Costs and resource needs for primary health care in Ethiopia: evidence to inform planning and budgeting for universal health coverage.

Introduction: The Government of Ethiopia (GoE) has made significant progress in expanding access to primary health care (PHC) over the past 15 years. However, achieving national PHC targets for universal health coverage will require a significant increase in PHC financing. The purpose of this study was to generate cost evidence and provide recommendations to improve PHC efficiency. Methods: We used the open access Primary Health Care Costing, Analysis, and Planning (PHC-CAP) Tool to estimate actual and normative recurrent PHC costs in nine Ethiopian regions. The findings on actual costs were based on primary data collected in 2018/19 from a sample of 20 health posts, 25 health centers, and eight primary hospitals. Three different extrapolation methods were used to estimate actual costs in the nine sampled regions. Normative costs were calculated based on standard treatment protocols (STPs), the population in need of the PHC services included in the Essential Health Services Package (EHSP) as per the targets outlined in the Health Sector Transformation Plan II (HSTP II), and the associated costs. PHC resource gaps were estimated by comparing actual cost estimates to normative costs. Results: On average, the total cost of PHC in the sampled facilities was US$ 11,532 (range: US$ 934-40,746) in health posts, US$ 254,340 (range: US$ 68,860-832,647) in health centers, and US$ 634,354 (range: US$ 505,208-970,720) in primary hospitals. The average actual PHC cost per capita in the nine sampled regions was US$ 4.7, US$ 15.0, or US$ 20.2 depending on the estimation method used. When compared to the normative cost of US$ 38.5 per capita, all these estimates of actual PHC expenditures were significantly lower, indicating a shortfall in the funding required to deliver an expanded package of high-quality services to a larger population in line with GoE targets. Discussion: The study findings underscore the need for increased mobilization of PHC resources and identify opportunities to improve the efficiency of PHC services to meet the GoE's PHC targets. The data from this study can be a critical input for ongoing PHC financing reforms undertaken by the GoE including transitioning woreda-level planning from input-based to program-based budgeting, revising community-based health insurance (CBHI) packages, reviewing exempted services, and implementing strategic purchasing approaches such as capitation and performance-based financing.

Optimizing tubal ligation service delivery: a prospective cohort study to measure the task-sharing experience of Marie Stopes International Ethiopia.

The Ethiopian government implements a progressive task-sharing policy for health services as a strategy to address shortages of highly skilled providers and increase access to critical services, such as family planning. Since 2009, Marie Stopes International Ethiopia has trained health officers to provide tubal ligations, a permanent method of family planning, as part of its task-sharing strategy. The objectives of this research were to evaluate task-sharing tubal ligations to health officers at Marie Stopes International Ethiopia, specifically: (a) to investigate safety, as measured by the proportion of major adverse events; (b) to evaluate the feasibility, as measured by adherence to the standard tubal ligation procedure protocol and (c) to investigate acceptability to clients of the tubal ligation procedure provided by health officers. We established a prospective cohort of women aged ≥18 years presenting for tubal ligation at Marie Stopes International Ethiopia sites in three regions in Ethiopia (March­May 2014). Data on adverse events (incomplete procedure, pain, bleeding, infection, perforation) were collected intra-operatively; peri-operatively (1-h post-procedure); and post-operatively (7 days post-procedure). To measure feasibility, 65% of procedures were selected for 'audit', where a nurse observed and scored health officers adherence to standard protocol using an 18-item checklist. To assess acceptability, women were asked about their satisfaction with the procedure. In total, 276 women were enrolled in the study. 97.5% of procedures took place in rural settings. All participants were followed up 7 days post-procedure (100% response rate). The overall proportion of major adverse events was 3% (95% CI 1­6%). The most frequent adverse event was 'failure to complete the TL' (2.2%, n = 6). The average score on protocol adherence was 96.9%. Overall, 98.2% (n = 271) of clients would recommend the procedure to a friend. Findings from this study, indicating safety, feasibility and acceptability, are consistent with the existing literature, which indicate safety and acceptability for task-sharing tubal ligations, and other methods of contraception with non-physician health providers. This study adds to scant literature on task-sharing tubal ligations in rural and low-resource settings.