Social Health Insurance and Healthcare Seeking Behavior in Urban Ethiopia.

Background: After years of planning, in 2024 the government of Ethiopia proposes to introduce a compulsory Social Health Insurance (SHI) program for formal sector employees. The proposed scheme will provide access to contracted healthcare facilities at a premium of 3% of the gross monthly income of employees with another 3% coming from the employer. Objectives: Several studies have examined the willingness to pay (WTP) this premium, however, little is known about the healthcare seeking behavior (HSB) of formal sector employees. This paper investigates both - the determinants of healthcare seeking behavior and among other aspects, WTP the premium. Through these explorations, the paper sheds light on the potential challenges for implementation of SHI. Methods: Descriptive statistics, logit, and multinomial logit (MNL) models are used to analyze retrospective survey data (2,749 formal sector employees) which covers the major regions of the country. Findings: Regarding outpatient care, a majority of the visits (55.9%) were to private healthcare providers. In the case of inpatient care, it was the opposite with a majority of healthcare seekers visiting public sector hospitals (62.5%). A majority of the sample (67%) supported the introduction of SHI but only 24% were willing to pay the proposed SHI premium. The average WTP was 1.6% of gross monthly income. Respondents in the two richest income quintiles were more likely to oppose SHI and consider it unfair. Conclusion: The prominent role of the private sector and the resistance to SHI amongst the two richest income quintiles, suggests that the SHI program needs to actively include private healthcare facilities within its ambit. Additionally, concerted efforts at enhancing the quality of care available at public health facilities, both, in terms of perception and patient-centered care and addressing drug and equipment availability bottlenecks, are needed, if SHI is to garner wider support.

Use of healthcare services during the COVID-19 pandemic in urban Ethiopia: evidence from retrospective health facility survey data.

OBJECTIVES: In recent years, Ethiopia has made enormous strides in enhancing access to healthcare, especially, maternal and child healthcare. With the onset and spread of COVID-19, the attention of the healthcare system has pivoted to handling the disease, potentially at the cost of other healthcare needs. This paper explores whether this shift has come at the cost of non-Covid related healthcare, especially the use of maternal and child health (MCH) services. SETTING: Data covering a 24-month period are drawn from 59 health centres and 29 public hospitals located in urban Ethiopia. PRIMARY AND SECONDARY OUTCOMES MEASURES: The primary outcome measures are the use of MCH services including family planning, antenatal and postnatal care, abortion care, delivery and immunisation. The secondary outcome measures are the use of health services by adults including antiretroviral therapy (ART), tuberculosis (TB) and leprosy and dental services RESULTS: There is a sharp reduction in the use of both inpatient (20%-27%, p<0.001) and outpatient (27%-34%, p<0.001) care, particularly in Addis Ababa, which has been most acutely affected by the virus. This decline does not come at the cost of MCH services. The use of several MCH components (skilled birth attendant deliveries, immunisation, postnatal care) remains unaffected throughout the period while others (family planning services, antenatal care) experience a decline (8%-17%) in the immediate aftermath but recover soon after. CONCLUSION: Concerns about the crowding out of MCH services due to the focus on COVID-19 are unfounded. Proactive measures taken by the government and healthcare facilities to ring-fence the use of essential healthcare services have mitigated service disruptions. The results underline the resilience and agility displayed by one of the world's most resource-constrained healthcare systems. Further research on the approaches used to mitigate disruptions is needed.

Spatiotemporal variability of land surface temperature in north-western Ethiopia.

