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Inequalities in Healthcare Resources and Outcomes Threatening Sustainable Health Development in Ethiopia: Panel Data Analysis

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Inequalities in Healthcare Resources and Outcomes Threatening Sustainable Health Development in Ethiopia: Panel Data Analysis Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-022923 on 30 January 2019. Downloaded from Inequalities in healthcare resources and outcomes threatening sustainable health development in Ethiopia: panel data analysis Abraha Woldemichael,1,2 Amirhossein Takian,1,3,4 Ali Akbari Sari,1 Alireza Olyaeemanesh1,4,5 To cite: Woldemichael A, ABSTRACT Strengths and limitations of this study Takian A, Akbari Sari A, et al. Objective To measure inequalities in the distributions of Inequalities in healthcare selected healthcare resources and outcomes in Ethiopia resources and outcomes ► This study attempted to provide a comprehensive from 2000 to 2015. threatening sustainable health picture of the extent of healthcare resources and A panel data analysis was performed to measure development in Ethiopia: panel Design outcomes inequalities in relation to government data analysis. BMJ Open inequalities in distribution of healthcare workforce, health expenditure (GHE) within an under resourced 2019;9:e022923. doi:10.1136/ infrastructure, outcomes and finance, using secondary country. bmjopen-2018-022923 data. ► The application of different inequality measures and Setting The study was conducted across 11 regions in ► Prepublication history for Gini inequality decomposition models helped char- this paper is available online. Ethiopia. acterise the inequalities in healthcare resources and To view these files, please visit Participants Regional population and selected healthcare outcomes in a decentralised health system. the journal online (http:// dx. doi. workforce. ► The estimated Shapley value of the total GHE share org/ 10. 1136/ bmjopen- 2018- Outcomes measured Aggregate Theil and Gini indices, of the selected explanatory variables indicated the 022923). changes in inequalities and elasticity of healthcare priority resources, while the multidimensional Gini resources. inequality decomposition provided the relative in- Received 17 March 2018 Results Despite marked inequality reductions over a 16 Revised 15 November 2018 equalities, the marginal changes and the elasticity year period, the Theil and Gini indices for the healthcare Accepted 19 November 2018 values of the distributions. resources distributions remained high. Among the ► The regional overall Gini values for the distributions http://bmjopen.bmj.com/ healthcare workforce distributions, the Gini index (GI) analysed are biased downwards around 10%. was lowest for nurses plus midwives (GI=0.428, 95% CI ► The analysis emphasised only the supply perspec- 0.393 to 0.463) and highest for specialist doctors (SPDs) tive of the health system. (GI=0.704, 95% CI 0.652 to 0.756). Inter-region inequality was the highest for SPDs (95.0%) and the lowest for health officers (53.8%). The GIs for hospital beds, hospitals and INTRODUCTIOn health centres (HCs) were 0.592(95% CI 0.563 to 0.621), The concept of health has both moral and 0.460(95% CI 0.404 to 0.517) and 0.409(95% CI 0.380 right elements. The central objective of many to 0.439), respectively. The interaction term was highest health systems is to ensure health equity on September 27, 2021 by guest. Protected copyright. for HC distributions (47.7%). Outpatient department visit among populations. Health equity may be per capita (GI=0.349, 95% CI 0.321 to 0.377) and fully viewed as the absence of systematic differences immunised children (GI=0.307, 95% CI 0.269 to 0.345) showed inequalities; inequality in the under 5 years of age in health among populations regardless of mortality rate increased overtime (P=0.048). Overall, GI for their social, economic, geographical, power 1–3 government health expenditure (GHE) was 0.596(95% CI and prestige status. The guiding principle 4 0.544 to 0.648), and the estimated relative GHE share of within this concept is health equality that the healthcare workforce and infrastructure distributions may be achieved by making healthcare acces- © Author(s) (or their were 46.5% and 53.5%, respectively. The marginal sible and by addressing any socially unaccept- employer(s)) 2019. Re-use changes in the healthcare resources distributions were able inequalities within healthcare, which permitted under CC BY-NC. No 4–6 commercial re-use. See rights towards the advantaged populations. are amenable to policy decisions. Thus and permissions. Published by Conclusion This study revealed high inequalities the principle of health equality begins with BMJ. in healthcare resources in favour of the advantaged creating equal opportunities for people to For numbered affiliations see populations which can hinder equal access to healthcare access needed