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Measuring Progress Towards Universal Health Coverage: National and Subnational Analysis in Ethiopia

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Measuring Progress Towards Universal Health Coverage: National and Subnational Analysis in Ethiopia Research BMJ Glob Health: first published as 10.1136/bmjgh-2019-001843 on 1 November 2019. Downloaded from Measuring progress towards universal health coverage: national and subnational analysis in Ethiopia Getachew Teshome Eregata,1,2 Alemayehu Hailu,1,2 Solomon Tessema Memirie,1,3 Ole Frithjof Norheim1,4 To cite: Eregata GT, Hailu A, ABSTRACT Key questions Memirie ST, et al. Measuring Introduction Aiming for universal health coverage (UHC) progress towards universal as a country- level goal requires that progress is measured What is already known? health coverage: national and tracked over time. However, few national and and subnational analysis in Measurement of service coverage is important for subnational studies monitor UHC in low- income countries ► Ethiopia. BMJ Global Health monitoring progress towards universal health cov- and there is none for Ethiopia. This study aimed to estimate 2019;4:e001843. doi:10.1136/ erage (UHC). the 2015 national and subnational UHC service coverage bmjgh-2019-001843 The WHO and the World Bank has made country es- status for Ethiopia. ► timates of UHC service coverage, including Ethiopia. Handling editor Seye Abimbola Methods The UHC service coverage index was constructed from the geometric means of component What are the new findings? Received 16 July 2019 indicators: first, within each of four major categories and ► This paper estimates UHC service coverage for Revised 6 September 2019 then across all components to obtain the final summary Ethiopia for the year 2015. Accepted 28 September 2019 index. Also, we estimated the subnational level UHC service ► The estimated subnational UHC service coverage coverage. We used a variety of surveys data and routinely varies substantially across regions and programme collected administrative data. areas. Results Nationally, the overall Ethiopian UHC service coverage for the year 2015 was 34.3%, ranging from What do the new findings imply? 52.2% in the Addis Ababa city administration to 10% ► Ethiopia should make an extra effort to achieve UHC in the Afar region. The coverage for non- communicable service coverage goals in the next decade. diseases, reproductive, maternal, neonatal and child health ► Policymakers in Ethiopia should be cognisant of the and infectious diseases were 35%, 37.5% and 52.8%, subnational variation in UHC service coverage and respectively. The national UHC service capacity and access should take corrective measures to narrow the gap coverage was only 20% with large variations across across regions. http://gh.bmj.com/ regions, ranging from 3.7% in the Somali region to 41.1% in the Harari region. Conclusion The 2015 overall UHC service coverage UHC by 2030.2 Health services that should be © Author(s) (or their for Ethiopia was low compared with most of the other provided include essential promotive, preven- employer(s)) 2019. Re- use countries in the region. Also, there was a substantial tive, curative, rehabilitative and palliative permitted under CC BY. variation among regions. Therefore, Ethiopia should rapidly on September 27, 2021 by guest. Protected copyright. health services.1 However, each year, almost Published by BMJ. scale up promotive, preventive and curative health services 1 Department of Global Public through increasing investment in primary healthcare if half of the world’s population cannot access Health and Primary Care, Ethiopia aims to reach the UHC service coverage goals. needed health services and about 100 million University of Bergen, Bergen, Also, policymakers at the regional and federal levels people are forced into extreme poverty Norway should take corrective measures to narrow the gap across because of health expenses. Globally, about 2Ministry of Health of Ethiopia, Addis Ababa, Ethiopia regions, such as redistribution of the health workforce, 800 million people experience catastrophic 3Department of Paediatrics increase resources allocated to health and provide focused financial hardship due to out- of- pocket and Child Health, College of technical and financial support to low- performing regions. healthcare spending (ie, spending more than Health Sciences, Addis Ababa 10% of their total income for healthcare).3 University, Addis Ababa, Ethiopia Ethiopia is one of the countries with a 4Department of Global Health and Population, Harvard substantial disease burden from reproduc- University T H Chan School INTRODUCTION tive, maternal, neonatal and childhealth 4 of Public Health, Boston, Universal health coverage (UHC) is realised (RMNCH) and infectious diseases. Recent Massachusetts, USA when everyone has access to quality essential evidence also shows