As literacy and socioeconomic status improves in Ethiopia, the demand for quality service is also increasing. Besides, changes in the demographic trends, epidemiology and mushrooming urbanization require more comprehensive services covering a wide range and quality of curative, promotive and preventive services.
The government of Ethiopia is working towards building a universal health care system through a community-based health insurance model, where households can pay into the official health insurance fund of their woreda, or district, and draw upon it when in need of medical care. As of 2020, it was estimated that 45% to 50% of the population had health insurance coverage.[1]
Overview
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Ethiopia is one of the fastest growing countries in Africa, having more than 104 million people (the second most-populous in the region). It experiences the public health problems typical of an underdeveloped country, such as communicable diseases (HIV, malaria, tuberculosis, etc), maternal and child health problems (diarrhoea & dehydration, pneumonia, neonatal problems etc) and malnutrition; these account for the majority of public health problems. But there is also significant growth in noncommunicable diseases (cardiovascular conditions, cancers, mental illness, etc) and injury.[2]
The current health care financing strategy of Ethiopia focuses on financing of primary health care services in a sustainable manner. It envisions reaching universal health coverage by 2035. The prioritized initiatives are mobilizing adequate resources mainly from domestic sources, reducing out-of-pock et spending at the point of service use, enhancing efficiency and effectiveness, strengthening public private partnership and capacity development for improved health care financing. To operationalize the strategy, various reform measures were implemented. These reforms include: revenue retention and use at the health facility level; systematizing fee waiver system; standardization of exempted services; setting and revision of user fees; allowing establishment of private wing in public hospitals; outsourcing of non-clinical services; and, promotion of health facility autonomy through establishment of a governance body; and establishment of health insurance system.
According to the 6th National Health Accounts (2013/14),[6] health service in Ethiopia is primarily financed from four sources: the federal and regional governments; grants and loans from bilateral and multilateral donors; non-governmental organizations and private contributions. The total health expenditure per capita has increased from $4.5 per capita in 1995/1966 to 20.77 in 2010/11 and $28.65 per capita in 2013/14.The share of total health expenditure coming from domestic sources has increased from 50 percent in 2010/11 to 64 percent in 2013/14.
Purchasing of services
While mobilizing sufficient public resources and organizing pooling to maximize re-distributive capacity are essential for achieving equitable and affordable health care access for all, it is of equal importance that collected resources be efficiently used in order to maximize and sustain the provision of benefits for the population. Strategic use of the purchasing function is the key health financing instrument for this purpose. The main purchasers of health service in Ethiopia are: the Ministry of Health; Regional Health Bureaus; District/Woreda Health Offices in the form of line-item budgets; Ethiopia Health Insurance Agency; and, other government entities that transfer budget to service providers to reimburse service delivery cost; and households in the form of user fee. There is fee waiver system to covers Indigents but with various challenges in implementation. Two million people are presently are covered by this.[6]
History
In Ethiopia, the quest for modern medicine beyond traditional practice started during Emperor Lebna Dengel’s reign in the 15th century, when the emperor appealed to the Portuguese king for physicians and surgeons to cure illnesses. Later in 1866, western medicine was introduced by Swedish missionary doctors and nurses. The first Ethiopian hospital was established in 1897, the Ministry of Health in 1948 and the first medical school in the country opened in 1964. It was only during Emperor Menelik’s time (1889-1913) that the first foreign-trained Ethiopian medical doctor, Hakim Workneh Eshete, began practicing medicine in Addis Ababa.[7]
Throughout the 1990s, the government, as part of its reconstruction program, devoted ever-increasing amounts of funding to the social and health sectors, which brought corresponding improvements in school enrolments, adult literacy, and infant mortality rates. These expenditures stagnated or declined during the 1998–2000 war with Eritrea, but since outlays for health have grown steadily. In 2000–2001, the budget allocation for the health sector was approximately US$144 million; health expenditures per capita were estimated at US$4.50, compared with US$10 on average in sub-Saharan Africa. In 2000 the country counted one hospital bed per 4,900 population and more than 27,000 people per primary health care facility. The physician to population ratio was 1:48,000, the nurse to population ratio, 1:12,000. Overall, there were 20 trained health providers per 100,000 inhabitants. Health care is disproportionately available in urban centers; in rural areas where the vast majority of the population resides, access to health care varied from limited to nonexistent.