The aggravating deforestation, industrialization, and urbanization are becoming the principal causes for environmental challenges worldwide. As a result, satellite-based remote sensing helps to explore the environmental challenges spatially and temporally. This investigation analyzed the spatiotemporal variability in land surface temperature (LST) and its link with elevation in the Amhara region, Ethiopia. The Moderate Resolution Imaging Spectroradiometer (MODIS) LST data (2001-2020) were used. The pixel-based linear regression model was used to explore the spatiotemporal variability of LST changes. Furthermore, Sen's slope and Mann-Kendall trend test were used to determine the magnitude of temporal shifts of the areal average LST and evaluate trends in areal average LST, respectively. Coefficient of variation (CV) was also used to analyze spatial and temporal variability in seasonal and annual LST. The seasonal LST CV varied from 1.096-10.72%, 0.7-11.06%, 1.29-14.76%, and 2.19-10.35% for average autumn (September to November), summer (June to August), spring (March to May), and winter (December to February) seasons, respectively. The highest inter-annual variability was observed in the eastern, northern, and south-western districts than that in the other parts. The seasonal spatial LST trend varied from -0.7-0.16, -0.4-0.224, 0.6-0.19, and -0.6-0.32 for average autumn, summer, spring, and winter seasons, respectively. Besides, the annual spatial LST slope varied from -0.58 to 0.17. Negative slopes were found in the central, mid-western, and mid-northern districts in annual LST, unlike the other parts. The annual variations of mean areal LST decreased insignificantly at the rate of 0.046°C year-1 (P<0.05). However, the inter-annual variability trend of annual LST increased significantly. Generally, the LST is tremendously variable in space and time and negatively correlated with elevation.

Economic Consequences of Ill-Health in Rural Ethiopia.

We use three years of household panel data to analyze the effects of ill-health on household economic outcomes in rural Ethiopia. We examine the immediate effects of various ill-health measures on health expenditure and labor supply, the subsequent coping responses, and finally the effect on income and consumption. We find evidence of substantial economic risk in terms of increased health expenditure and reduced agricultural productivity. Households are able to smooth consumption by resorting to intra-household labor substitution, borrowing and depleting assets. However, maintaining current consumption through borrowing and depletion of assets is unlikely to be sustainable and displays the need for health financing reforms and safety nets that reduce the financial consequences of ill-health.

Status of energy utilization and factors affecting rural households' adoption of biogas technology in north-western Ethiopia.

The National Biogas Policy of Ethiopia introduces plans for the implementation of biogas technologies in rural areas. However, rural households' decision to adopt biogas energy technology has been influenced by different socio-economic and institutional factors. This research was therefore undertaken to determine the actual energy consumption status and factors impacting the adoption of biogas technology by rural households in northwestern Ethiopia. Primary data from 182 randomly chosen households and 15 key informants were obtained. Different databases, such as journal articles, annual accounts, and unpublished papers, were used to gather secondary data. The data were analyzed using social science statistical package (SPSS 21st edition) tools using descriptive statistics, chi-square test, and independent-sample t-test. The results indicated that about 84.2% of the households have been using traditional biomass fuels (fuelwood, agricultural crop residue, dung cake, and charcoal) for baking Enjera and heating while the remaining 17.6% of the households have been using biogas energy. The kerosene lamp, battery cell, small size solar panel, and biogas were energy sources for lighting. The higher installation costs, inadequate water availability, shortage of cow dung, and lack of awareness were the main factors that hinder biogas installation in the study site. An independent sample t-test result revealed a statistically significant mean difference of the average time spent (in hours) to collect fuelwood per week between biogas technology adopters (M = 9.563, SD = 4.697) and non-adopters (M = 11.887, SD = 4.703; t (180) = 2.539, p = 0.012). In addition, findings of the binary logistic regression showed that education, access to markets, heads of cattle, and electronic media were the principal factors affecting biogas technology adoption significantly in the study area.

The Effect of Ethiopia's Community-Based Health Insurance Scheme on Revenues and Quality of Care.

Ethiopia's Community-Based Health Insurance (CBHI) scheme was established with the objectives of enhancing access to health care, reducing out-of-pocket expenditure (OOP), mobilizing financial resources and enhancing the quality of health care. Previous analyses have shown that the scheme has enhanced health care access and led to reductions in OOP. This paper examines the impact of the scheme on health facility revenues and quality of care. This paper relies on a difference-in-differences approach applied to both panel and cross-section data. We find that CBHI-affiliated facilities experience a 111% increase in annual outpatient visits and annual revenues increase by 47%. Increased revenues are used to ameliorate drug shortages. These increases have translated into enhanced patient satisfaction. Patient satisfaction increased by 11 percentage points. Despite the increase in patient volume, there is no discernible increase in waiting time to see medical professionals. These results and the relatively high levels of CBHI enrollment suggest that the Ethiopian CBHI has been able to successfully negotiate the main stumbling block-that is, the poor quality of care-which has plagued similar CBHI schemes in Sub-Saharan Africa.

