Perspectives of key decision makers on out-of-pocket payments for medicines in the Ethiopian healthcare system: a qualitative interview study.

OBJECTIVE: This study aimed to explore the perspectives of key decision makers on out-of-pocket (OOP) payment for medicines and its implications in the Ethiopian healthcare system. DESIGN: A qualitative design that employed audiorecorded semistructured in-depth interviews was used in this study. The framework thematic analysis approach was followed in the analysis. SETTING: Interviewees came from five federal-level institutions engaged in policymaking (three) and tertiary referral-level healthcare service provision (two) in Ethiopia. PARTICIPANTS: Seven pharmacists, five health officers, one medical doctor and one economist who held key decision-making positions in their respective organisations participated in the study. RESULT: Three major themes were identified in the areas of the current context of OOP payment for medicines, its aggravating factors and a plan to reduce its burden. Under the current context, participants' overall opinions, circumstances of vulnerability and consequences on households were identified. Factors identified as aggravating the burden of OOP payment were deficiencies in the medicine supply chain and limitations in the health insurance system. Suggested mitigation strategies to be implemented by the health providers, the national medicines supplier, the insurance agency and the Ministry of Health were categorised under plans to reduce OOP payment. CONCLUSION: The findings of this study indicate that there is widespread OOP payment for medicines in Ethiopia. System level constraints such as weaknesses in the supply system at the national and health facility levels have been identified as critical factors that undermine the protective effects of health insurance in the Ethiopian context. Ensuring steady access to essential medicines requires addressing health system and supply constraints in addition to a well-functioning financial risk protection systems.

The financial burden of out of pocket payments on medicines among households in Ethiopia: analysis of trends and contributing factors.

BACKGROUND: In Ethiopia, out-of-pocket (OOP) payment is the key means of healthcare financing, and expenses on medicines are a crucial component of such payment. This study aims to investigate the financial implications of OOP payments on medicines for Ethiopian households. METHODS: The study involved a secondary data analysis of the national household consumption and expenditure surveys of 2010/11 and 2015/16. The "capacity-to-pay" method was used to calculate catastrophic OOP medicine expenditures. The extent of economic status related to catastrophic medicine payment inequity was calculated using concentration index estimation. The impoverishment consequences of OOP payment on medicine were estimated using poverty headcount and poverty gap analysis methods. Logistic regression models were used to identify the variables that predict catastrophic medicine payments. RESULTS: Medicines accounted for the majority of healthcare spending (> 65%) across the surveys. From 2010 to 2016, the total percentage of households facing catastrophic medicine payments decreased from 1% to 0.73%. However, the actual number of people expected to have experienced catastrophic medicine payments increased from 399,174 to 401,519 people. Payment for medicines pushed 11,132 households into poverty in 2015/16. The majority of disparities were explained by economic status, place of residence, and type of health services. CONCLUSION: OOP payment on medicine accounted for the majority of total health expenses in Ethiopia. A high medicine OOP payment continued to push households into catastrophic payments and impoverishment. Household seeking inpatient care, those with lower economic status and urban residents were among the most affected. Hence, innovative approaches to improve the supply of medicines in public facilities especially those in urban settings and risk protection mechanisms for medicine expenditures particularly for inpatient care are recommended.

Health professionals' perceptions on local production and bioequivalence study of generic medicines: A cross-sectional survey of physicians and pharmacy professionals in Addis Ababa, Ethiopia.

