Center of Excellence at Together, these measures support the provision of data
Jimma University, and an eHealth architecture and needed for decision-making and the identification of
interoperability academy at Mekelle University. opportunities for improvements or efficiencies.

HEALTH SYSTEMS STRENGTHENING PRACTICE SPOTLIGHT 4

 ETHIOPIA’S INFORMATION REVOLUTION

Pillar 2: Promising practices Ethiopia’s eHA also ensures that Information Revolution
improvements to coordination and efficiency will
Activities under the Information Revolution’s second
extend to new systems and technologies, and that
pillar focused on the technological implementation of
investments in digital health contribute to the overall
HIS as well as the enabling environment required for
strengthening of health data use. By following eHA and
scale and sustainability. As noted under Pillar 1 above,
other national standards, future digitalization efforts will
the promising practices described below are drawn
align with the national vision of digital health, while
from the Information Revolution activities and were
protecting flexibility and responsiveness to future health
highlighted during stakeholder interviews.
system needs.
Create a unified national health information system.
Establish supportive policies and governance
One of the most significant shifts under the Information
structures. Under the Information Revolution, the MoH
Revolution was the implementation of DHIS2 as a
focused on four key areas of HIS governance:
national health management information system
accountability and transparency; policy and strategy;
platform, replacing the two legacy systems that had
legislation and regulation; and coordination and
covered separate regions of the country.
partnerships.
“DHIS2 is now accepted as a primary source of
A national HIS governance framework was developed
information for planning and decision making at all levels
and endorsed in 2018. A guide to how the HIS
in the health system, partners and donors are utilizing
governing bodies function in the country, the
the data for planning interventions and support, and
framework defines the roles of different committees
increased use of DHIS2 data [has been used] for health
and technical working groups, the cadences of meetings,
service quality improvements.” (Information Revolution
and other operational processes. The national
booklet)
framework was used to develop a generic regional
In addition, the activities under the Information governance framework that can be customized for
Revolution strengthened other complementary health subnational use.
information and reference systems, including the
Ensure interoperability and set standards. The
Electronic Community Health Information System, the
Information Revolution instituted several mechanisms
Public Health Emergency Management System, the
that ensured digital systems worked together. A
Master Facility Registry, the Human Resource
national health data dictionary has been developed as a
Information System, the Logistics Management
data standard. It identifies and clearly defines 131
information System, and the Regulatory Information
priority indicators and the national classification of
System.
diseases from ICD-10. These indicators help standardize
Create a national eHealth architecture. Under the which information is collected by Ethiopia’s health
Information Revolution, the government of Ethiopia information systems and mapped to global standards,
instituted a national eHealth architecture (eHA) (Figure such as Snomed and ICD-10.
2), which serves as a blueprint for the information,
An interoperability layer is included in the eHealth
software, and hardware needs of the health system. The
architecture, providing technical guidance and reference
eHa can be used to “coordinate IT choices, ensuring
information needed to promote data sharing between
appropriate resource utilization, and facilitating access
systems and reduce duplicative data entry. This work
and integration of data.” (Information Revolution
also includes the development of shared services like a
booklet)
terminology reference service and a master facility
registry.

HEALTH SYSTEMS STRENGTHENING PRACTICE SPOTLIGHT 5

 ETHIOPIA’S INFORMATION REVOLUTION

FIGURE 2: DIAGRAM OF ETHIOPIA'S EHEALTH ARCHITECTURE (EHA) AS SHARED IN THE FIVE YEAR PROGRESS REPORT

Source: JSI (2021)

Acronyms in the figure: Business intelligence (BI); civil registration and vital statistics system (CRVS); District Health Information Software 2
(DHIS2); electronic community health information system (eCHIS); electronic health management information system (eHMIS); Ethiopia
Health Data Analytics Platform (EHDAP); electronic human resources information system (eHRIS); electronic logistic management information
system (eLMIS); enterprise master patient index (EMPI); electronic medical records (EMR); electronic public health emergency management
system (ePHEM); electronic regulatory information system (eRIS); geographical information system (GIS); health commodity management
information system (HCMIS); health information system (HIS); integrated disease surveillance and response system (IDSR); integrated financial
management information system (IFMIS); interactive voice response system (IVR); electronic laboratory information system (eLIS); Service
Provision Assessment plus (SPA+)

