The path to universal health coverage in five African and Asian countries: examining the association between insurance status and health-care use.

Despite major efforts to achieve universal health coverage (UHC), progress has lagged in many African and Asian countries. A key strategy pursued by many countries is the use of health insurance to increase access and affordability. However, evidence on insurance coverage and on the association between insurance and UHC is mixed. We analysed nationally representative cross-sectional data collected between 2022 and 2023 in Ethiopia, Kenya, South Africa, India, and Laos. We described public and private insurance coverage by sociodemographic factors and used logistic regression to examine the associations between insurance status and seven health-care use outcomes. Health insurance coverage ranged from 25% in India to 100% in Laos. The share of private insurance ranged from 1% in Ethiopia to 13% in South Africa. Relative to the population with private insurance, the uninsured population had reduced odds of health-care use (adjusted odds ratio 0·68, 95% CI 0·50-0·94), cardiovascular examinations (0·63, 0·47-0·85), eye and dental examinations (0·54, 0·42-0·70), and ability to get or afford care (0·64, 0·48-0·86); private insurance was not associated with unmet need, mental health care, and cancer screening. Relative to private insurance, public insurance was associated with reduced odds of health-care use (0·60, 0·43-0·82), mental health care (0·50, 0·31-0·80), cardiovascular examinations (0·62, 0·46-0·84), and eye and dental examinations (0·50, 0·38-0·65). Results were highly heterogeneous across countries. Public health insurance appears to be only weakly associated with access to health services in the countries studied. Further research is needed to improve understanding of these associations and to identify the most effective financing strategies to achieve UHC.

COVID-19 and resilience of healthcare systems in ten countries.

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Effect of the COVID-19 pandemic on health service utilization across regions of Ethiopia: An interrupted time series analysis of health information system data from 2019-2020.

The spread of COVID-19 and associated deaths have remained low in Ethiopia. However, the pandemic could pose a public health crisis indirectly through disruptions in essential health services. The aim of this study was to examine disruptions in health service utilization during the first nine months of the COVID-19 pandemic across 10 regions in Ethiopia. We analyzed utilization of 21 different health services across all of Ethiopia (except the Tigray region) for the period of January 2019 to December 2020. Data were extracted from the Ethiopian district health information system (DHIS2). Monthly visits in 2020 were graphed relative to the same months in 2019. Interrupted time series analysis was used to estimate the effect of the pandemic on service utilization in each region. We found that disruptions in health services were generally higher in urban regions which were most affected by COVID. Outpatient visits declined by 52%, 54%, and 58%, specifically in Dire Dawa, Addis Ababa and Harari, the three urban regions. Similarly, there was a 47% reduction in inpatient admissions in Addis Ababa. In agrarian regions, the pandemic caused an 11% to 17% reduction in outpatient visits and a 10% to 27% decline in inpatient admissions. Visits for children with diarrhea, pneumonia and malnutrition also declined substantially while maternal health services were less affected. Our study indicates that disruptions in health services were more pronounced in areas that were relatively harder hit by the pandemic. Our results show that the Ethiopian health system has a limited capacity to absorb shocks. During future waves of COVID or future pandemics, the Ethiopian health system must be better prepared to maintain essential services and mitigate the indirect impact of the pandemic on public health, particularly in urban areas.

Early estimates of COVID-19 infections in small, medium and large population clusters.

INTRODUCTION: Since its emergence in late December 2019, COVID-19 has rapidly developed into a pandemic in mid of March with many countries suffering heavy human loss and declaring emergency conditions to contain its spread. The impact of the disease, while it has been relatively low in the sub-Saharan Africa (SSA) as of May 2020, is feared to be potentially devastating given the less developed and fragmented healthcare system in the continent. In addition, most emergency measures practised may not be effective due to their limited affordability as well as the communal way people in SSA live in relative isolation in clusters of large as well as smaller population centres. METHODS: To address the acute need for estimates of the potential impacts of the disease once it sweeps through the African region, we developed a process-based model with key parameters obtained from recent studies, taking local context into consideration. We further used the model to estimate the number of infections within a year of sustained local transmissions under scenarios that cover different population sizes, urban status, effectiveness and coverage of social distancing, contact tracing and usage of cloth face mask. RESULTS: We showed that when implemented early, 50% coverage of contact tracing and face mask, with 33% effective social distancing policies can bringing the epidemic to a manageable level for all population sizes and settings we assessed. Relaxing of social distancing in urban settings from 33% to 25% could be matched by introduction and maintenance of face mask use at 43%. CONCLUSIONS: In SSA countries with limited healthcare workforce, hospital resources and intensive care units, a robust system of social distancing, contact tracing and face mask use could yield in outcomes that prevent several millions of infections and thousands of deaths across the continent.

Structured integration of family planning curriculum: comparative assessment of knowledge and skills among new medical graduates in Ethiopia.

OBJECTIVE: The objective was to assess if structured integration of a comprehensive family planning (FP) training into a medical school curriculum improves FP knowledge and skill scores of medical interns. STUDY DESIGN: We compared mean contraception knowledge scores of interns in a medical school with the integrated FP curriculum [intervention school] (n=56) to interns at four conventional medical curriculum schools without structured reinforcement of FP content [control schools] (n=161) in Ethiopia. A survey with 19 multiple choice contraception questions was administered. We also compared the mean contraception skills scores of the two groups at four Objective Structured Clinical Examination stations. The survey included self-reported number of contraception procedures and self-assessed competencies on a Likert scale. RESULTS: A total of 217 interns who have completed an Obstetrics and Gynecology rotation participated in the study. Interns from the intervention school reported performing substantially higher numbers of contraception procedures and rated themselves as being competent/highly competent across all procedures compared to the control schools (p<.001 for both). The mean knowledge score was significantly higher in the intervention school [13.1 vs. 8.7, difference 4.5, 95% CI: (3.7-5.2), p<.001]. The mean contraceptive implant insertion skill score was twofold higher for interns in the intervention school [22 points vs. 11, difference 10.7, 95% CI: (8.6-12.8), p<.001 out of a maximum possible point of 30]. Statistically significant differences in skill scores were also observed for intrauterine device IUD insertion [15 vs. 12, p<.01] and implant removal [11 vs. 9, p=.01]. CONCLUSION: A structured integration of family planning curriculum was associated with higher scores in knowledge, clinical skills and self-assessed competencies. IMPLICATIONS: Integrating comprehensive family planning training in medical curriculum can lead to graduating physicians who are more competent to offer the full range of FP options.