Local production of generic medicines in developing countries has a critical role to meet public health needs by ensuring the availability of essential medicines and providing patients' relief from the burden of unaffordable medical bills. Compliance with bioequivalence (BE) requirements increase the quality and competitiveness of generic drugs regardless of the source. In this regard, a regional BE center has been established in Addis Ababa, Ethiopia to serve the needs of Ethiopia and neighbouring countries. The present study aimed to assess the knowledge and perceptions of health professionals working in Addis Ababa regarding local production and BE studies of generic medicines. A cross-sectional survey was employed and physician participants working at public hospitals and pharmacists from various practice settings were selected using convenient sampling technique. Data was collected using self-administered structured questionnaire. Descriptive statistics was used to summarize the data and multinomial logistic regression analyses was used to assess predictors of health professionals' perception towards the source of drugs. Statistically significant association was declared at p-value < 0.05. A total of 416 participants responded and 272 (65.4%) of them were male. Nearly half of the study participants (n = 194) preferred the imported products. Compared to physicians, participants with diploma (AOR = 0.40; 95%CI: 0.18-0.91, p = 0.028) and bachelor degree and above holders (AOR = 0.32; 95%CI: 0.15-0.68, p = 0.003) in pharmacy were more likely to prefer locally produced products. Participants who practiced in pharmaceutical industries (AOR = 0.40, 95%CI: 0.22-0.77, p = 0.006) preferred locally manufactured products as compared to those practicing in the hospital. While a majority (321, 77.2%) believed in the advantages of doing BE studies locally, only 106 (25.5%) recognized that local pharmaceutical manufacturers did not implement BE studies for their generic products and lack of enforcement by the national regulatory body was raised as a reason for not conducting BE studies by most of the participants (67.9%). The present study revealed a modest preference by physicians and pharmacy professionals towards locally produced products. Majority of participants supported the idea of doing BE studies locally. However, manufacturers and regulators should devise ways to increase health professionals' confidence in local products. Strengthening local BE study capacity is also highly recommended.

Local pharmaceutical research and development capacity in a developing country: a qualitative exploration of perspectives from key stakeholders in Ethiopia.

PURPOSE: Despite its importance in ensuring sustainable healthcare, there are huge challenges with pharmaceutical research and development (R&D) especially for developing countries mainly due to the high investment costs naturally associated with such activities. In this regard, the pharmaceutical sector in Ethiopia, the most populous nation in East Africa, faces numerous challenges. The current study aimed at assessing the R&D capacity of the local pharmaceutical manufacturers from the perspectives of key informants working in the companies and supporting government offices and education institutions. METHODS: A qualitative study design employing in-depth interviews using semi-structured interview guides with flexible probing techniques was used for data collection. The study involved purposively selected participants who represented major stakeholders such as managers in the R&D departments of pharmaceutical manufacturers, officers and leaders in concerned government agencies and researchers in a local university. All transcribed interviews were subjected to thematic analysis and the Qualitative Data Analysis software in family R (RQDA) was used for data analysis. RESULTS: A total of 14 participants were involved in the study and three major themes were identified from the interviews. Current R&D capacity, opportunities and challenges for involvement in R&D were the major themes. Under current R&D capacity, the weak R&D status of local pharmaceutical plants and minimal university-industry linkage were identified. The challenges of pharmaceutical R&D in Ethiopia included weak governmental and managerial support; difficult procurement processes for R&D input; and the high cost of R&D. Availability of trainable human power and planned government incentives were identified as the opportunities. CONCLUSION: Overall, there is a low level of R&D capacity in local pharmaceutical industries and timely interventional strategies should be implemented through collaboration of academia, research institutions and pharmaceutical industries.

Cost-utility analysis of caspofungin and fluconazole for primary treatment of invasive candidiasis and candidemia in Ethiopia.