HEALTH SYSTEMS STRENGTHENING PRACTICE SPOTLIGHT 6

 ETHIOPIA’S INFORMATION REVOLUTION

IMPLEMENTATION • Support the creation and sustainment of strong

governance frameworks to monitor
CONSIDERATIONS implementation and ensure activities are technically
Ethiopia’s Information Revolution is an example of a strong and aligned with the national digital health
national, system-wide digital health transformation. It roadmap. (Coordinating Digital Transformation:
addresses multiple building blocks of sustainable, Ethiopia; USAID Vision for Action in Digital Health,
impactful digital health systems, and demonstrates how Priority 1)
a holistic, systematic approach to digital health can
strengthen a health system. Connect a strategic vision to core priorities
Key lessons from the first five years of work under the The Information Revolution Roadmap is a strong
Information Revolution include the following. example of how digital transformation can support
broad health system goals while also defining near-term
digital priorities. Both are necessary for success, but the
Government-led partnerships are critical
importance of near-term priorities is less often
It is widely acknowledged that government ownership recognized. Digital transformation is a significant
over digital transformation is critical for sustainability and undertaking that requires years of large-scale effort and
long-term success (Conclusions of the digital health hub change. To make this feasible, governments and their
of the Transform Africa Summit, 2018). By centering partners should establish shorter-term strategies or
the digitalization process on government priorities, work plans with prioritized activities. The Information
donors and supporting partners have greater clarity and Revolution Roadmap continues to guide Ethiopia’s
accountability. This approach also increases buy-in from digital transformation, ensuring that all efforts to digitize
government stakeholders and promotes engagement health systems contribute to the country’s long-term
from stakeholders of all types. vision.

Digital transformation requires a network of partners

who can contribute resources and expertise (How to “Donors and implementing partners now are better
govern the digital transformation of health services). In coordinated in their efforts because they have aligned with
Ethiopia, the Information Revolution was supported by
one another and monitor their activities against a common
significant investments from USAID, technical guidance
from John Snow, Inc., and contributions by other action plan and monitoring and evaluation framework.”
international global health organizations. By creating and (Coordinating Digital Transformation: Ethiopia)
participating in governance mechanisms, the
government and its partners were able to collectively
clarify roles and responsibilities, as well as gain insight
into the digital transformation efforts across all partners. Recommendations
Support the creation and evolution of a national
Recommendations digital health strategy that clearly connects digital
transformation priorities to other health system
• Co-create with government officials to ensure
priorities. Ideally, the strategy should include the
investments align with national priorities and
creation of a costed roadmap and a national digital
digital health strategies. Investments should align
health architecture. (USAID Vision for Action in Digital
with national digital health strategies, policies, or
Health, Priority 2 and 3)
roadmaps. When prioritized, co-creation also
deepens the country ownership of digital health
• Support the creation and evolution of supportive
programs. (Coordinating Digital Transformation:
policies and frameworks beyond the national
Ethiopia; USAID Vision for Action in Digital Health,
digital health strategy. Government policies can
Priority 2)
HEALTH SYSTEMS STRENGTHENING PRACTICE SPOTLIGHT 7
 ETHIOPIA’S INFORMATION REVOLUTION

incentivize or require the use of specific digital Information Revolution has succeeded in part because
systems by health system managers or health of its focus on embedding a culture of data use at all
workers. These policies can play a critical role in levels and within all departments of the MoH. This has
addressing issues of data privacy, security, and transformed health system workers themselves into
sharing. Implementation or investment roadmaps champions, improving both the demand for and supply
and other frameworks support the of data insights.
operationalization of a national strategy and can
provide more granularity on priorities and activities Recommendations
for the MoH and its partners. (USAID Vision for
Action in Digital Health, Priority 1) • Support country capacity activities, including
expanded capacity for digital health governance,
implementation, oversight, and coordination. This
Balance digital health champions with includes both short-term training needs and
sustained capacity development continued learning. Working directly with academic
Ethiopia’s Information Revolution benefited from many institutions, centers of excellence, and other training
digital health champions who prioritized digital organizations can contribute to stronger capacity
transformation. Such champions are essential for strengthening and ensure human resource needs
building buy-in and momentum for significant system are met. (USAID Vision for Action in Digital Health,
changes. They are often the early instigators of Priority 1)
transformation and enable the process to move • Encourage information sharing and peer learning
forward more quickly (Digital Health: A Call for to capture best practices, enable collective
Government Leadership and Cooperation between ICT problem-solving, cultivate a cadre of digital health
and Health). leaders, and bolster digital health capacity across
countries. (Principles of Donor Alignment for Digital
However, the long-term success of digital Health)
transformation cannot rely on a small number of
individuals. As noted in key stakeholder interviews, the

