An Assessment of Provider Payment Mechanisms (PPMs) in Ethiopia: Implications for Redesign of PPMs and Progress Toward Universal Health Coverage.

Ethiopia has made great strides in improving population health but sustaining health system and population health improvements in the current fiscal environment is challenging. Provider payment, as a function of purchasing, is a tool to use limited health resources better. This study describes the design and implementation of Ethiopia's provider payment mechanisms (PPMs) and how they influence health system objectives and contribute to universal health coverage goals. The research team adapted the framework and analytical tools of the Joint Learning Network for Universal Health Coverage guide for assessing PPMs. Data were collected through literature review and key informant interviews with 11 purchasers and 17 health care providers. Content analysis was used to describe PPM design and implementation arrangements, and thematic analysis was used to distill effects on equity in resource distribution and access to care, efficiency, quality of care, and financial sustainability. The study revealed the PPMs had positive and negative consequences. Line-item budgets were perceived to be predictable and sustainable but had little effect on efficiency and provider performance. Fee-for-service was perceived to have negative effects on efficiency and financial sustainability but viewed positively on its ability to incentivize quality health services. Capitation and performance-based financing effects were viewed positively on equity in distribution of resources and quality respectively, but both were perceived negatively on their high administrative burden to providers. Ethiopia may consider a more nuanced approach to design blended provider payment to mitigate negative consequences while providing incentives for better quality of care and efficiency.

Barriers to uptake of community-based health insurance in sub-Saharan Africa: a systematic review.

In the past two decades, community-based Health Insurance (CBHI) is expanding in most of sub-Saharan African countries with the aim of improving equitable access to health services for the informal sector population. However, population enrolment into CBHI and membership renewals thereafter remains stubbornly low. The purpose of this systematic review is to generate an evidence to better understand barriers to uptake of CBHI in sub-Saharan African countries. We systematically searched for relevant studies from databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychInfo, ProQest, Excerpta Medica dataBASE (EMBASE) and Africa-Wide Information. The search strategy combined detailed terms related to (i) CBHI, (ii) enrolment/renewal and (iii) sub-Saharan African countries. A narrative synthesis of findings was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol for this systematic review was registered with International Prospective Register of Systematic Reviews (PROSPERO) (ref: CRD42020183959). The database search identified 4055 potential references from which 15 articles reporting on 17 studies met the eligibility criteria. The findings revealed that barriers to uptake of CBHI in sub-Saharan Africa were multidimensional in nature. Lack of awareness about the importance of health insurance, socio-economic factors, health beliefs, lack of trust towards scheme management, poor quality of health services, perceived health status and limited health benefit entitlements were reported as barriers that affect enrolments into CBHI and membership renewals. The methodological quality of studies included in this review has been found to be mostly suboptimal. The overall findings of this systematic review identified major barriers of CBHI uptake in sub-Saharan African countries which may help policymakers to make evidence-informed decisions. Findings of this review also highlighted that further research with a robust methodological quality, depth and breadth is needed to help better understand the factors that limit CBHI uptake at individual, societal and structural levels in sub-Saharan Africa.

Hospital-based ciprofloxacin use evaluation in Eastern Ethiopia: a retrospective assessment of clinical practice.

INTRODUCTION: ciprofloxacin is a second-generation fluoroquinolone, which has been used as one of the top three antibacterial agents prescribed in Ethiopia. However, its use has deviated from the recommendation of standard treatment guidelines resulting in a gradual increase in antimicrobial resistance. Therefore, this study aimed to evaluate the annual use of ciprofloxacin in 2016 based on the standard Ethiopian treatment and World Health Organization guidelines, in governmental hospitals, in Eastern Ethiopia from 1st May to 30th June 2018. METHODS: a hospital-based retrospective cross-sectional study was conducted to evaluate medical records of patients who had taken ciprofloxacin in 2016. The total sample size (n=522) was proportionally allocated to each hospital based on the respective consumption data. A simple random sampling method was employed to collect the required sample. The collected data were entered into SPSS version 21 and analyzed using descriptive analysis. RESULTS: in this study, 522 medical records were reviewed, with a male to female ratio of 1.03: 1. Ciprofloxacin was indicated in 478 (91.6%) participants whose age was greater than eighteen years. The majority were treated in the medical and emergency outpatient departments (n=477, 91.4%). Urinary tract infections (n=224, 42.9%), acute febrile illnesses (n=68, 13.0%), and typhoid fever (n=54, 10.4%) were the top indications to which ciprofloxacin was prescribed. Non-steroidal anti-inflammatory drugs (NSAIDs) (n=241, 34.7%) and antimicrobials (n=135, 19.6%) were among the most frequently co-indicated agents. Based on the standard Ethiopian treatment guidelines, therapy was appropriate in 30% (n= 159) of patients. The major reason for inappropriate utilization (95%) was the wrong duration of antibiotic use (n=228). Evaluation based on World Health Organization criteria showed that indication, dose, and frequency were in line with the recommendation. CONCLUSION: ciprofloxacin was primarily indicated for urinary tract infections. The drug was appropriately used in less than one-third of patients, with the wrong duration being the main reason for overall inappropriate utilization. This trend may potentially impose a high risk to the emergence of drug-resistant microorganisms. To this end, further studies addressing the susceptibility pattern of bacterial isolates towards ciprofloxacin should be carried out.