BACKGROUND: Invasive candidiasis and/or candidemia (IC/C) is a common fungal infection leading to significant health and economic losses worldwide. Caspofungin was shown to be more effective than fluconazole in treating inpatients with IC/C. However, cost-effectiveness of caspofungin for treating IC/C in Ethiopia remains unknown. We aimed to assess the cost-utility of caspofungin compared to fluconazole-initiated therapies as primary treatment of IC/C in Ethiopia. METHODS: A Markov cohort model was developed to compare the cost-utility of caspofungin versus fluconazole antifungal agents as first-line treatment for adult inpatients with IC/C from the Ethiopian health system perspective. Treatment outcome was categorized as either a clinical success or failure, with clinical failure being switched to a different antifungal medication. Liposomal amphotericin B (L-AmB) was used as a rescue agent for patients who had failed caspofungin treatment, while caspofungin or L-AmB were used for patients who had failed fluconazole treatment. Primary outcomes were expected quality-adjusted life years (QALYs), costs (US$2021), and the incremental cost-utility ratio (ICUR). These QALYs and costs were discounted at 3% annually. Cost data was obtained from Addis Ababa hospitals while locally unavailable data were derived from the literature. Cost-effectiveness was assessed against the recommended threshold of 50% of Ethiopia's gross domestic product/capita (i.e.,US$476). Deterministic and probabilistic sensitivity analyses were conducted to assess the robustness of the findings. RESULTS: In the base-case analysis, treatment of IC/C with caspofungin as first-line treatment resulted in better health outcomes (12.86 QALYs) but higher costs (US$7,714) compared to fluconazole-initiated treatment followed by caspofungin (12.30 QALYs; US$3,217) or L-AmB (10.92 QALYs; US$2,781) as second-line treatment. Caspofungin as primary treatment for IC/C was not cost-effective when compared to fluconazole-initiated therapies. Fluconazole-initiated treatment followed by caspofungin was cost-effective for the treatment of IC/C compared to fluconazole with L-AmB as second-line treatment, at US$316/QALY gained. Our findings were sensitive to medication costs, drug effectiveness, infection recurrence, and infection-related mortality rates. At a cost-effectiveness threshold of US$476/QALY, treating IC/C patient with fluconazole-initiated treatment followed by caspofungin was more likely to be cost-effective in 67.2% of simulations. CONCLUSION: Our study showed that the use of caspofungin as primary treatment for IC/C in Ethiopia was not cost-effective when compared with fluconazole-initiated treatment alternatives. The findings supported the use of fluconazole-initiated therapy with caspofungin as a second-line treatment for patients with IC/C in Ethiopia.

A systematic review of scope and quality of health economic evaluations conducted in Ethiopia.

There has been an increased interest in health technology assessment and economic evaluations for health policy in Ethiopia over the last few years. In this systematic review, we examined the scope and quality of healthcare economic evaluation studies in Ethiopia. We searched seven electronic databases (PubMed/MEDLINE, EMBASE, PsycINFO, CINHAL, Econlit, York CRD databases and CEA Tufts) from inception to May 2021 to identify published full health economic evaluations of a health-related intervention or programme in Ethiopia. This was supplemented with forward and backward citation searches of included articles, manual search of key government websites, the Disease Control Priorities-Ethiopia project and WHO-CHOICE programme. The quality of reporting of economic evaluations was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. The extracted data were grouped into subcategories based on the subject of the economic evaluation, organized into tables and reported narratively. This review identified 34 full economic evaluations conducted between 2009 and 2021. Around 14 (41%) of studies focussed on health service delivery, 8 (24%) on pharmaceuticals, vaccines and devices, and 4 (12%) on public-health programmes. The interventions were mostly preventive in nature and focussed on communicable diseases (n = 19; 56%) and maternal and child health (n = 6; 18%). Cost-effectiveness ratios varied widely from cost-saving to more than US $37 313 per life saved depending on the setting, perspectives, types of interventions and disease conditions. While the overall quality of included studies was judged as moderate (meeting 69% of CHEERS checklist), only four out of 27 cost-effectiveness studies characterized heterogeneity. There is a need for building local technical capacity to enhance the design, conduct and reporting of health economic evaluations in Ethiopia.

Cost-Utility Analysis of Dolutegravir- Versus Efavirenz-Based Regimens as a First-Line Treatment in Adult HIV/AIDS Patients in Ethiopia.