The impact of the Ethiopian health extension program and health development army on maternal mortality: A synthetic control approach.

The Ethiopian government has implemented nationwide strategies to improve access to basic health services and enhance health outcomes. The Health Extension Program (HEP) launched in 2003, expanded basic health infrastructure and local human resources. In 2011, the government introduced the Health Development Army (HDA). HDA is a women-centered community movement inspired by military structures and discipline. Its special objective is to improve maternal health outcomes. This paper uses a synthetic control approach to assess the effects of HEP and HDA on maternal mortality ratios (MMR). The MMR data are from the Global Burden of Diseases (GBD) database. A pool of 42 Sub-Saharan African countries, covering the period 1990 to 2016, is used to construct a synthetic comparator which displays a mortality trajectory similar to Ethiopia prior to the interventions. On average, since 2004, maternal mortality in the control countries exhibits a moderate downward trend. In Ethiopia, the downward trend is considerably steeper as compared to its synthetic control. By 2016, maternal mortality in Ethiopia was lower by 171 (p-value 0.048) maternal deaths per 100,000 live births as compared to its synthetic control. Between 2003 and 2016, Ethiopia's maternal mortality ratio declined from 728 to 357. These estimates suggest that a substantial proportion of this decline may be attributed to HEP/HDA. The Ethiopian experience of enhancing nation-wide access to and use of maternal health services in a short time-span is remarkable. Whether such a model may be transplanted is an open question.

The impact of Ethiopia's pilot community based health insurance scheme on healthcare utilization and cost of care.

In June 2011, the Government of Ethiopia introduced a pilot Community Based Health Insurance (CBHI) scheme in rural parts of the country. Based on a fixed effects analysis of household panel data, this paper assesses the impact of the scheme on utilization of modern healthcare and the cost of accessing healthcare. It adds to the relatively small body of work that provides a rigorous evaluation of CBHI schemes. We find that in the case of public health facilities, enrolment leads to a 30-41% increase in utilization of outpatient care, a 45-64% increase in the frequency of visits and at least a 56% decline in the cost per visit. The impact on utilization and costs combined with a high uptake rate of almost 50% within two years of scheme establishment underlines the relative success of the Ethiopian scheme. While there are several reasons for this success, a comparative analysis of the design and execution of the Ethiopia CBHI with the existing body of work yields two distinct features. First, the Ethiopian scheme is embedded within existing government administrative structures and to signal government commitment, scheme performance and uptake is used as a yardstick to measure the success of the administration. Second, an existing social protection scheme was used to spread information, raise scheme awareness and encourage uptake of health insurance. The alignment of the interests of administrators with scheme performance and interlinking of social protection schemes are innovative design features that are worth considering as developing countries strive to enhance access to health care through voluntary insurance schemes.

Uptake of health insurance and the productive safety net program in rural Ethiopia.

Due to lack of well-developed insurance and credit markets, rural families in Ethiopia are exposed to a range of covariate and idiosyncratic risks. In 2005, to deal with the consequences of covariate risks, the government implemented the Productive Safety Net Program (PSNP), and in 2011, to mitigate the financial consequences of ill-health, the government introduced a pilot Community Based Health Insurance (CBHI) Scheme. This paper explores whether scheme uptake and retention is affected by access to the PSNP. Based on household panel data and qualitative information, the analysis shows that participating in the PSNP increases the probability of CBHI uptake by 24 percentage points and enhances scheme retention by 10 percentage points. A large proportion of this effect may be attributed to explicit and implicit pressure applied by government officials on PSNP beneficiaries. Whether this is a desirable approach is debatable. Nevertheless, the results suggest that membership in existing social protection programs may be leveraged to spread new schemes and potentially accelerate poverty reduction efforts.

Prevalence of rheumatic heart disease among school children in Ethiopia: A multisite echocardiography-based screening.

