Effectiveness of public health spending: Investigating the moderating role of governance using partial least squares structural equation modelling (PLS-SEM).

BACKGROUND: The link between public health spending (PHS) and population health outcomes (PHO) has been extensively studied. However, in sub-Saharan Africa (SSA), the moderating effects of governance in this relationship are little known. Furthermore, studies have focused on mortality as the main health outcome. This study contributes to this literature by investigating the moderating role of governance in the relationship by simultaneously assessing three dimensions of governance (corruption control, government effectiveness and voice accountability) using disability-adjusted life years (DALYs) as a measure of outcomes. METHODS: The study applies the two-stage moderation approach using partial least squares structural equation modelling (PLS-SEM) to panel data from 43 SSA nations from 2013 to 2019. The study also uses domestic general government health expenditure (DGGHE) as an independent variable and disability-adjusted life years (DALY) as the dependent variable in this relationship. RESULTS: The analysis reveals that DGGHE affects DALY negatively and that governance improves the effect of DGGHE on DALY, with bigger improvements among countries with worse governance. CONCLUSION: These findings provide evidence that good governance is crucial to the effectiveness of PHS in SSA nations. Sub-Saharan Africa (SSA) countries should improve governance to improve population health.

Chronic respiratory disease observatory for Africa (CHEST-Africa): study protocol for the prevalence, determinants and economic impacts of asthma and COPD in Africa.

INTRODUCTION: Contemporary data on the burden of chronic respiratory diseases in sub-Saharan Africa is limited. More so, their economic burden is not well described. This study aims to establish a chronic respiratory disease observatory for Africa. Specific study aims are (1) to describe the prevalence and determinants of asthma with a target to screen up to 4000 children and adolescents across four African cities; (2) to determine the prevalence and determinants of chronic obstructive pulmonary disease (COPD) with a target to screen up to 3000 adults (≥18 years) across five African cities; (3) to describe the disease burden by assessing the frequency and severity of symptoms and exacerbations, medication use, emergency healthcare utilisation and hospitalisation; and (4) to assess the economic burden and affordability of the medicines for these diseases. METHODS AND ANALYSIS: Surveys will be conducted in schools to identify children and adolescents with asthma using the Global Asthma Network screening questionnaire in Ghana, Nigeria, the Democratic Republic of Congo, and Uganda. Community surveys will be conducted among adults using an adapted version of the Burden of Obstructive Lung Disease Questionnaire to identify persons with COPD symptoms in Nigeria, Burkina Faso, Mozambique, Rwanda, and Sierra Leone. Fractional exhaled nitric oxide and pre-bronchodilator and post-bronchodilator spirometry will be done for children with asthma or asthma symptoms and for all adult participants. Children and adults with respiratory symptoms or diagnoses will complete the health economic questionnaires. Statistical analysis will involve descriptive and analytical statistics to determine outcomes. ETHICS AND DISSEMINATION: Ethical approval has been obtained from participating institutions. This study's results will inform deliberations at the United Nations General Assembly high-level meeting on non-communicable diseases in 2025. The results will be shared through academic conferences and journals and communicated to the schools and the communities.

Health technology assessment for sexual reproductive health and rights benefits package design in sub-Saharan Africa: A scoping review of evidence-informed deliberative processes.

BACKGROUND: Health technology assessment uses a multidisciplinary approach to support health benefits package design towards universal health coverage. The evidence-informed deliberative process framework has been used alongside Health technology assessment to enhance stakeholder participation and deliberations in health benefits package design. Applying the evidence-informed deliberative framework for Health assessment could support the morally diverse sexual reproductive health and rights (SRHR) benefits package design process. However, evidence on participation and deliberations for stakeholders in health technology assessment for SRHR benefits package design has not been curated in sub-Saharan Africa. This study synthesises literature to fill this gap. METHODS: This scoping review applies the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews, and deductive analysis following the evidence-informed deliberative processes framework. The search strategy uses the Guttmacher-Lancet Commission-proposed comprehensive definition of SRHR and the World Health Organisation's universal health coverage compendium of SRHR interventions to generate search terms. Six databases and biographical hand searches were used to identify studies in Sub-Saharan Africa from 1994. RESULTS: A total of 14 studies met the inclusion criteria. Evidence for yearly public budgets and explicit SRHR health technology assessment processes was not found. In 12 of the studies reviewed, new advisory committees were set up specifically for health technology assessment for SRHR priority-setting and benefits package design. In all decision-making processes reviewed, the committee member roles, participation and deliberations processes, and stakeholder veto powers were not clearly defined. Patients, the public, and producers of health technology were often excluded in the health technology assessment for the SRHR benefits package design. Most health technology assessment processes identified at least one decision-making criterion but failed to use this in their selection and appraisal stages for SRHR benefits design. The identification, selection, and scoping stages in health technology assessment for SRHR were non-existent in most studies. In 11 of the 14 processes of the included studies, stakeholders were dissatisfied with the health policy recommendation from the appraisal process in health technology assessment. Perceived benefits for evidence-informed deliberative processes included increased stakeholder engagement and fairness in decision-making. CONCLUSION: To support the integration of diverse social values in health technology assessment for fairer SRHR benefits package design, evidence from this review suggests the need to institutionalise health technology assessment, establish prioritisation decision criteria, involve all relevant stakeholders, and standardise the process and assessment methodological approaches.

