Routine data in a primary care performance dashboard, Ethiopia.

Objective: To explore the feasibility of building a primary care performance dashboard using DHIS2 data from Ethiopia's largest urban (Addis Ababa), agrarian (Oromia) and pastoral (Somali) regions. Methods: We extracted 26 data elements reported by 12 062 health facilities to DHIS2 for the period 1 July 2022 to 30 June 2023. Focusing on indicators of effectiveness, safety and user experience, we built 14 indicators of primary care performance covering reproductive, maternal and child health, human immunodeficiency virus, tuberculosis, noncommunicable disease care and antibiotic prescription. We assessed data completeness by calculating the proportion of facilities reporting each month, and examined the presence of extreme outliers and assessed external validity. Findings: At the regional level, average completeness across all data elements was highest in Addis Ababa (82.9%), followed by Oromia (66.2%) and Somali (52.6%). Private clinics across regions had low completeness, ranging from 38.6% in Somali to 58.7% in Addis Ababa. We found only a few outliers (334 of 816 578 observations) and noted that external validity was high for 11 of 14 indicators of primary care performance. However, the 12-month antiretroviral treatment retention rate and proportions of patients with controlled diabetes or hypertension exhibited poor external validity. Conclusion: The Ethiopian DHIS2 contains information for measuring primary care performance, using simple analytical methods, at national and regional levels and by facility type. Despite remaining data quality issues, the health management information system is an important data source for generating health system performance assessment measures on a national scale.

Receipt of core antenatal care components and associated factors in Ethiopia: a multilevel analysis.

Background: Despite recent promising progress, maternal morbidity and mortality are still unacceptably high in Ethiopia. This is partly attributed to the lack of quality health services. Pregnant women may not receive adequate services that are essential to protect the health of women and their unborn children. This study aimed to examine the extent of receiving prenatal care components and associated factors in Ethiopia. It also assessed prenatal service use inequality between urban and rural residents. Methods: The analysis was carried out using the 2016 Ethiopian Demographic and Health Survey (EDHS), which is nationally representative survey data. A weighted sample of 4,772 women nested within 595 communities who had live births five years preceding the survey was included in the study. Necessary adjustments were made to account for the design of the survey, and sampling weights were used to adjust for nonproportional allocation of the sample to strata. Bivariate and multivariable multilevel ordered logit models were used to analyze factors associated with receiving comprehensive ANC contents. Statistically significant predictors were identified at p value ≤ 0.05. Results: Among those women who had at least one ANC visit, only 15% (95% CI: 13, 16) received six core elements of antenatal care. The proportion of mothers who had essential prenatal components in rural areas was less than 13 percentage points. Approximately 43% of women did not receive at least two doses of tetanus toxoid vaccines to protect them and newborn infants against this life-threatening disease. Moreover, the majority of them, particularly those in rural Ethiopia, were not informed about pregnancy danger signs. Mothers who had at least four ANC visits received more types of prenatal components compared to those who had fewer ANC visits. The multilevel regression analysis revealed that receiving adequate ANC content is positively associated with having more frequent ANC visits, attaining a higher education level, being a member of a household in the highest wealth quintile and residing in urban areas. Conclusion: The evidence implies that the quality of maternal health services needs to be improved. Health programs and interventions should also give priority to rural areas where the majority of Ethiopian women reside.

Catastrophic Health Expenditure and Associated Factors Among Hospitalized Cancer Patients in Addis Ababa, Ethiopia.

Background: Out-of-pocket (OOP) health expenditures for cancer care expose households to unanticipated economic consequences. When the available health services are mainly dependent on OOP expenditure, the household faces catastrophic health expenditure (CHE). This study aimed to estimate the incidence and intensity of CHE in hospitalized cancer patients and identify coping strategies and associated factors. Method and Material: Hospital-based cross-sectional study design was conducted on 305 cancer inpatients in Addis Ababa between November 2021 and February 2022. All patients with cancer who were hospitalized during the data collection period were included in the study. The incidence of CHE was estimated at the 40% threshold of households' non-food expenditure and the intensity of CHE was captured based on the amount by which household expenditure exceeded the threshold and mean positive overshoot, the mean level by which CHE exceeds the threshold used. Multivariate logistic regression was used to assess the relationship between CHE levels and the independent variables. Results: The incidence of CHE at the 40% threshold of households' non-food expenditure was 77.7%, while the O and MPO were 36.2% and 46.6%, respectively. CHE for cancer care was significantly associated with patient residence, increased number of chemotherapy cycles, increased duration of hospital admission, lack of insurance enrolment, and lower-income quintiles. Saving and selling assets were identified as the primary coping mechanisms. Conclusion: The incidence and intensity of CHE among inpatients with cancer were high and which could lead to impoverishment of households. Improved quality and coverage of health insurance and decentralizing cancer care to regions standards similar to Addis Ababa will save households from incurring CHE.