In 1993 the government published the country's first health policy in 50 years, articulating a vision for the health care sector development. The policy fully reorganized the health services delivery system as contributing positively to the country's overall socioeconomic development efforts. Its major themes focussed on:
Democratization and decentralization of health system;
Expanding the primary health care system and emphasizing preventive, promotional, and basic curative health services; and
Encouraging partnerships and the participation of the community and nongovernmental actors.
A Health Sector development Program was developed every five years beginning in 1997/98.[8]
In 2002 the government embarked on a poverty reduction program that called for outlays in education, health, sanitation, and water. A poliovaccination campaign for 14 million children was carried out. In 2003 the government launched the Health Extension Program intended to provide universal primary health care coverage by 2009. This included placing two government-salaried female Health Extension Workers in every kebele, with the aim of shifting the emphasis of health care to prevention. About 2,700 completed their training by the end of 2004 at 11 technical and vocational education centers, while 7,000 were still in training in 2005, and over 30,000 were expected to complete their training by 2009. However, these trainees encountered a lack of adequate facilities, including classrooms, libraries, water, and latrines. The selection of trainees was flawed, with most being urban inhabitants and not from the rural villages they would be working in. Reimbursement was haphazard as trainees in some regions did not receive stipends while those in other regions did.[9] In January 2005, the government began distributing antiretroviral drugs, hoping to reach up to 30,000 HIV-infected adults.
According to the head of the World Bank's Global HIV/AIDS Program, in 2007 Ethiopia had only 1 medical doctor per 100,000 people.[10] However, the World Health Organization in its 2006 World Health Report gives a figure of 1936 physicians (for 2003),[11] which is about 2.6 per 100,000. There were 119 hospitals (12 in Addis Ababa alone) and 412 health centers in Ethiopia in 2005.[12] Globalization is said to affect the country, with many educated professionals leaving Ethiopia for a better economic opportunity in better-developed countries.
Ethiopia's main health problems are said to be communicable diseases caused by poor sanitation and malnutrition. These problems are exacerbated by the shortage of trained manpower and health facilities.[13] Ethiopia has a relatively low average life expectancy of 62/65 years in 2012.[14] Only 20 percent of children nationwide have been immunized against all six vaccine-preventable diseases: tuberculosis, diphtheria, whooping cough, tetanus, polio, and measles. Rates of immunization are less than 3% of children in Afar and Somali Regions and less than 20% in Amhara, Benishangul-Gumuz, and Gambela. In contrast, almost 70% of children have received all vaccinations in Addis Ababa and 43%in Dire Dawa; children in urban areas were three times as likely to be fully immunized as children living in rural areas in 2008.[15]
Health Extension Program
The Health Extension Program (HEP) was introduced in 2002/03 with a fundamental philosophy that if the right health knowledge and skill is transferred, households can take responsibility for producing and maintaining their own health. It is a community-based intervention designed to make basic health services accessible to the rural and underserved segments of the population.[16] The HEP was launched in the four big agrarian regions, expanded to the remaining regions in subsequent years.[17][18]
It was planned to cover all rural kebeles with the aim of achieving universal primary health care coverage by 2008. Services are organized along geographic lines with construction of a comprehensive network of primary health care units throughout the country with one health post in every rural kebele of 5000 people linked to a referral health center. A health post is a two-room structure of most peripheral health care unit and the first level for the provision of healthcare for the community, emphasizing preventive and promotive care.[19] 33,819 health extension workers were trained and deployed surpassing the target of 33,033. Model households who have been trained and graduated have reached a cumulative total of 4,061,532 from an eligible total of 15,850,457 households. This only represented a coverage of 26% leaving a huge gap of more than 11 million households to be trained.