BACKGROUND: In several countries, the dolutegravir (DTG)-based regimen is generally preferred as first-line antiretroviral therapy (ART) over the efavirenz (EFV)-based regimen, but the evidence in low-income countries is limited. OBJECTIVE: Our study aimed to evaluate the cost effectiveness of DTG- versus EFV-based first-line human immunodeficiency virus (HIV) treatment in Ethiopia. METHODS: We developed a microsimulation model for the progression of HIV/acquired immune deficiency syndrome (AIDS) to examine the cost effectiveness of DTG-based first-line ART compared with an EFV-based regimen from a healthcare payer perspective. We used a lifetime horizon with a 1-month cycle length and a 3% annual discount rate. The primary outcomes were a lifetime cost in US dollars ($), quality-adjusted life-months (QALMs) that converted to QALYs using the formula QALY = QALM/12, and incremental cost-effectiveness ratio (ICER). Deterministic sensitivity analysis was conducted to account for parameter uncertainty. RESULTS: Compared with the EFV-based regimen, the DTG-based regimen was associated with an expected lifetime cost of $12,709 (vs. $12,701) and expected QALYs of 15.3 (vs. 14.7 QALYs) per patient, resulting in an ICER value of $13.33 per QALY. From an alternative analysis with a 5-year time horizon, DTG-based ART was found to be dominant, with expected gains of 0.17 QALYs at a lower cost of $1 per patient. The deterministic sensitivity analysis depicted that the maximum increase in ICER value was $72 per QALY, and all ICER values were below the estimated threshold value. CONCLUSIONS: The DTG-based first-line regimen appears to be cost effective compared with the EFV-based regimen for the treatment of HIV/AIDS patients in an Ethiopian setting.

Health-related quality of life of patients with HIV/AIDS at a tertiary care teaching hospital in Ethiopia.

BACKGROUND: Patients' health-related quality of life (HRQoL) and health state utility values are critical inputs in the clinical and economic evaluation of treatments for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). However, information on health state utility values is lacking in the context of Ethiopia. Here, we aimed to assess HRQoL and determine health state utility values and factors that influence the values among HIV/AIDS patients in Ethiopia. METHODS: A cross-sectional study was conducted among 511 HIV/AIDS patients at Tikur Anbessa Specialized Hospital in Ethiopia. Patients aged 18 years or older were eligible for the interview and those who were mentally unstable and with hearing impairment were excluded from the study. We performed face-to-face interviews using EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) in combination with EuroQol-Visual Analog Scales (EQ-VAS). Level-specific disutility coefficients obtained from the general population were used for computing utility values. Patients' health profiles were described using percentages and different statistical analysis were conducted to determine factors associated with the EQ-5D index and EQ-VAS scores. RESULTS: A total of 511 patients participated in the study. A higher proportion of patients reported slight or more severe problems on the anxiety/depression (55.2%) and pain/discomfort (51.3%) dimensions. The overall median utility value of HIV/AIDS patients was 0.94 (IQR = 0.87, 1) from the EQ-5D index and 80% (IQR = 70%, 90%) from the EQ-VAS scores. Demographic characteristics including age, occupational status, and household monthly income significantly affected patient's utility values. Moreover, statistically significant (p < 0.001) differences were seen between the EQ-5D index values of patients with different CD4 count intervals. Furthermore, number of medicines that the patients were taking at the time of the study and comorbidities were significantly associated with the EQ-5D utility index and EQ-VAS score, p < 0.001. CONCLUSIONS: The anxiety/depression and pain/ discomfort dimensions were identified to have critical influence in reducing the HRQoL of adult HIV/AIDS patients in the context of Ethiopia. The study is also the first to use the EQ-5D-5L tool to identify health state utility values for Ethiopian adult HIV/AIDS patients. Future economic evaluations of HIV/AIDS interventions are encouraged to employ the identified utility values.