Public health spending in Sub-Saharan Africa: exploring transmission mechanisms using the latent growth curve mediation model.

In response to the imperatives of universal health coverage, structural factors that may hinder the effectiveness of increased spending in sub-Saharan Africa (SSA) need attention. This study assessed the mediating role of these factors in domestic general government health expenditure (DGGHE) effects to propose solutions for improving population health outcomes (PHO). The analysis used the Latent Growth Curve Mediation Model (LGCMM) approach within the structural equation model (SEM) framework for panel data from 42 SSA countries from 2015 to 2018. The findings were that malaria and female education formed a channel through which DGGHE imparted its effects on DALY in SSA, and these effects were achieved via the specific path from the DGGHE slope to the DALY slope, via malaria and female education slopes. However, the paper found no evidence of immunization coverage mediating the relationship between DGGHE and DALY in SSA. The paper concludes that structural factors affect the effectiveness of DGGHE on PHO, implying that governments should emphasize existing programs to fight against malaria and increase immunization coverage.

Health and total factor productivity nexus in selected sub-Saharan African countries: quadratic and threshold modelling.

OBJECTIVES: The sub-Saharan African (SSA) countries have been recording a decline in total factor productivity (TFP) growth, inadequate health funding and poor health outcomes are regarded as problems that might have impeded productivity in the region. This study therefore aligns with Grossman's theory that better health could be instrumental to productivity growth. In this paper, we establish a predictive TFP model that accommodates the roles of health, which has been omitted in prior studies. To corroborate our findings we examine the threshold relationship between health and TFP. METHODS: The study employs the fixed and random effect model, panel two-stage least squares, static and dynamic panel threshold regression model on a balanced panel data of 25 selected SSA countries from 1995 to 2020 as the estimating technique for the linear relationship and the non-linear relationship between health and TFP. RESULTS: The result of the analysis reveals a positive relationship between health expenditure and TFP, health expenditure per capita and TFP. Education and other non-health factors, like Information Communication Technology (ICT) and control of corruption equally have significant positive impact on TFP. The result further shows the existence of a threshold relationship between TFP and health at 3.5% level of public health expenditure. We also discover threshold relationship between TFP and some non-health variables like education and ICT at 2.56% and 21%, respectively CONCLUSIONS: More importantly, the study confirms health as a determinant of TFP and also validates the existence of a non-linear relationship between TFP and health. Overall, improvements in health and its proxies have implications for TFP growth in SSA. Therefore, the increase in public health expenditure stipulated in this study should be passed into law for optimal productivity growth rate.

Macro-economic determinants, maternal and infant SDG targets in Nigeria: Correlation and predictive modeling.