Health system quality and COVID-19 vaccination: a cross-sectional analysis in 14 countries.

The social and behavioural determinants of COVID-19 vaccination have been described previously. However, little is known about how vaccinated people use and rate their health system. We used surveys conducted in 14 countries to study the health system correlates of COVID-19 vaccination. Country-specific logistic regression models were adjusted for respondent age, education, income, chronic illness, history of COVID-19, urban residence, and minority ethnic, racial, or linguistic group. Estimates were summarised across countries using random effects meta-analysis. Vaccination coverage with at least two or three doses ranged from 29% in India to 85% in Peru. Greater health-care use, having a regular and high-quality provider, and receiving other preventive health services were positively associated with vaccination. Confidence in the health system and government also increased the odds of vaccination. By contrast, having unmet health-care needs or experiencing discrimination or a medical mistake decreased the odds of vaccination. Associations between health system predictors and vaccination tended to be stronger in high-income countries and in countries with the most COVID-19-related deaths. Access to quality health systems might affect vaccine decisions. Building strong primary care systems and ensuring a baseline level of quality that is affordable for all should be central to pandemic preparedness strategies.

Social Health Insurance and Healthcare Seeking Behavior in Urban Ethiopia.

Background: After years of planning, in 2024 the government of Ethiopia proposes to introduce a compulsory Social Health Insurance (SHI) program for formal sector employees. The proposed scheme will provide access to contracted healthcare facilities at a premium of 3% of the gross monthly income of employees with another 3% coming from the employer. Objectives: Several studies have examined the willingness to pay (WTP) this premium, however, little is known about the healthcare seeking behavior (HSB) of formal sector employees. This paper investigates both - the determinants of healthcare seeking behavior and among other aspects, WTP the premium. Through these explorations, the paper sheds light on the potential challenges for implementation of SHI. Methods: Descriptive statistics, logit, and multinomial logit (MNL) models are used to analyze retrospective survey data (2,749 formal sector employees) which covers the major regions of the country. Findings: Regarding outpatient care, a majority of the visits (55.9%) were to private healthcare providers. In the case of inpatient care, it was the opposite with a majority of healthcare seekers visiting public sector hospitals (62.5%). A majority of the sample (67%) supported the introduction of SHI but only 24% were willing to pay the proposed SHI premium. The average WTP was 1.6% of gross monthly income. Respondents in the two richest income quintiles were more likely to oppose SHI and consider it unfair. Conclusion: The prominent role of the private sector and the resistance to SHI amongst the two richest income quintiles, suggests that the SHI program needs to actively include private healthcare facilities within its ambit. Additionally, concerted efforts at enhancing the quality of care available at public health facilities, both, in terms of perception and patient-centered care and addressing drug and equipment availability bottlenecks, are needed, if SHI is to garner wider support.

Quality of routine health data at the onset of the COVID-19 pandemic in Ethiopia, Haiti, Laos, Nepal, and South Africa.

BACKGROUND: During the COVID-19 pandemic, governments and researchers have used routine health data to estimate potential declines in the delivery and uptake of essential health services. This research relies on the data being high quality and, crucially, on the data quality not changing because of the pandemic. In this paper, we investigated those assumptions and assessed data quality before and during COVID-19. METHODS: We obtained routine health data from the DHIS2 platforms in Ethiopia, Haiti, Lao People's Democratic Republic, Nepal, and South Africa (KwaZulu-Natal province) for a range of 40 indicators on essential health services and institutional deaths. We extracted data over 24 months (January 2019-December 2020) including pre-pandemic data and the first 9 months of the pandemic. We assessed four dimensions of data quality: reporting completeness, presence of outliers, internal consistency, and external consistency. RESULTS: We found high reporting completeness across countries and services and few declines in reporting at the onset of the pandemic. Positive outliers represented fewer than 1% of facility-month observations across services. Assessment of internal consistency across vaccine indicators found similar reporting of vaccines in all countries. Comparing cesarean section rates in the HMIS to those from population-representative surveys, we found high external consistency in all countries analyzed. CONCLUSIONS: While efforts remain to improve the quality of these data, our results show that several indicators in the HMIS can be reliably used to monitor service provision over time in these five countries.