Design Considerations in the Development of App-Based Oral Anticancer Medication Management Systems: a Qualitative Evaluation of Pharmacists' and Patients' Perspectives.

Smartphone apps can potentially help in enhancing oral anticancer medication (OAM) adherence. Patient adoption and efficacy of such apps depends on inclusion of user-centred and evidence-based features. The objective of this study was to identify important design considerations from the perspectives of patients taking OAMs, caregivers and oncology pharmacists. The study employed a qualitative study design. Data were collected using in-depth interviews with patients (n = 15), caregivers (n = 3) and pharmacists (n = 16). Interviews were audio-recorded, transcribed verbatim and inductive thematic analysis approach was used in data analysis. Monitoring medication-related problems, medication information, replacement of or integration with current systems and accessibility of app content on devices other than smartphones were the key themes identified in the analysis. Flexible input methods for monitored data, glanceability of monitored reports/information, near real-time adherence enhancing and symptom management interventions and customisable reminder options were design considerations identified under the monitoring medication-related problems theme. Participants suggested the provision of focused and easily understandable medication information with a potential for personalisation. Integration of app-based adherence systems with patients' electronic medical records with added mechanisms for alerts in the dispensing system was also suggested as a key design requirement to improve quality of patient care and facilitate adoption by clinicians. Finally, smartphones were the most favoured platform with optional accessibility of app content on other devices. In conclusion, important design considerations were identified through a user-centred design approach. The findings will help developers and clinicians in the design of new app-based systems and evaluation of existing ones.

User acceptance of an app-based adherence intervention: Perspectives from patients taking oral anticancer medications.

BACKGROUND: Widespread adoption by patients is imperative for the success of app-based interventions for enhancing adherence to oral anticancer medications. Patients' attitudes and beliefs should be evaluated to understand determinants of their acceptance and adoption of such interventions. OBJECTIVE: To identify factors that influence cancer patients' intention to adopt an app-based system for enhancing oral anticancer medication adherence. METHODS: This study was conducted as part of the usability evaluation of an app-based system for enhancing adherence. We followed the grounded theory approach employing audio-recorded face-to-face interviews for data collection from patients taking oral anticancer medications (n = 15) and caregivers of such patients (n = 3). Data analysis involved verbatim transcription of all interviews, coding of the transcripts and field notes, detailed memo writing, and constant comparative evaluation of emergent categories. RESULTS: A conceptual framework of facilitating and hindering factors for users' adoption intention for an oral anticancer medication adherence app was developed. Findings suggest that facing difficulties in maintaining adherence and patients' perceived superiority of the app over their current methods facilitate adoption intention. In contrast, having to pay, lack of language options and users' perception of low competence in using an app were the hindrance factors. CONCLUSION: This study showed that adoption of adherence apps could be explained by technology acceptance constructs, such as performance expectancy. Adoption intention was also facilitated by patients perceived vulnerabilities in maintaining adherence to their medications, which was a health behaviour construct. Implementation of app-based programs should address patients' perceived vulnerabilities and relative advantage of the app over their current methods. Clinicians and app developers should also consider the financial, technological and language barriers for end users.

MedAd-AppQ: A quality assessment tool for medication adherence apps on iOS and android platforms.