Objectives: Unambiguously, Nigeria is off-track in achieving the health-related SDGs. Consequentially, this study aligns with SDG 3 which calls for "good health and wellbeing for people by ensuring healthy lives and promoting wellbeing for all at all ages". This article examines the combined effect of health expenditure and other key macro-economic factors on health indices such as maternal and newborn and child mortality in Nigeria. Contrary to existing literature, we formulated a model that predicts the level of macro-economic determinants needed to achieve the SDG targets for maternal and newborn and child mortality in Nigeria by 2030. Methodology: The study used Autoregressive Distributed Lag (ARDL), which is usually used for large T models. The study period spans from 1995 to 2020. Results: We found a significant negative relationship between health outcomes and macro-economic determinants namely, household consumption, total health expenditure, and gross fixed capital while we determined a significant positive relationship between health outcomes and unemployment. Our findings are further supported by out-of-sample forecast results suggesting a reduction in unemployment to 1.84 percent and an increase in health expenditure, gross fixed capital, household consumption, control of corruption to 1,818.87 billon (naira), 94.46 billion (naira), 3.2 percent, and -4.2 percent respectively to achieve SDG health targets in Nigeria by 2030. Policy implication: The outcome of this result will give the Nigerian government and stakeholders a deeper understanding of the workings of the macro-economic factors, concerning health performance and will help position Nigeria, and other SSA countries by extension, toward reducing maternal mortality to 70 per 100,000 and newborn and child mortality to 25 per 1,000 births by 2030. The African leaders should consider passing into law the need for improvement in macro-economic factors for better health in Africa. We also recommend that the Nigerian government should steadily increase health expenditure to reach and move beyond the forecast level for improvement in maternal and infant mortality, given the present low and unimpressive funding for the health sector in the country.

Sustainable thresholds, health outcomes, health expenditures and education nexus in selected African countries: quadratic and moderation modelling.

BACKGROUND: This study aligns with Sustainable Development Goal 3 which borders on "good health and well-being for people by ensuring healthy lives and promoting well-being for all at all ages". It contributes to the health literature by evaluating the roles of health expenditures and educational quality on three health outcomes (infant mortality, maternal mortality and life expectancy at birth). METHODS: The study uses the panel spatial correlation consistent (PSCC) approach on balanced panel data on 25 selected sub-Saharan African countries from 2000 to 2020 to interrogate the nexus. RESULTS: The following findings are documented. First, health expenditures reveal significant asymmetric quadratic effects on health outcomes. Second, the interactions between health expenditures and educational quality reduce infant and maternal mortalities while enhancing life expectancy. Third, the threshold points from the interaction effects indicate that enhancing educational quality beyond some critical thresholds of 1.51 and 1.49 can induce a drop in maternal and child mortalities while a point beyond 1.84 exerts an improvement in life expectancy. CONCLUSIONS: Hence, policy makers should ensure that both health expenditures and educational quality exceed the established thresholds for sustainable health outcomes.

Institutional Arrangements for Providing HIV and AIDS Services in Uganda: A Transaction Cost Economics Analysis.

Transaction cost economics (TCE) theory predicts that features of institutional arrangements determine the intensity of their governance instruments. Consequently, institutional features link to transaction costs, but the linkages have received little attention in the public health literature. This study sought to address this gap. It examined the governance features of institutional arrangements and their transaction cost implications for providing HIV prevention and social support services in Uganda. The analysis was based on 4 proposed TCE governance instruments: administrative controls, adaptation, incentives and contract laws. These governance instruments were assessed in 3 modes of delivery( institutional arrangments) for HIV and AIDS Services in Uganda: Contracting-Out - the case of DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe); a Public-Non-Governmental Organisation (NGO) partnership - the case of the CHAI (Community-led HIV/AIDS Initiative); and direct Public Sector Delivery. These assessed delivery modes follow Williamson's TCE framework of 3 institutional arrangements to deliver goods and services, notably market, hybrid (partnership) and internal (hierarchy) delivery, with related governance features. Within this framework, the discriminating alignment hypothesis guided the analysis. According to the hypothesis, the delivery modes of goods and services result in smaller transaction costs when their governance features are as predicted by TCE. The hypothesis was assessed by analysing, with qualitative methods, the differences in HIV and AIDS services characteristics across the 3 arrangements and their differences with theory prediction, and hence the difference in transaction cost implications. The study found that the delivery arrangements that minimised cost are those whose HIV and AIDS services were aligned with the TCE theory prediction. The aligned 'public-NGO partnership' arrangement (CHAI) had fewer sources of transactional costs than the misaligned arrangements - 'contracting-out' (DREAMS) and 'public sector'. The analysis revealed that the DREAMS and public sector delivery models suffered some flaws in efficiencies. DREAMS had high administrative controls, high-powered tangible incentive intensity and intensive monitoring mechanisms for performance adaptation due to the lack of 'trust' on the part of the financing agency, contrary to the TCE prediction. In contrast with the TCE prediction, low administrative controls in the public sector arose from the failure to invest in performance monitoring systems. The high-powered incentive intensity and low administrative controls observed in the CHAI arrangement primarily stemmed from the reliance on informal institutions (trust, social expectations and reputation) rather than principal-agent arms-length sanctions. These results suggest that the level of transaction costs is associated with features of institutional arrangements. The valuable insights from TCE could contribute to policymaking during the design of institutional arrangements to efficiently deliver HIV and AIDS services.