HEALTH SYSTEMS STRENGTHENING PRACTICE SPOTLIGHT 8

 ETHIOPIA’S INFORMATION REVOLUTION

FURTHER READING
A Vision for Action in Digital Health 2020–2024 | USAID
https://www.usaid.gov/sites/default/files/documents/USAID-A-Digital-Health-Vision-for-Action-
v10.28_FINAL_508.pdf
Classification of Digital Health Interventions v1.0 | WHO
https://apps.who.int/iris/bitstream/handle/10665/260480/WHO-RHR-18.06-eng.pdf
Coordinating Digital Transformation: Ethiopia | Digital Square
https://static1.squarespace.com/static/59bc3457ccc5c5890fe7cacd/t/5d07a359fb33ed00011e21e1/1560781660177/
Donor-Coord-Case-Studies_ETHIOPIA.pdf
Ethiopia Health Sector Transformation Plan 2015/16–2019/20 | Ethiopia MoH
https://www.globalfinancingfacility.org/sites/gff_new/files/Ethiopia-health-system-transformation-plan.pdf
Ethiopia Information Revolution Roadmap | Ethiopia MoH
http://repository.iifphc.org/bitstream/handle/123456789/316/Information%20Revolution%20Roadmap.pdf
Ethiopia’s Information Revolution: Five Year Progress Report | JSI
https://www.jsi.com/resource/ethiopias-information-revolution-five-year-progress-report/
Information Revolution booklet | Ethiopia MoH
https://www.moh.gov.et/ejcc/sites/default/files/2020-10/Information%20Revolution%20Booklet-.pdf
Recommendations on Digital Interventions for Health System Strengthening | WHO
https://apps.who.int/iris/bitstream/handle/10665/311941/9789241550505-eng.pdf
USAID Vision for Health System Strengthening 2030 | USAID
Vision for Health System Strengthening 2030 | U.S. Agency for International Development (usaid.gov)

HEALTH SYSTEMS STRENGTHENING PRACTICE SPOTLIGHT 9

 ETHIOPIA’S INFORMATION REVOLUTION

About the Health Systems Strengthening Practice Spotlight Series

The Health Systems Strengthening Practice Spotlight series is an initiative of USAID’s Office of Health Systems.
Practice Spotlight briefs contribute to the global knowledge base in health system strengthening and support
implementation of USAID’s Vision for Health System Strengthening 2030 and the accompanying Health System
Strengthening Learning Agenda. Learn more:
Vision for Health System Strengthening 2030 | U.S. Agency for International Development (usaid.gov)
Health System Strengthening Learning Agenda | U.S. Agency for International Development (usaid.gov)

Acknowledgements
This document benefitted from key informant interviews with individuals involved in the design and implementation
of Ethiopia’s Information Revolution. The individuals interviewed included:
• Natsant Animut, Technical Director, Data Use Partnership, Digital Health Activity, John Snow Inc.
• Tewodrow Berihun, Senior Health Information Systems Advisor, Health System and Resilience Team, United
States Agency for International Development
• Eyob Kebede, Director, Health Information Technology Directorate, Ministry of Health, Ethiopia
• Al Shiferaw, Deputy Director, Digital Health Activity, John Snow Inc.
• Solomon Zewdu, Deputy Director, Africa, Bill & Melinda Gates Foundation

Recommended citation
Health Systems Strengthening Practice Spotlight. October 2021. Ethiopia’s Information Revolution: Using Digitalization
to Improve the Health System. Washington, DC: USAID. Available at: www.lhssproject.org

The Local Health System Sustainability Project (LHSS) under the USAID Integrated Health Systems IDIQ
contributed to the development of this brief. The Health Systems Strengthening Practice Spotlight briefs are made
possible by the support of the American people through the United States Agency for International Development
(USAID). The contents are the sole responsibility of the authors and do not necessarily reflect the views of USAID
or the United States government.

October 2021

HEALTH SYSTEMS STRENGTHENING PRACTICE SPOTLIGHT 10