BACKGROUND: With the recent proliferation of smartphone medication adherence applications (apps), it is increasingly more difficult for patients and clinicians to identify the most useful app. OBJECTIVE: To develop a quality assessment tool for medication adherence apps, and evaluate the quality of such apps from the major app stores. METHODS: In this study, a Medication Adherence App Quality assessment tool (MedAd-AppQ) was developed and two evaluators independently assessed apps that fulfilled the following criteria: availability in English, had at least a medication reminder feature, non-specific to certain disease conditions (generic apps), free of technical malfunctions and availability on both the iPhone Operating System (iOS) and Android platforms. Descriptive statistics, Mann-Whitney U test, Pearson product moment correlation and Spearman rank-order correlation were used for statistical analysis. RESULTS: MedAd-AppQ was designed to have 24 items (total 43 points) categorized under three sections: content reliability (11 points), feature usefulness (29 points) and feature convenience (3 points). The three sections of MedAd-AppQ were found to have inter-rater correlation coefficients of 0.801 (p-value < .001) or higher. Based on analysis of 52 apps (27 iOS and 25 Android), quality scores ranged between 7/43 (16.3%) and 28/43 (65.1%). There was no significant difference between the quality scores of the Android and iOS versions. None of the apps had features for self-management of side effects. Only two apps in each platform provided disease-related and/or medication information. CONCLUSIONS: MedAd-AppQ can be used to reliably assess the quality of adherence apps. Clinicians can use the tool in selecting apps for use by patients. Developers of adherence apps should consider features that provide therapy-related information and help patients in medications and side-effects management.

Patients' Perception of App-based Educational and Behavioural Interventions for Enhancing Oral Anticancer Medication Adherence.

Well-designed smartphone apps can potentially help in enhancing adherence to oral anticancer medications (OAMs). The objective of this study was to evaluate patients' perception on inclusion of various adherence-enhancing strategies as features of an app and their interest in using such app. A cross-sectional survey was conducted at the National Cancer Centre Singapore. A structured self-administered questionnaire was used to collect data from patients taking OAMs. Final analysis was based on 409 surveys and most of the respondents were female (291, 71.1%), Chinese (332, 81.2%), married (296, 72.4%) and breast cancer patients (211, 51.6%). Close to two-thirds of respondents rated medication information (65.0%), disease information (60.2%) and side effect self-management (60.2%) features as having the highest level of importance in an adherence app. Three hundred thirty-two (81.2%) of the respondents owned a smartphone, among which 92 (27.7%) reported using health-related apps. From respondents with smartphones, 219 (66.0%) were interested in using an app for OAM adherence. Age 65 and older compared to 21-54 years old (adjusted OR = 0.34; 95% CI = 0.15-0.76) and current use of a health app (adjusted OR = 1.91; 95% CI = 1.07-3.41) were significant predictors of interest to adopt an adherence app. In conclusion, patients value the inclusion of educational and behavioural interventions in adherence apps. Developers of adherence apps should consider including tools for side effect self-management and provision of information to educate patients on their medications and disease condition.

Prevalence and Determinants of Adherence to Oral Adjuvant Endocrine Therapy among Breast Cancer Patients in Singapore.

OBJECTIVE: The success of oral adjuvant endocrine therapy (OAET) is greatly influenced by patients' level of adherence to treatment. The objective of this study is to measure the prevalence and determinants of adherence to OAET among breast cancer patients in Singapore. METHODS: A cross-sectional survey of patients supplemented by analysis of their prescription records was used to collect data. Adherence to OAET was assessed using the Morisky Medication Adherence Scale-4 items and evaluation of refill gaps. Univariate and multivariate analyses were done to evaluate the association between patients' characteristics and adherence to OAET. RESULTS: A total of 157 women who have started OAET at least 6 months before the time of interview participated in the study, of which less than half (64 patients, 40.8%) of the patients had high adherence. Univariate analysis identified patients who were 57 years or older (P = 0.027), unemployed (P = 0.027), on aromatase inhibitors (P = 0.023), on three or more concurrent medications (P = 0.001), and had one or more comorbidities (P = 0.000) to be significantly more adherent. However, only the number of comorbidities was found to be an independent predictor of adherence in a multiple logistic regression analysis (adjusted odds ratio = 2.60; 95% confidence interval = 1.208-5.593; P = 0.015). Forgetfulness was the main reason for nonadherence mentioned by 63 (67.7%) of the 93 nonadherent patients. CONCLUSIONS: Low level of OAET adherence was found in this study, and forgetfulness was cited as the main reason for nonadherence. Patients were generally receptive to the implementation of various strategies to assist them with their medication-taking behavior.

