Primary health care contributions to universal health coverage, Ethiopia.

Many global health institutions, including the World Health Organization, consider primary health care as the path towards achieving universal health coverage (UHC). However, there remain concerns about the feasibility and effectiveness of this approach in low-resource countries. Ethiopia has been implementing the primary health-care approach since the mid-1970s, with primary health care at the core of the health system since 1993. Nevertheless, comprehensive and systemic evidence on the practice and role of primary health care towards UHC is lacking in Ethiopia. We made a document review of publicly available qualitative and quantitative data. Using the framework of the Primary Health Care Performance Initiative we describe and analyse the practice of primary health care and identify successes and challenges. Implementation of the primary health-care approach in Ethiopia has been possible through policies, strategies and programmes that are aligned with country priorities. There has been a diagonal approach to disease control programmes along with health-systems strengthening, community empowerment and multisectoral action. These strategies have enabled the country to increase health services coverage and improve the population's health status. However, key challenges remain to be addressed, including inadequate coverage of services, inequity of access, slow health-systems transition to provide services for noncommunicable diseases, inadequate quality of care, and high out-of-pocket expenditure. To resolve gaps in the health system and beyond, the country needs to improve its domestic financing for health and target disadvantaged locations and populations through a precision public health approach. These challenges need to be addressed through the whole sustainable development agenda.

De nombreux organismes sanitaires internationaux, dont l'Organisation mondiale de la Santé, considèrent que les soins de santé primaires représentent un jalon essentiel du cheminement vers une couverture maladie universelle (CMU). Néanmoins, des inquiétudes subsistent quant à la faisabilité et à l'efficacité de cette approche dans les pays à faible revenu. L'Éthiopie a adopté cette approche depuis le milieu des années 1970, et les soins de santé primaires figurent au cœur du système sanitaire depuis 1993. Pourtant, rares sont les preuves exhaustives et généralisées concernant la pratique et le rôle des soins de santé primaires dans l'évolution vers une CMU en Éthiopie. Nous avons donc procédé à un examen des documents contenant des données qualitatives et quantitatives accessibles au public. À l'aide du cadre instauré par l'initiative PHCPI (Primary Health Care Performance Initiative), nous avons décrit et analysé la pratique des soins de santé primaires; nous avons également identifié les réussites et les défis. C'est grâce à des politiques, stratégies et programmes en adéquation avec les priorités nationales que cette méthode axée sur les soins de santé primaires a pu être mise en œuvre en Éthiopie. Le pays a emprunté une approche diagonale vis-à-vis des programmes de contrôle des maladies, tout en renforçant les systèmes de santé, l'autonomie des communautés et l'action multisectorielle. Ces stratégies lui ont permis d'augmenter la prise en charge des services de santé et d'améliorer l'état de santé de la population. Il reste cependant d'importants défis à relever: couverture insuffisante des services, inégalités d'accès, lenteur de transition entre systèmes sanitaires pour la fourniture de prestations liées aux maladies non transmissibles, qualité médiocre des soins et frais non remboursables élevés. Afin de combler les lacunes au sein et en dehors du système de santé, le pays doit revoir le montant du financement octroyé aux soins de santé à la hausse, mais aussi cibler les régions et populations défavorisées par le biais d'une approche de précision en matière de santé publique. Ces défis doivent être abordés tout au long du programme de développement durable.

Varias instituciones sanitarias mundiales, incluida la Organización Mundial de la Salud, opinan que la atención primaria de salud es la vía hacia el logro de la cobertura sanitaria universal (CSU). Sin embargo, persisten las preocupaciones acerca de la viabilidad y la eficacia de este enfoque en los países de bajos recursos. Etiopía aplica el enfoque de la atención primaria de salud desde mediados del decenio de 1970, por lo que la atención primaria de salud es el núcleo del sistema de salud desde 1993. No obstante, Etiopía carece de pruebas integrales y generales sobre la práctica y la función de la atención primaria de salud orientada a la CSU. Se realizó un análisis documental de los datos cualitativos y cuantitativos a disposición del público. Se describe y analiza la práctica de la atención primaria de salud y se determinan los éxitos y los desafíos por medio del marco de la Iniciativa sobre el desempeño de la atención primaria de salud. La aplicación del enfoque de la atención primaria de salud en Etiopía fue posible gracias a las políticas, las estrategias y los programas que se adaptaron a las prioridades del país. Existe un enfoque diagonal de los programas de control de enfermedades sumado al fortalecimiento de los sistemas sanitarios, a la participación de la comunidad y a las medidas multisectoriales. Gracias a estas estrategias, el país ha logrado aumentar la cobertura de los servicios sanitarios y mejorar el estado de salud de la población. Sin embargo, aún quedan por resolver algunos desafíos fundamentales, como la cobertura insuficiente de los servicios, la falta de equidad en el acceso, la lentitud de la transición de los sistemas sanitarios para prestar los servicios correspondientes a las enfermedades no transmisibles, la calidad deficiente de la atención y los elevados gastos de bolsillo. Para resolver las deficiencias del sistema sanitario y otros aspectos, el país debe mejorar su financiamiento nacional para la salud y centrarse en los lugares y las poblaciones desfavorecidos a través de un enfoque preciso de la salud pública. Se debe abordar estos desafíos en todo el programa de desarrollo sostenible.

Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in Ethiopia.

Weakness of primary health-care (PHC) systems has represented a challenge to the achievement of the targets of disease control programmes (DCPs) despite the availability of substantial development assistance for health, in resource-poor settings. Since 2005, Ethiopia has embraced a diagonal investment approach to strengthen its PHC systems and concurrently scale up DCPs. This approach has led to a substantial improvement in PHC-system capacity that has contributed to increased coverage of DCPs and improved health status, although gaps in equity and quality in health services remain to be addressed. Since 2013, Ethiopia has had a decline in development assistance for health. Nevertheless, the Ethiopian Government has been able to compensate for this decline by increasing domestic resources. We argue that the diagonal investment approach can effectively strengthen PHC systems, achieve DCP targets, and sustain the gains. These goals can be achieved if a visionary and committed leadership coordinates its development partners and mobilises the local community, to ensure financial support to health services and improve population health. The lessons learnt from Ethiopia's efforts to improve its health services indicate that global-health initiatives should have a proactive and balanced investment approach to concurrently strengthen PHC systems, achieve programme targets, and sustain the gains, in resource-poor settings.

Outcomes of antiretroviral treatment program in Ethiopia: retention of patients in care is a major challenge and varies across health facilities.

BACKGROUND: Many resource-limited countries are scaling up antiretroviral treatment (ART) towards universal access. However, there are few studies which evaluated outcomes of ART programs in these countries. In addition, these studies generally include a limited number of facilities and patients creating a clear need for studies with a wide range of facilities and large numbers of patients. In this study, we intended to evaluate the outcomes of the ART services in 55 health facilities in Ethiopia. METHODS: A retrospective longitudinal study was conducted to determine levels of patient retention in care, CD4 count and shift to second-line ART regimen in 30 hospitals and 25 health centers selected as sentinel sites for monitoring the outcomes of ART program in the country. The outcomes were determined at baseline, after 6, 12 and 24 months on ART. Data was collected from routine patient registers and charts, and entered and analyzed using EPI-Info statistical software. RESULTS: Health facilities were able to retain 29,893 (80%), 20,079 (74%) and 5,069 (68%) of their patients after 6, 12 and 24 months on ART, respectively. Retention rates vary across health facilities, ranging from 51% to 85% after 24 months on ART. Mortality was 5%, 6% and 8% after 6, 12 and 24 months on ART. More than 79% of patients with available CD4-cell counts had a baseline CD4-cell counts less than 200 cells per micro-liter of blood. The median CD4-cell counts (based on patients who were retained after 24 months on ART) increased from 125 (inter-quartile (IQ), 68-189) at baseline to 242 (IQ, 161-343), 269 (IQ, 185-380) and 316 (IQ, 226-445) cells per micro-liter after 6, 12, and 24 months on ART, respectively. The transition to second-line ART remained very low, 0.33%, 0.58% and 2.13% after 6, 12 and 24 months on ART. CONCLUSION: The outcomes of the ART services in the 55 health facilities in Ethiopia are similar to those in other countries. Retention of patients in care is a major challenge and varies across health facilities with high, medium and low retention rates. We therefore recommend further studies to understand the organization of care in health facilities with high, medium and low retention rates. It is also imperative that early initiation of patients on ART is taken seriously as more than 79% of the patients had baseline CD4-cell counts less than 200 cells per micro-liter of blood. Finally, we recommend that the shift to second-line ART might be too low and warrants close monitoring.