The total number of health professionals increased from the baseline of 6,191 in 2004/05 to 14,416 in 2009/10 but this was only 89% of the target. Equipping Health posts with medical kits remained a major challenge. Only 83.1% or 13,510 HPs out the planned target of 16,253 were fully equipped. Supportive supervision technical, reference books for rural HEP and manuals for school health program were prepared. An implementation Manual for Pastoralist and semi-pastoralist areas was finalized and distributed to respective regions. In order to expand the Urban Health Extension program in seven regions of the country, 15 packages along with implementation manual were developed and distributed for implementation in Tigray, Amhara, Oromia, the Southern Nations, Nationalities, and Peoples' Region, Harari, Dire Dawa, and Addis Ababa. These regions have trained and deployed a total of 2,319 Urban Health Extension workers achieving 42% of the required number.
The focus is disease prevention and health promotion, with limited curative care. It is the healthcare service delivery mechanism of the people, by the people, and for the people by involving the community in the whole process of healthcare delivery and by encouraging them to maintain their own health. The program involves women in decision-making processes and promotes community ownership, empowerment, autonomy and self-reliance. Ethiopia has achieved most health related Millennium Development Goals.[20]
Addressing equity and quality of health services are the main focuses of the new Ethiopian Health Sector Transformation Plan. Improving the competence of health extension workers and the Women's Development Army is crucial. The second generation rural plan will include: upgrading health extension workers to level four Community Health Nurses, renovation and expansion of health posts, equipping and supplying health posts with the necessary equipment and supplies, shifting basic services to the community level and institutionalizing the WDA platform. In cities and urban areas, the Family Health Team approach will be introduced. The team will be composed of clinicians, public health professionals, environmental technicians, other health professional, social workers and health extension professionals to provide services for urban dwellers. Considering the varied nature of the community residing in the pastoralist and developing regions, the Ministry of Health, along with the Regional Health Bureaus is committed to developing a unique strategy to address pastoralist communities' health issues.[20]
Health facility construction and expansion
Major activities under the health facility construction, expansion, rehabilitation, furnishing and equipping focused mainly on the primary healthcare facilities: the number of public health centres increased from 412 in 1996/97 to 519 in 2003/04. For the same periods, the number of HPs increased from 76 in 1996/97 to 2,899. The number of hospitals (both public and private) increased from 87 in 1996/97 to 126 in 2003/04. There has been also considerable health facility rehabilitation program and furnishing. As a result, the potential health service coverage increased from 45% in 1996/97 to 64.02% by 2003/04. The plan was to attain a 100% general potential health service coverage by availing 3200 centres through construction, equipping and furnishing of 253 new ones and upgrading 1,457 HSs to HC level and also upgrading of 30% of HC to enable them perform emergency obstetric and neonatal care services.
At the beginning of HSDP III, there were 82 all types of hospitals (37 district, 39 zonal and 6 specialized hospitals). The planned target was to increase the number of hospitals to 89 (42 district and 41 zonal). By 2008/09 there were 111 public hospitals.
In addition, 12,292 health posts have been equipped which represents 75.6% of the target of equipping 16,253 health posts. 511 new ones will be equipped following their completion. The construction of 21 blood banks in six regions was 95% completed in 2009 and the preparation of a National Laboratory Master Plan has also been already completed.
Health human resource development
There has been a focus on scaling up the training of community and mid-level health professionals. Accelerated Health Officer Training Program was launched in 2005, in five universities and 20 hospitals to address the clinical service and public health sector management need at district level. So far more than 5,000 health officer trainees (generic and upgrade) have been enrolled and 3,573 health officers were graduated and deployed. In addition to address the need for comprehensive emergency obstetric care and other emergency surgery services, a curriculum for masters program on emergency surgery has been developed and training has been started in five universities. To address the critical shortage and maldistribution of doctors, in addition to the existing medical schools a new medical school that uses innovative approach has been opened in St. Paul's Hospital Millennium Medical College.
A human resources for health situation analysis conducted in 2015/2016 showed that between 2009 and 2014/15:
The number of medical schools increased from 7 to 35 (28 public and 7 private)
Annual enrollment of medical students increased from 200 to 4,000.