Quality Assessment of Medical Apps that Target Medication-Related Problems.

BACKGROUND: The advent of smartphones has enabled a plethora of medical apps for disease management. As of 2012, there are 40,000 health care-related mobile apps available in the market. Since most of these medical apps do not go through any stringent quality assessment, there is a risk of consumers being misinformed or misled by unreliable information. In this regard, apps that target medication-related problems (MRPs) are not an exception. There is little information on what constitutes quality in apps that target MRPs and how good the existing apps are. OBJECTIVE: To develop a quality assessment tool for evaluating apps that target MRPs and assess the quality of such apps available in the major mobile app stores (iTunes and Google Play). METHODS: The top 100 free and paid apps in the medical categories of iTunes and Google Play stores (total of 400 apps) were screened for inclusion in the final analysis. English language apps that targeted MRPs were downloaded on test devices to evaluate their quality. Apps intended for clinicians, patients, or both were eligible for evaluation. The quality assessment tool consisted of 4 sections (appropriateness, reliability, usability, privacy), which determined the overall quality of the apps. Apps that fulfilled the inclusion criteria were classified based on the presence of any 1 or more of the 5 features considered important for apps targeting MRPs (monitoring, interaction checker, dose calculator, medication information, medication record). Descriptive statistics and Mann-Whitney tests were used for analysis. RESULTS: Final analysis was based on 59 apps that fulfilled the study inclusion criteria. Apps with interaction checker (66.9%) and monitoring features (54.8%) had the highest and lowest overall qualities. Paid apps generally scored higher for usability than free apps (P = 0.006) but lower for privacy (P = 0.003). Half of the interaction checker apps were unable to detect interactions with herbal medications. Blood pressure and heart rate monitoring apps had the highest overall quality scores (67.7%), while apps that monitored visual, hearing, and temperature changes scored the lowest (35.5%). CONCLUSIONS: A quality assessment tool for evaluating medical apps targeting MRPs has been developed. Clinicians can use this tool to guide their assessments of medical apps that are appropriate for use in the health care setting. Although potentially useful apps were identified, many apps were found to have deficiencies in quality, among which was poor reliability scores for most of the apps. Continued assessments of the quality of apps targeting MRPs are recommended to ensure their usefulness for clinicians and patients. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interests directly related to this study. Study concept and design were contributed by Loy and Yap. Loy collected the data and took the lead in data interpretation, along with Ali and Yap. The manuscript was primarily written by Loy, along with Yap, and revised primarily by Ali, along with Yap.

Health Care Financing in Ethiopia: Implications on Access to Essential Medicines.

BACKGROUND: The Ethiopian health care system is under tremendous reform. One of the issues high on the agenda is health care financing. In an effort to protect citizens from catastrophic effects of the clearly high share of out-of-pocket expenditure, the government is currently working to introduce health insurance. OBJECTIVE: This article aims to highlight the components of the Ethiopian health care financing reform and discuss its implications on access to essential medicines. METHODS: A desk review of government policy documents and proclamations was done. Moreover, a review of the scientific literature was done via PubMed and search of other local journals not indexed in PubMed. RESULTS: Revenue retention by health facilities, systematizing the fee waiver system, standardizing exemption services, outsourcing of nonclinical services, user fee setting and revision, initiation of compulsory health insurance (community-based health insurance and social health insurance), establishment of a private wing in public hospitals, and health facility autonomy were the main components of the health care financing reform in Ethiopia. Although limited, the evidence shows that there is increased health care utilization, access to medicines, and quality of services as a result of the reforms. CONCLUSIONS: Encouraging progress has been made in the implementation of health care financing reforms in Ethiopia. However, there is shortage of evidence on the effect of the health care financing reforms on access to essential medicines in the country. Thus, a clear need exists for well-organized research on the issue.