Socio-economic drivers and effects of contraceptive usage on breast cancer among women in Nigeria.

Certain types of contraceptives might have adverse effects on women's health including the possibility of causing breast cancer (BC). Furthermore, the types of contraceptives used might depend on the socioeconomic status of women. The triangular linkage of socioeconomic factors, contraceptives, and some factors causing BC among women are scarce in the literature, especially in developing countries. Consequently, the objectives of the study are to investigate the socio-economic drivers of BC and assess effects of contraceptive on BC among women in Nigeria. Cross-sectional data were collected on a one-off participant at a particular point in time using questionnaires on 200 women with confirmed cases of BC in Southwest, Nigeria, on a continuous visitation to the hospitals over six months. Structural equation modeling (SEM) with strong evidence from path analysis was adopted to achieve the objectives. Exploratory factors analysis was adopted to identify the socio-economic factors. The study analysed certain socioeconomic pre-determinants of BC through the use of contraceptives among women in Southwest Nigeria. The study provided evidence that some tested socioeconomic factors influence women in the use of contraceptive implants (C2) and oral contraceptives (C3), at a 1% level of significance. While about 76.8% of variations in socio-economic factors cause women to adopt a contraceptive implant, 81.1% of socioeconomic factors cause women to adopt oral contraceptives. Again, the result further provided evidence that socioeconomic factors (CCT) are strong determinants of BC at a 1% level of significance. Given the women-specific peculiarities, implanted contraceptives and oral contraceptives should be carefully administered by medical scientists.

Socio-economic drivers and effects of contraceptive usage on breast cancer among women in Nigeria

Certain types of contraceptives might have adverse effects on women's health including the possibility of causing breast cancer (BC). Furthermore, the types of contraceptives used might depend on the socioeconomic status of women. The triangular linkage of socioeconomic factors, contraceptives, and some factors causing BC among women are scarce in the literature, especially in developing countries. Consequently, the objectives of the study are to investigate the socio-economic drivers of BC and assess effects of contraceptive on BC among women in Nigeria. Cross-sectional data were collected on a one-off participant at a particular point in time using questionnaires on 200 women with confirmed cases of BC in Southwest, Nigeria, on a continuous visitation to the hospitals over six months. Structural equation modeling (SEM) with strong evidence from path analysis was adopted to achieve the objectives. Exploratory factors analysis was adopted to identify the socio-economic factors. The study analysed certain socioeconomic pre-determinants of BC through the use of contraceptives among women in Southwest Nigeria. The study provided evidence that some tested socioeconomic factors influence women in the use of contraceptive implants (C2) and oral contraceptives (C3), at a 1% level of significance. While about 76.8% of variations in socio-economic factors cause women to adopt a contraceptive implant, 81.1% of socioeconomic factors cause women to adopt oral contraceptives. Again, the result further provided evidence that socioeconomic factors (CCT) are strong determinants of BC at a 1% level of significance. Given the women-specific peculiarities, implanted contraceptives and oral contraceptives should be carefully administered by medical scientists.

Socio-economic inequalities in the multiple dimensions of access to healthcare: the case of South Africa.

BACKGROUND: The National Development Plan (NDP) strives that South Africa, by 2030, in pursuit of Universal Health Coverage (UHC) achieve a significant shift in the equity of health services provision. This paper provides a diagnosis of the extent of socio-economic inequalities in health and healthcare using an integrated conceptual framework. METHOD: The 2012 South African National Health and Nutrition Examination Survey (SANHANES-1), a nationally representative study, collected data on a variety of questions related to health and healthcare. A range of concentration indices were calculated for health and healthcare outcomes that fit the various dimensions on the pathway of access. A decomposition analysis was employed to determine how downstream need and access barriers contribute to upstream inequality in healthcare utilisation. RESULTS: In terms of healthcare need, good and ill health are concentrated among the socio-economically advantaged and disadvantaged, respectively. The relatively wealthy perceived a greater desire for care than the relatively poor. However, postponement of care seeking and unmet need is concentrated among the socio-economically disadvantaged, as are difficulties with the affordability of healthcare. The socio-economic divide in the utilisation of public and private healthcare services remains stark. Those who are economically disadvantaged are less satisfied with healthcare services. Affordability and ability to pay are the main drivers of inequalities in healthcare utilisation. CONCLUSION: In the South African health system, the socio-economically disadvantaged are discriminated against across the continuum of access. NHI offers a means to enhance ability to pay and to address affordability, while disparities between actual and perceived need warrants investment in health literacy outreach programmes.

