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Historically, in the late 1970's, Ethiopia adopted a six-tier health plan as the national strategy to achieve equitable access to health services for all. The 1993-health policy, however, adopted a four-tier system consisting of a primary health care unit (five satellite health posts and one health center), a district hospital, a regional/zonal hospital and a specialized hospital), which primarily gave emphasis to prevention and primary health care (1, 2).  Very recently, the health sector has introduced a three-tier system that includes a primary health care unit (PHCU), general hospitals and specialized hospitals. The PHCU consists of five satellite health posts, one health center and one primary hospital (see below for the detail). The Federal Ministry of Health (FMOH) of Ethiopia formulated and launched the 20-year rolling Health Sector Development program (HSDP) in 1998, which has reached its fourth stage (HSDP IV). Among the foremost priorities given by the HSDP IV are maternal health and neonatal health (3).  The HDSP IV has identified the following performance indicators that reflect improved access in maternal and neonatal health: decrease the maternal mortality ratio to 267/100,000 live births, increase the contraceptive prevalence rate to 66%, reduce teenage pregnancy to 5%, increase focused ANC1+ to 90% and ANC 4+ to 86%, increase deliveries attended by skilled birth attendants to 62% and decrease infant mortality rate of 31/1000 live births (3). The Health Extension Program (HEP) (established in 2003 and became operational in 2005) was primarily designed to reduce maternal and neonatal mortality through the provision of family planning at the lowest level (household, health post) and provision of clean and safe delivery services at home and in the health posts (1). The health extension workers are not only expected to provide service to the community in their vicinity but also to bridge the gap between the community and health facilities.  Taking these into account, the goals of the Ethiopian National Reproductive Health Strategy in the years 2006–2015 are: reducing of unwanted pregnancies to enable individuals to achieve their desired family size, reduction of maternal and neonatal mortality, reduction of HIV infection and improvement of the quality of life of people living with the virus, and enhancement of the reproductive health and well-being of the youth (4).  To materialize the planned goals, the strategy has identified six priority areas (social and cultural determinants of women's reproductive health, fertility and family planning, maternal and newborn health, HIV/AIDS, reproductive health of young people, reproductive organ cancers) and three levels of intervention (community, system and policy) (4).  To address the maternal and newborn health issues, there are some working guidelines developed by FMOH. Among others, the National Guideline for Prevention of Mother to Child Transmission of HIV, Adolescent and Youth Reproductive Health Strategy, the Revised Abortion Law and the Management Protocol on Selected Obstetric Topics are at the forefront.  Very recently, the FMOH has been implementing a Health Management Information System (HMIS) across the country for regular monitoring and evaluation of programs and to improve service delivery and health care management, which is expected to provide comprehensive information on maternal and neonatal health service and outcome at the health facility level. The ministry also uses regular surveys like Ethiopian Demographic and Health Survey (DHS) to generate data on the set indicators.  Another recent development is the establishment of a Women Health Development Team (previously, The Health Development Army) at the community level each composed of 30 households. There are 5 ‘nucleus’ units under it and each has a leader.  The purposes of this commentary are: to highlight the already implemented actions on health and predict what to come, to show supportive evidences from the experience of other countries, and to propose new strategies to reduce the maternal and perinatal mortality in Ethiopia.  A) Actions in the pipeline to reduce the maternal and perinatal mortality in Ethiopia Now-a-days, the Ethiopian government's commitment is above all times to improve the maternal and perinatal health in particular. As a result, a breakthrough in maternal and perinatal mortality reduction is highly anticipated in the coming ten to fifteen years. Some of the inputs and processes which make the likelihood of maternal and perinatal mortality reduction foreseeable are the ongoing construction of a large number of hospitals and health centers, the human resource development for health, roads construction, ambulance procurement, universal education and the continuously growing economy.    1. Construction of hospitals and health centers The targets of HSDP IV are one health post for 3,000– 5,000 population, one health center for 40,000 (urban) and 15,000–25,000 (rural) population, one primary hospital for 60,000 – 100,000 population, one general hospital for 1 –1.5 million population, and one specialized hospital for 3.5–5 million population (3). To achieve these targets, the government of Ethiopia has already started constructing 800 primary hospitals across the nation (more than 12-fold of the hospitals in 2006). The authors have got the chance to observe 18 primary hospitals under construction (almost being finalized) in three zones in the Southern Regional State. They also have the information that similar undertakings (more than 110) are under construction in other regional states. The majority of these constructions base in already functioning health centers that will enable them to provide major emergency surgical procedures which is one of the signal function of Comprehensive Emergency Obstetric Care.  So far, nearly 16,000 health posts and more than 3500 health centers have been constructed, which is about 6 times higher than the number of health centers in 2005 (5). The plan is to construct 200 general hospitals and 50 specialized hospitals (more than 20-fold of the existing specialized hospitals) in the coming few years (Federal Ministry of Health unpublished report). Taking the recent experiences on the government's commitment for infrastructure construction, the authors are confident that all or beyond the planned construction will be materialized very soon. This is a breakthrough action in terms of increasing the hospitals to population ratio. Figure 1 shows the predicted hospitals to population ratio (number of hospitals per 100,000 people by type of hospitals). The scheme of one primary hospital for 100, 000 people is expected to be achieved by 2025.    Figure 1  Predicted number of hospitals by type, Ethiopia, 2010–2050

Commentary: Actions in the Pipeline and the Way Forward to Reduce Maternal and Perinatal Mortality in Ethiopia