The number of physicians in the country increased from 1,540 to 5,372.
Midwifery teaching institutions increased from 23 to 49.
The number of midwives increased from 1,270 to 11,349
Apart from these selected health professionals, overall health professionals to population ratio increased from 0.84 per 1000 in 2010 to 1.5 per 1000 in 2016. This is remarkable progress for a 5-year period. If the current pace is sustained, Ethiopia will be able to meet the minimum threshold of health professionals to population ratio of 2.3 per 1000 population, the 2025 benchmark set by the World Health Organization (WHO), for Sub-Saharan Africa.[21]
Table 3: The total number of available Human Resource for Health during the successive HSDP phases
HR Category
End HSDP I
1994 HSDP II
End 1997 HSDP III
Total No
Ratio to population
Total No
Ratio to population
Total No
Ratio to Population
All physicians
1,888
1:35,603
1,996
1:35,604
2152
1: 34,986
Specialist
652
1:103,098
775
1:91,698
1151
1:62,783
General practitioners
1,236
1: 54,385
1221
1:58,203
1001
1:76,302
Public health officers
484
1:138,884
683
1:104,050
3,760
1: 20,638
Nurses Bsc, & Diploma (except midwives)
11,976
1:5,613
14,270
1: 4,980
20109
1: 4,895
Midwives (Senior)
862
1:77,981
1,274
1: 55,782
1379
1: 57,354
Pharmacists
118
1:569,661
172
1:413,174
661
1: 117,397
Pharmacy Tech.
793
1: 84,767
1171
1: 60,688
3013
1: 25,755
Environmental HW
971
1: 69,228
1169
1: 60,792
1,819
1: 42,660
Laboratory technicians & technologists
1,695
1:39,657
2,403
1: 29,574
2,989
1: 25,961
Health Extension Workers
–
–
2,737
1: 23,775
31,831
1: 2,437
Health insurance
A strategy on health Insurance was developed since 2008. To increase access to health care and reduce household vulnerability to out of pocket health expenditure.[22]
Table 1 source of health financing in Ethiopia[23]
Source
share of health spending
1
Donors
36%
2
Households (OOP)
33%
3
Government
30%
4
Private sectors
1%
As shown in the table above, this is the source of health financing that can be seen in Ethiopia, which explains that the donors, households and government have almost equal expenditures. To minimize financial disasters, the government has developed an affordable health insurance strategy. The strategy identified two types of health insurance Provided with essential health care regardless of their economic status and ability.
Social health insurance (SHI) is a formal sector affordable only for rich people.
Community-based health insurance (CBHI) is for rural & urban informal sector.
The SIH system doesn't include 85% poorest society of Ethiopian living in a rural area, so I have given attention to CBHI.
Community-based health insurance development
Pilot implementation was initiated in 2011 in 13 districts in four big regions (Oromia, Amhara, Tigray and South nation and nationality). The aim is to reach and cover the very large rural and agricultural sector and small informal sectors in an urban setting. To give equitable, accessible and increased financial risk protection.
Membership to CBHI schemes is currently on a voluntary basis, planned to move to a mandatory system. Enrollment is done on a household, not on an individual basis, to reduce the possibility of adverse selection.[25] Indigents are eligible to be a member of CBHI schemes after screened by the sub-district leader. Premium/contribution collected once in a year (mostly January to March).
Benefit package
The benefits packages emanated from the national essential service list. Services included in the benefits package: Outpatient department and Inpatient department services - Examination, laboratory/diagnosis, drugs, hospitalization. Services are accessed mostly from public health centers and primary hospitals.[26]
Exclusions
Excluded services are tooth implantation and eyeglasses for ophthalmic cases.
Achievements
Per capital health expenditure of Ethiopia (USD)
Program reports and small-scale studies showed it improved: service utilization, financial hardship, health care quality and women’s decision-making capacity in health care.[27] The figure also shows the improvement in per capita health expenditure in Ethiopia from 1996 to 2013.