Impact of the adolescent and youth sexual and reproductive health strategy on service utilisation and health outcomes in Zimbabwe.

Poor reproductive health among youth and adolescents threatens their future health and economic wellbeing in Zimbabwe amidst a high HIV/AIDS prevalence. This study evaluates the impact of a multi-pronged adolescent sexual and reproductive health (ASRH) strategy implemented by government of Zimbabwe between 2010 and 2015 to improve ASRH in terms of the uptake of condoms and HIV testing as well as outcomes in terms of sexually transmitted infection (STI) prevalence and HIV prevalence. We combine the difference in difference and propensity score matching methods to analyse repeated Zimbabwe demographic health survey cross-sectional datasets. Young people aged 15-19 years at baseline in 2010, who were exposed for the entire five-year strategy are designated as the treatment group and young adults aged 25-29 at baseline as the control. We find that the ASRH strategy increased HIV testing amongst youth by 36.6 percent, whilst treatment of STIs also increased by 30.4 percent. We also find that the HIV prevalence trajectory was reduced by 0.7 percent. We do not find evidence of impact on condom use and STI prevalence. The findings also suggest that although HIV testing increased for all socio-economic groups that were investigated, the effect was not the same. Lastly, we do not find evidence supporting that more resources translate to better ASRH outcomes. We recommend designing future ASRH strategies in a way that differentiates service delivery for youths in HIV hotspots, rural areas and out of school. We also recommend improving the strategy's coordination and monitoring, as well as aligning and enforcing government policies that promote sexual and reproductive health rights.

Assessing the cost of providing a prevention of mother-to-child transmission of HIV/AIDS service in Ethiopia: urban-rural health facilities setting.

BACKGROUND: While local context costing evidence is relevant for healthcare planning, budgeting and cost-effectiveness analysis, it continues to be scarce in Ethiopia. This study assesses the cost of providing a prevention of mother-to-child transmission of HIV/AIDS (PMTCT) service across heterogeneous prevalence (high, low) and socio-economic (urban, rural) contexts. METHODS: A total of 12 health facilities from six regions in Ethiopia were purposively selected from the latest 2012 antenatal sentinel HIV prevalence report. Six health facilities with the highest HIV prevalence (8.1 to 17.3%) in urban settings and six health facilities with the lowest prevalence (0.0 to 0.1%) in rural settings were selected. A micro-costing approach was applied to identify, measure and value resources used for the provision of a comprehensive PMTCT service. The analysis was conducted across different PMTCT service packages. We also estimated national costs in urban and rural contexts. RESULTS: The average cost per pregnant woman-infant pair per year (PPY) ranged from ETB 6280 (USD 319) to ETB 21,620 (USD 1099) in the urban high HIV prevalence health facilities setting. In rural low HIV prevalence health facilities, the cost ranged from ETB 4323 (USD 220) to ETB 7539 (USD 383).PMTCT service provision in urban health facilities costs more than twice the cost in rural health facilities. The average cost per PPY in an urban setting was more than double the cost in a rural setting due to the higher cost of inputs and possible inefficiencies (although there were a higher number of visits). Consumables (including antiretroviral drugs) and infrastructure were the major cost drivers in both the urban and rural health facilities. Among PMTCT service components, anti-retroviral treatment Option B+ follow-up and counselling accounted for the highest proportion of costs, which ranged from 58 to 72%. Nationally, at the current coverage, the cost of PMTCT service was USD 6 million and USD 3 million in urban and rural settings, respectively. CONCLUSIONS: The analysis suggests that resources used for PMTCT service packages varied across health facilities and HIV prevalence contexts. Providing PMTCT service in the high HIV prevalence urban health facilities costs more than in the rural facilities. Context-specific costing was vital to provide locally sensitive evidence for health service management and priority setting.

Factors associated with the utilization of antenatal care and prevention of mother-to-child HIV transmission services in Ethiopia: applying a count regression model.