Household satisfaction with a pilot community-based health insurance scheme and associated factors in Addis Ababa.

Background: Many countries introduce CBHI as their healthcare financing system to ensure healthcare access. Understanding the level of satisfaction and factors associated with it is essential to ensure the sustainability of the program. Therefore, this study aimed to assess household satisfaction with a CBHI scheme and its associated factors in Addis Ababa. Design and methods: Institutional-based cross-sectional study was conducted in the 10 health centers found in the 10 sub-cities of Addis Ababa. Both quantitative and qualitative methods were used. Logistic regression analysis was carried out to identify its associated factors and thematic analysis was used for qualitative data. Finally, variables with a p-value of <0.05 have been considered statistically significant. Results: In this study, the overall satisfaction level of households with CBHI was 46.3%. Satisfaction was associated with valid CBHI management regulations (AOR = 1.96, 95% CI: 1.12, 3.46), participants who received the right drug (AOR = 1.77, 95% CI: 1.08, 2.93), households who got immediate care (AOR = 4.95, 95% CI: 2.72, 8.98), those who agreed with the adequacy of medical equipment (AOR = 1.65, 95% CI: 1.02, 2.69), and households who agreed with qualification of health personnel (AOR = 1.89, 95% CI: 1.12, 3.20) were more satisfied with the scheme than their counterparts. The challenges mentioned by the discussants were the shortage of drugs, poor attitude of health professionals, absence of kenema pharmacy, lack of laboratory services, lack of awareness about the CBHI scheme, and tight payment schedule. Conclusions: the satisfaction level of households was low. To achieve a better result, the concerned bodies should work to improve the availability of medication, and medical equipment and improve the attitude of healthcare workers.

Associations between the stringency of COVID-19 containment policies and health service disruptions in 10 countries.

BACKGROUND: Disruptions in essential health services during the COVID-19 pandemic have been reported in several countries. Yet, patterns in health service disruption according to country responses remain unclear. In this paper, we investigate associations between the stringency of COVID-19 containment policies and disruptions in 31 health services in 10 low- middle- and high-income countries in 2020. METHODS: Using routine health information systems and administrative data from 10 countries (Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, South Korea, and Thailand) we estimated health service disruptions for the period of April to December 2020 by dividing monthly service provision at national levels by the average service provision in the 15 months pre-COVID (January 2019-March 2020). We used the Oxford COVID-19 Government Response Tracker (OxCGRT) index and multi-level linear regression analyses to assess associations between the stringency of restrictions and health service disruptions over nine months. We extended the analysis by examining associations between 11 individual containment or closure policies and health service disruptions. Models were adjusted for COVID caseload, health service category and country GDP and included robust standard errors. FINDINGS: Chronic disease care was among the most affected services. Regression analyses revealed that a 10% increase in the mean stringency index was associated with a 3.3 percentage-point (95% CI -3.9, -2.7) reduction in relative service volumes. Among individual policies, curfews, and the presence of a state of emergency, had the largest coefficients and were associated with 14.1 (95% CI -19.6, 8.7) and 10.7 (95% CI -12.7, -8.7) percentage-point lower relative service volumes, respectively. In contrast, number of COVID-19 cases in 2020 was not associated with health service disruptions in any model. CONCLUSIONS: Although containment policies were crucial in reducing COVID-19 mortality in many contexts, it is important to consider the indirect effects of these restrictions. Strategies to improve the resilience of health systems should be designed to ensure that populations can continue accessing essential health care despite the presence of containment policies during future infectious disease outbreaks.

Effect of community-based health insurance on catastrophic health expenditure among chronic disease patients in Asella referral hospital, Southeast Ethiopia: a comparative cross-sectional study.