that the magnitude healthcare services with financial risk protec- of non-communicable disease (NCD) and Correspondence to 1 5 Getachew Teshome Eregata; tion. The United Nations General Assembly, injuries is rising in Ethiopia. In addition, ereg atag etac hewt eshome@ as part of the Sustainable Development Goal coverage of both basic health services and gmail. com for health, calls on all countries to ensure health service utilisation is low, and there Eregata GT, et al. BMJ Global Health 2019;4:e001843. doi:10.1136/bmjgh-2019-001843 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-001843 on 1 November 2019. Downloaded from is a high geographical (urban-rural area and regional/ UHC status at the country level. Barasa, Nguhiu and McIn- subnational) inequality in service coverage.6 Further- tyre use Demographic and Health Survey (DHS) data to more, catastrophic out- of- pocket spending is high.7 estimate Kenya’s UHC progress using tracer indicators Cognisant of these challenges, the government of Ethi- grouped as preventive and treatment interventions.14 In opia has developed key strategies to lead to UHC. These Ethiopia, a case study regarding the identification of a strategies include the following: first, defining the Essen- UHC monitoring tool recommends that the UHC tracer tial Health Service Package of the country and identifying indicators should be comprehensive, few in number and prioritised health interventions; second, exemption or focused on impact, outcome and health systems dimen- cost- sharing of high- priority interventions; third, expan- sion indicators. The case study also supports the inclu- sion of community- based health insurance programmes; sion of indicators that can capture NCDs.15 Except for fourth, integration of health services within other sectors Hogan et al,3 we have not found other empirical studies from the national to the district level to address social estimating the UHC status for Ethiopia, and none have determinants of health and fifth, establish emergency attempted to demonstrate subnational variations in preparedness and response units at the level of both the universal service coverage. In addition, the Ministry of national and Regional Health Bureaus (RHBs). Taken Health does not use an explicitly defined UHC moni- together, these strategies can improve the coverage of toring framework. Therefore, this study aimed to esti- essential health services, reduce inequalities and provide mate the 2015 national and subnational UHC status for financial risk protection.8 9 Ethiopia, which could serve as a baseline to monitor Ethi- Despite a promise to provide all needed service to the opia’s progress towards UHC. whole population, UHC must be realised progressively, especially in resource-constrained countries. Respon- sibilities in the provision of UHC need to be redefined to a comprehensive set of essential health services that METHODS the government can guarantee to the entire popula- The Ethiopian health system tion.10 Therefore, with UHC as a global and country-level­­ Ethiopia is the second most populous country in Africa, 16 health policy goal, the need to measure and track its with a total population of about 105 million in 2016. progress over time is imperative. WHO and World Bank Administratively, Ethiopia is divided into nine regional (WB) have jointly identified two indicators for moni- states (Tigray, Afar, Amhara, Oromia, BenshangulGu- toring progress towards UHC: essential health service muze, Southern Nations, and National Region (SNNPR), coverage (target number 3.8.1) and financial risk protec- Somali and Harari) and two chartered cities (Addis tion (target number 3.8.2). The 2030 UHC- Sustainable Ababa and Dire Dawa). DevelopmentGoals (SDG) targets are intended to reach Healthcare delivery in Ethiopia is organised in a three- 8 at least 80% for service coverage and 100% for financial tier system. The first, at the district level, is the primary risk protection.11 healthcare unit (PHCU). The PHCU comprises one One challenge in the identification of UHC moni- primary hospital, which can serve a population of about http://gh.bmj.com/ toring indicators is to decide how comprehensive the 60 000–100 000; four health centres (each serving a indicators should be to represent all essential health population of 15 000–25 000) and five health posts are services in the system and control the number of indica- attached to each health centre (each health post serving tors to enable comparability across countries that differ 3000–5000 people). The second level comprises general in terms of epidemiological and demographic character- hospitals, each serving a population of 1–1.5 million, istics. Boerma et al argue that country- level monitoring while the third level comprises specialised hospitals for a on September 27, 2021 by guest. Protected copyright. of UHC should address the epidemiological
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