Achievements: effects on health service quality
CBHI has contributed to improvements in the quality of healthcare services through an Increased flow of resources that are predictable, clinical audit findings help to identify crucial challenges encountered by the health facilities and improved community demand.[27] In addition to this, it has other achievements like contributing to women's empowerment and its impact on equity and reduction in financial hardship not yet studied.
Indicators
Table 4: Numbers of different level and types of Health Facilities in 2018
The healthcare industry is an aggregation and integration of sectors within the economic system that provides goods and services to treat patients with curative, preventive, rehabilitative, and palliative care. It encompasses the creation and commercialization of products and services conducive to the preservation and restoration of well-being. The contemporary healthcare sector comprises three fundamental facets, namely services, products, and finance. It can be further subdivided into numerous sectors and categories and relies on interdisciplinary teams of highly skilled professionals and paraprofessionals to address the healthcare requirements of both individuals and communities.
A public hospital, or government hospital, is a hospital which is government owned and is fully funded by the government and operates solely off the money that is collected from taxpayers to fund healthcare initiatives. In almost all the developed countries but the United States of America, and in most of the developing countries, this type of hospital provides medical care free of charge to patients, covering expenses and wages by government reimbursement.
The healthcare reform in China refers to the previous and ongoing healthcare system transition in modern China. China's government, specifically the National Health and Family Planning Commission, plays a leading role in these reforms. Reforms focus on establishing public medical insurance systems and enhancing public healthcare providers, the main component in China's healthcare system. In urban and rural areas, three government medical insurance systems—Urban Residents Basic Medical Insurance, Urban Employee Basic Medical Insurance, and the New Rural Co-operative Medical Scheme—cover almost everyone. Various public healthcare facilities, including county or city hospitals, community health centers, and township health centers, were founded to serve diverse needs. Current and future reforms are outlined in Healthy China 2030.
Access to water supply and sanitation in Ethiopia is amongst the lowest in Sub-Saharan Africa and the entire world. While access has increased substantially with funding from foreign aid, much still remains to be done. Some factors inhibiting the achievement of these goals are the limited capacity of water bureaus in the country's nine regions, two city administrations and water desks in the 770 districts of Ethiopia (woredas); insufficient cost recovery for proper operation and maintenance; and different policies and procedures used by various donors, notwithstanding the Paris Declaration on Aid Effectiveness.
Health care in Australia operates under a shared public-private model underpinned by the Medicare system, the national single-payer funding model. State and territory governments operate public health facilities where eligible patients receive care free of charge. Primary health services, such as GP clinics, are privately owned in most situations, but attract Medicare rebates. Australian citizens, permanent residents, and some visitors and visa holders are eligible for health services under the Medicare system. Individuals are encouraged through tax surcharges to purchase health insurance to cover services offered in the private sector, and further fund health care.
Health in Ethiopia has improved markedly since the early 2000s, with government leadership playing a key role in mobilizing resources and ensuring that they are used effectively. A central feature of the sector is the priority given to the Health Extension Programme, which delivers cost-effective basic services that enhance equity and provide care to millions of women, men and children. The development and delivery of the Health Extension Program, and its lasting success, is an example of how a low-income country can still improve access to health services with creativity and dedication.
Healthcare in Thailand is overseen by the Ministry of Public Health (MOPH), along with several other non-ministerial government agencies. Thailand's network of public hospitals provide universal healthcare to all Thai nationals through three government schemes. Private hospitals help complement the system, especially in Bangkok and large urban areas, and Thailand is among the world's leading medical tourism destinations. However, access to medical care in rural areas still lags far behind that in the cities.
Healthcare in Senegal is a center topic of discourse in understanding the well-being and vitality of the Senegalese people. As of 2008, there was a need to improve Senegal's infrastructure to promote a healthy, decent living environment for the Senegalese.
Healthcare in Ghana is mostly provided by the national government, and less than 5% of GDP is spent on healthcare. The healthcare system still has challenges with access, especially in rural areas not near hospitals.