BACKGROUND: Chronic disease-related catastrophic health spending is frequent in Ethiopia affecting several households, particularly the poorest ones. A community-based health insurance (CBHI) scheme has been in place in Ethiopia since 2011. The scheme aims to provide financial protection against health expenditure but there is little evidence of how well it protects chronic patients financially. OBJECTIVE: The objective of the study was to evaluate the effect of community-based health insurance in reducing the incidence of catastrophic health expenditure among patients attending chronic disease follow-up departments in Asella referral hospital, Southeast Ethiopia. METHOD: A health facility-based comparative cross-sectional study was conducted in Asella referral hospital from March 2022 to May 2022. Systematic random sampling was used to select 325 chronic patients. Data were collected using an open data kit (ODK) collect app and then imported to STATA version 16 for analysis. Propensity score matching was used to evaluate the effect of community-based health insurance on catastrophic health expenditure. RESULT: The study enrolled a total of 325 chronic patients (157 insurance members and 168 nonmembers). More than 30% of the study participants incurred health spending that could be catastrophic based on the 15% nonfood threshold. Catastrophic health expenditure was found in 31% of insured and 47% of uninsured participants. Overshoot and mean positive overshoot were 10% and 33% for insured members, respectively and the corresponding figures were 18% and 39% for nonmembers. Community-based health insurance contributes to a 19% ((ATT = -0.19, t = -2.97)) reduction in the incidence of catastrophic health expenditure among chronic patients. This result is found to be consistent for alternative measurements of the outcome variable and the use of alternative matching algorithms. CONCLUSION: Chronic patients, particularly those in uninsured households, had a high incidence and intensity of catastrophic health expenditure. Hence, it is relevant to expand community-based health insurance to provide financial protection for people suffering from chronic conditions.

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.

Use of healthcare services during the COVID-19 pandemic in urban Ethiopia: evidence from retrospective health facility survey data.

OBJECTIVES: In recent years, Ethiopia has made enormous strides in enhancing access to healthcare, especially, maternal and child healthcare. With the onset and spread of COVID-19, the attention of the healthcare system has pivoted to handling the disease, potentially at the cost of other healthcare needs. This paper explores whether this shift has come at the cost of non-Covid related healthcare, especially the use of maternal and child health (MCH) services. SETTING: Data covering a 24-month period are drawn from 59 health centres and 29 public hospitals located in urban Ethiopia. PRIMARY AND SECONDARY OUTCOMES MEASURES: The primary outcome measures are the use of MCH services including family planning, antenatal and postnatal care, abortion care, delivery and immunisation. The secondary outcome measures are the use of health services by adults including antiretroviral therapy (ART), tuberculosis (TB) and leprosy and dental services RESULTS: There is a sharp reduction in the use of both inpatient (20%-27%, p<0.001) and outpatient (27%-34%, p<0.001) care, particularly in Addis Ababa, which has been most acutely affected by the virus. This decline does not come at the cost of MCH services. The use of several MCH components (skilled birth attendant deliveries, immunisation, postnatal care) remains unaffected throughout the period while others (family planning services, antenatal care) experience a decline (8%-17%) in the immediate aftermath but recover soon after. CONCLUSION: Concerns about the crowding out of MCH services due to the focus on COVID-19 are unfounded. Proactive measures taken by the government and healthcare facilities to ring-fence the use of essential healthcare services have mitigated service disruptions. The results underline the resilience and agility displayed by one of the world's most resource-constrained healthcare systems. Further research on the approaches used to mitigate disruptions is needed.

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.

Economic Consequences of Ill-Health in Rural Ethiopia.

We use three years of household panel data to analyze the effects of ill-health on household economic outcomes in rural Ethiopia. We examine the immediate effects of various ill-health measures on health expenditure and labor supply, the subsequent coping responses, and finally the effect on income and consumption. We find evidence of substantial economic risk in terms of increased health expenditure and reduced agricultural productivity. Households are able to smooth consumption by resorting to intra-household labor substitution, borrowing and depleting assets. However, maintaining current consumption through borrowing and depletion of assets is unlikely to be sustainable and displays the need for health financing reforms and safety nets that reduce the financial consequences of ill-health.

Cost of Treating Maternal Complications and Associated Factors in Mekelle General Hospital, Northern Ethiopia.