BACKGROUND: Prevention of Mother-to-Child HIV Transmission (PMTCT) coverage has been low in Ethiopia and the service has been implemented in a fragmented manner. Solutions to this problem have mainly been sought on the supply-side in the form of improved management and allocation of limited resources. However, this approach largely ignores the demand-side factors associated with low PMTCT coverage in the country. The study assesses the factors associated with the utilization of PMTCT services taking into consideration counts of visits to antenatal care (ANC) services in urban high-HIV prevalence and rural low-HIV prevalence settings in Ethiopia. METHODS: A multivariate regression model was employed to identify significant factors associated with PMTCT service utilization. Poisson and negative binomial regression models were applied, considering the number of ANC visits as a dependent variable. The explanatory variables were age; educational status; type of occupation; decision-making power in the household; living in proximity to educated people; a neighborhood with good welfare services; location (urban high-HIV prevalence and rural low-HIV prevalence); transportation accessibility; walking distance (in minutes); and household income status. The alpha dispersion test (a) was performed to measure the goodness-of-fit of the model. Significant results were reported at p-values of < 0.05 and < 0.001. RESULTS: Household income, socio-economic setting (urban high-HIV prevalence and rural low-HIV prevalence) and walking distance (in minutes) had a statistically significant relationship with the number of ANC visits by pregnant women (p < 0.05). A pregnant woman from an urban high-HIV prevalence setting would be expected to make 34% more ANC visits (counts) than her rural low-HIV prevalence counterparts (p < 0.05). Holding other variables constant, a unit increase in household income would increase the expected ANC visits by 0.004%. An increase in walking distance by a unit (a minute) would decrease the number of ANC visits by 0.001(p < 0.001). CONCLUSION: Long walking distance, low household income and living in a rural setting are the significant factors associated with low PMTCT service utilization. The primary strategies for a holistic policy to improve ANC/PMTCT utilization should thus include improving the geographical accessibility of ANC/PMTCT services, expanding household welfare and paying more attention to remote rural areas.

HIV-positive pregnant women attending the prevention of mother-to-child transmission of HIV/AIDS (PMTCT) services in Ethiopia: economic productivity losses across urban-rural settings.

HIV/AIDS impacts significantly on pregnant women and on children in Ethiopia. This impact has a multiplier effect on household economies and on productivity losses, and is expected to vary across rural and urban settings. Applying the human capital approach to data collected from 131 respondents, this study estimated productivity losses per HIV-positive pregnant woman-infant pair across urban and rural health facilities in Ethiopia, which in turn were used to estimate the national productivity loss. The study found that the annual productivity loss per woman-infant pair was Ethiopian birr (ETB) 7,433 or United States dollar (US$) 378 and ETB 625 (US$ 32) in urban and rural settings, respectively. The mean patient days lost per year due to inpatient admission at hospitals/health centres was 11 in urban and 22 in rural health facilities. On average, urban home care-givers spent 20 (SD = 21) days annually providing home care services, while their rural counterparts spent 23 days (SD = 26). The productivity loss accounted for 16% and 7% of household income in urban and rural settings, respectively. These high and varying productivity losses require preventive interventions that are appropriate to each setting to ensure the welfare of women and children in Ethiopia.

Economic Evaluation in Ethiopian Healthcare Sector Decision Making: Perception, Practice and Barriers.

BACKGROUND: Globally, economic evaluation (EE) is increasingly being considered as a critical tool for allocating scarce healthcare resources. However, such considerations are less documented in low-income countries, such as in Ethiopia. In particular, to date there has been no assessment conducted to evaluate the perception and practice of and barriers to health EE. OBJECTIVE: This paper assesses the use and perceptions of EE in healthcare decision-making processes in Ethiopia. METHODS: In-depth interview sessions with decision makers/healthcare managers and program coordinators across six regional health bureaus were conducted. A qualitative analysis approach was conducted on three thematic areas. RESULTS: A total of 57 decision makers/healthcare managers were interviewed from all tiers of the health sector in Ethiopia, ranging from the Federal Ministry of Health down to the lower levels of the health facility pyramid. At the high-level healthcare decision-making tier, only 56 % of those interviewed showed a good understanding of EE when explaining in terms of cost and consequences of alternative courses of action and value for money. From the specific program perspective, 50 % of the prevention of mother-to-child transmission of HIV/AIDS program coordinators indicated the relevance of EE to program planning and decision making. These respondents reported a limited application of costing studies on the HIV/AIDS prevention and control program, which were most commonly used during annual planning and budgeting. CONCLUSION: The study uncovered three important barriers to growth of EE in Ethiopia: a lack of awareness, a lack of expertise and skill, and the traditional decision-making culture.