Healthcare in Denmark is largely provided by the local governments of the five regions, with coordination and regulation by central government, while nursing homes, home care, and school health services are the responsibility of the 98 municipalities. Some specialised hospital services are managed centrally.
Tanzania has a hierarchical health system which is in tandem with the political-administrative hierarchy. At the bottom, there are the dispensaries found in every village where the village leaders have a direct influence on its running. The health centers are found at ward level and the health center in charge is answerable to the ward leaders. At the district, there is a district hospital and at the regional level a regional referral hospital. The tertiary level is usually the zone hospitals and at a national level, there is the national hospital. There are also some specialized hospitals that do not fit directly into this hierarchy and therefore are directly linked to the ministry of health.
Rashtriya Swasthya Bima Yojana is a government-run health insurance programme for the Indian poor. The scheme aims to provide health insurance coverage to the unrecognised sector workers belonging to the BPL category and their family members shall be beneficiaries under this scheme. It provides for cashless insurance for hospitalisation in public as well as private hospitals. The scheme started enrolling on April 1, 2008 and has been implemented in 25 states of India. A total of 36 million families have been enrolled as of February 2014. Initially, RSBY was a project under the Ministry of Labour and Employment. Now it has been transferred to Ministry of Health and Family Welfare from April 1, 2015
Examples of health care systems of the world, sorted by continent, are as follows.
Achieving Universal Health Care has been a key goal of the Indian Government since the Constitution was drafted. The Government has since launched several programs and policies to realize ‘Health for All’ in the nation. These measures are in line with the sustainable development goals set by the United Nations. Health disparities generated through the Hindu caste system have been a major roadblock in realizing these goals. The Dalit (untouchables) community occupies the lowest stratum of the Hindu caste system. Historically, they have performed menial jobs like - manual scavenging, skinning animal hide, and sanitation. The Indian constitution officially recognizes the Dalit community as ‘Scheduled Castes’ and bans caste-based discrimination of any form. However, caste and its far-reaching effects are still prominent in several domains including healthcare. Dalits and Adivasis have the lowest healthcare utilization and outcome percentage. Their living conditions and occupations put them at high risk for disease exposure. This, clubbed with discrimination from healthcare workers and lack of awareness makes them the most disadvantaged groups in society.
India has a multi-payer universal health care model that is paid for by a combination of public and government regulated private health insurances along with the element of almost entirely tax-funded public hospitals. The public hospital system is essentially free for all Indian residents except for small, often symbolic co-payments in some services.
Health insurance in India is a growing segment of India's economy. The Indian healthcare system is one of the largest in the world, with the number of people it concerns: nearly 1.3 billion potential beneficiaries. The healthcare industry in India has rapidly become one of the most important sectors in the country in terms of income and job creation. In 2018, one hundred million Indian households do not benefit from health coverage. In 2011, 3.9% of India's gross domestic product was spent in the health sector.
Healthcare in Rwanda was historically of poor quality, but in recent decades has seen great improvement. Rwanda operates a universal health care system, and is considered to have one of the highest-quality health systems in Africa.
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana(PM-JAY) is a national public health insurance scheme of the Government of India that aims to provide free access to health insurance coverage for low income earners in the country. Roughly, the bottom 50% of the country qualifies for this scheme. People using the program access their own primary care services from a family doctor and when anyone needs additional care, PM-JAY provides free secondary health care for those needing specialist treatment and tertiary health care for those requiring hospitalization.
Health insurance in China in 2019 was the fastest-growing category in the insurance industry in China. Health premiums rose by 23% in the first 10 months of 2018. It is expected that health premiums will reach an all-time high of CN¥539 billion for the year. Ping An Insurance, the China Life Insurance Company, New China Life Insurance and China Pacific Insurance Company are the biggest players with 42% total market share in 2017. Out-of-pocket expenses are around a third of the total Chinese health spending.
↑ Conacher, D.G. (January 1976). "Medical care in Ethiopia". Transactions of the Royal Society of Tropical Medicine and Hygiene. 70 (2): 141–144. doi:10.1016/0035-9203(76)90176-0. PMID785724.
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