healthcare resources,2 7 irre- end of article. and the achievements of healthcare outcomes. The spective of their personal characteristics and government should strengthen monitoring mechanisms ability to pay.8 9 Correspondence to to address inequalities based on the national healthcare The distinction between inequity and Dr Amirhossein Takian; standards. takian@ tums. ac. ir inequality can be blurred10 11 because both Woldemichael A, et al. BMJ Open 2019;9:e022923. doi:10.1136/bmjopen-2018-022923 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-022923 on 30 January 2019. Downloaded from concepts refer to unjust and socially unacceptable differ- appropriateness of the actions targeting identified unjust ences. The unfair inequities due to avoidable causes are inequalities. However, government policies may favour specific forms of inequalities.12 Nevertheless, the two the poor, especially when the share of the private sector concepts are not synonymous. Inequality is viewed as the is minimal,22 and the economic, political, moral or prac- quantitative description of avoidable unfair differences tical aspects may be used as criteria for the allocation of without value judgements that do not belong to the legit- resources.13 Despite the unclear link between decentral- imate occurrences from individual responsibility.13 14 In isation and inequality, decentralised policies have been the human rights field, the concept is used in a much common practice to ensure social justice and address broader sense to describe differences among individuals, inequalities.23 24 The local governments in decentralised of which some could be unavoidable, at least with current systems are likely to vary in power, boundaries, capacity, knowledge and approaches.15 Generally, the concept of socioeconomic and demographic factors, living condi- inequality is dynamic, open to different interpretations and tions and healthcare needs of their constituencies.20 25 26 is highly linked to the socioeconomic structure of people.16 These conditions highlight the complexity and the likely Like inequity, any measure of inequality involves norma- occurrence of inequalities, and the coexistence of tive judgements.17 We applied Braveman’s definition of inequalities and judgements. inequality which refers to "differences in the distribution Ensuring fair allocation of human and material health- of resources or outcomes among people due to conditions care resources to people across regions contributes to that can be minimised or modified by policies".5 better healthcare outcomes. Healthcare inequality is one The success of equality policies in healthcare is subject of the conditions that hinders the success of healthcare to the influences of the political context,18 quality of systems and has been a concern to policymakers and information concerning the inequality17 19–21 and the planners. However, little evidence is available regarding http://bmjopen.bmj.com/ on September 27, 2021 by guest. Protected copyright. Figure 1 Regions in Ethiopia, proportion shares and selected indicators for the year 2015 (Source: Central Statistical Agency of Ethiopia, 2015 and Ethiopia Health and Demographic Surveys, 2016). IMR, infant mortality rate; LB, live born; U5MR, under 5 child mortality rate. 2 Woldemichael A, et al. BMJ Open 2019;9:e022923. doi:10.1136/bmjopen-2018-022923 Open access BMJ Open: first published as 10.1136/bmjopen-2018-022923 on 30 January 2019. Downloaded from the extent of healthcare inequality in the decentralised changes with respect to the marginal change in the system of Ethiopia. Our study, therefore, aims to measure average GHE? inequalities in selected healthcare resources and outcomes from the year 2000 until 2015. The findings Variables (indicators) are anticipated to contribute to a better understanding of Total GHE and total number of each selected health the effects of the existing health policies, provide infor- professional were considered to analyse the finance mation for action towards minimising unfair inequali- and healthcare workforce dimensions of the health- ties, contribute to policy decisions for strengthening the care system. These dimensions are vital for the proper universal health coverage and eventually contribute to functioning of the healthcare infrastructure. The total achieve the sustainable development goals (SDGs) for number of each functional healthcare infrastructure health in Ethiopia and perhaps beyond. (health centres, the different levels of public hospitals together and public hospital beds) in each region were also healthcare resources related variables. The annual METHODS hospital outpatient department (OPD) visits per capita, Setting the proportions of fully immunised (FIMM) children, Ethiopia is a federal democratic country that consists and the Ethiopia Health and Demographic Surveys' of nine national regional states and two chartered
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