BACKGROUND: The government of Ethiopia introduced an exemption policy that guarantees free maternal healthcare services from public providers. This policy aims to ensure financial protection and enhance utilization of services especially for low-income people. However, patients in most cases incur health expenditure when seeking health care. This paper aims to assess direct and indirect medical costs of treating maternal complications and associated factors at a public hospital in Northern Ethiopia. METHODS: An institution-based cross-sectional study design was carried on 267 mothers with complications. A multivariate linear regression model at 5% level of significance was used to analyze factors driving the outcome. RESULTS: The median cost was more than seven times the monthly minimum wage, and this may cause severe financial consequences for the poor. Direct medical costs accounted for the major share (68%) of total cost, and this was mainly driven by lack of diagnostic services at public facilities and paying for private providers. Expenditure for treatment of maternal complications is positively associated with income, absence from work, travel time to the facility and being diagnosed at a private facility. CONCLUSION: The overall evidence in this study poses a concern about the context in which fee exemption reforms are being implemented.

The Effect of Ethiopia's Community-Based Health Insurance Scheme on Revenues and Quality of Care.

Ethiopia's Community-Based Health Insurance (CBHI) scheme was established with the objectives of enhancing access to health care, reducing out-of-pocket expenditure (OOP), mobilizing financial resources and enhancing the quality of health care. Previous analyses have shown that the scheme has enhanced health care access and led to reductions in OOP. This paper examines the impact of the scheme on health facility revenues and quality of care. This paper relies on a difference-in-differences approach applied to both panel and cross-section data. We find that CBHI-affiliated facilities experience a 111% increase in annual outpatient visits and annual revenues increase by 47%. Increased revenues are used to ameliorate drug shortages. These increases have translated into enhanced patient satisfaction. Patient satisfaction increased by 11 percentage points. Despite the increase in patient volume, there is no discernible increase in waiting time to see medical professionals. These results and the relatively high levels of CBHI enrollment suggest that the Ethiopian CBHI has been able to successfully negotiate the main stumbling block-that is, the poor quality of care-which has plagued similar CBHI schemes in Sub-Saharan Africa.

The impact of the Ethiopian health extension program and health development army on maternal mortality: A synthetic control approach.

The Ethiopian government has implemented nationwide strategies to improve access to basic health services and enhance health outcomes. The Health Extension Program (HEP) launched in 2003, expanded basic health infrastructure and local human resources. In 2011, the government introduced the Health Development Army (HDA). HDA is a women-centered community movement inspired by military structures and discipline. Its special objective is to improve maternal health outcomes. This paper uses a synthetic control approach to assess the effects of HEP and HDA on maternal mortality ratios (MMR). The MMR data are from the Global Burden of Diseases (GBD) database. A pool of 42 Sub-Saharan African countries, covering the period 1990 to 2016, is used to construct a synthetic comparator which displays a mortality trajectory similar to Ethiopia prior to the interventions. On average, since 2004, maternal mortality in the control countries exhibits a moderate downward trend. In Ethiopia, the downward trend is considerably steeper as compared to its synthetic control. By 2016, maternal mortality in Ethiopia was lower by 171 (p-value 0.048) maternal deaths per 100,000 live births as compared to its synthetic control. Between 2003 and 2016, Ethiopia's maternal mortality ratio declined from 728 to 357. These estimates suggest that a substantial proportion of this decline may be attributed to HEP/HDA. The Ethiopian experience of enhancing nation-wide access to and use of maternal health services in a short time-span is remarkable. Whether such a model may be transplanted is an open question.

The impact of Ethiopia's pilot community based health insurance scheme on healthcare utilization and cost of care.

In June 2011, the Government of Ethiopia introduced a pilot Community Based Health Insurance (CBHI) scheme in rural parts of the country. Based on a fixed effects analysis of household panel data, this paper assesses the impact of the scheme on utilization of modern healthcare and the cost of accessing healthcare. It adds to the relatively small body of work that provides a rigorous evaluation of CBHI schemes. We find that in the case of public health facilities, enrolment leads to a 30-41% increase in utilization of outpatient care, a 45-64% increase in the frequency of visits and at least a 56% decline in the cost per visit. The impact on utilization and costs combined with a high uptake rate of almost 50% within two years of scheme establishment underlines the relative success of the Ethiopian scheme. While there are several reasons for this success, a comparative analysis of the design and execution of the Ethiopia CBHI with the existing body of work yields two distinct features. First, the Ethiopian scheme is embedded within existing government administrative structures and to signal government commitment, scheme performance and uptake is used as a yardstick to measure the success of the administration. Second, an existing social protection scheme was used to spread information, raise scheme awareness and encourage uptake of health insurance. The alignment of the interests of administrators with scheme performance and interlinking of social protection schemes are innovative design features that are worth considering as developing countries strive to enhance access to health care through voluntary insurance schemes.