BACKGROUND: Auscultation-based surveys in Ethiopia conducted in the late 1990's reported a rural prevalence of 4.6/1000 and an urban prevalence of 6.4/1000 of rheumatic heart disease (RHD). With echo-based screening, we aimed to estimate the national prevalence of RHD in school children by taking school-based samples from six regions across the country using the 2012 World Heart Federation echocardiographic criteria. PATIENTS AND METHODS: We conducted a cross-sectional echocardiographic screening of RHD in school children aged 6-18years from 28 randomly selected primary and secondary schools found in six different geographic regions of Ethiopia. We used the standardized WHF echocardiographic criteria. RESULTS: A total of 3238 children (48.5% females) were screened. The mean age was 13.2±3.2years. Of these, 44 patients (1.4%) met the WHF criteria for definite RHD, while 15 (0.5%) met the criteria for borderline disease, yielding a prevalence of 19 [13.9-23.4, 95% CI] cases per 1000 school children between the ages of 6-18years. The majority of those who tested positive were girls (26/44). The prevalence was lowest in children aged 6-9years and otherwise uniformly distributed across ages 10-18years. Definite RHD involved the mitral valve in 42 subjects, 39 of whom had mitral regurgitation and 3 with mitral stenosis. The aortic valve was affected in 6 children. The ratio of definite to borderline cases was 2.9. CONCLUSION: This study demonstrated a consistent pattern of high prevalence of asymptomatic RHD with definite disease predominating over borderline involvement across six regions of Ethiopia.

Prevalence and determinants of Tuberculosis among HIV infected patients in south Ethiopia.

INTRODUCTION: Tuberculosis (TB) is a chronic infectious disease that has represented a major health problem over the centuries. The human immune deficiency virus (HIV)/AIDS has substantially altered the epidemiology of TB by increasing the risk of reactivating latent TB, increasing chance of TB infection once exposed to tubercle bacilli (re-infection) and by increasing the risk of rapid progression soon after infection. METHODOLOGY: This study employs a retrospective review analysis of patient medical records. A total of 499 HIV/AIDS patient cards were reviewed and variables were recorded. Frequencies and odds ratio were calculated to determine prevalence and associated risk factors respectively. RESULTS: A total of 499 HIV/AIDS positive patient cards were reviewed. Ninety one (18.2%) of the study participants were found to have tuberculosis of which 20 (22%), 58 (64%) and 13 (14%) were smear positive, smear negative and extra-pulmonary tuberculosis cases, respectively. In multivariate logistic regression being female (AOR=0.39; 95% CI:0.20-0.77), WHO clinical stage 3 (AOR=5.66; 95%CI:1.79-17.94); WHO clinical stage 4 (AOR=7.89;95%CI:2.01-30.96); and functional status being ambulatory (AOR=2.22; 95%CI:1.06-4.64) were independently associated with tuberculosis-HIV co-infection with p value <0.05. CONCLUSION: Prevalence of tuberculosis was high. Among tuberculosis positive cases, the proportion of smear negative cases was also high which requires strengthening of TB diagnostic techniques. Tuberculosis was associated with some social demographic characteristics and clinical variables.

Dropping out of Ethiopia's community-based health insurance scheme.

Low contract renewal rates have been identified as one of the challenges facing the development of community-based health insurance (CBHI) schemes. This article uses longitudinal household survey data gathered in 2012 and 2013 to examine dropout in the case of Ethiopia's pilot CBHI scheme. We treat dropout as a function of scheme affordability, health status, scheme understanding and quality of care. The scheme saw enrolment increase from 41% 1 year after inception to 48% a year later. An impressive 82% of those who enrolled in the first year renewed their subscriptions, while 25% who had not enrolled joined the scheme. The analysis shows that socioeconomic status, a greater understanding of health insurance and experience with and knowledge of the CBHI scheme are associated with lower dropout rates. While there are concerns about the quality of care and the treatment meted out to the insured by providers, the overall picture is that returns from the scheme are overwhelmingly positive. For the bulk of households, premiums do not seem to be onerous, basic understanding of health insurance is high and almost all those who are currently enrolled signalled their desire to renew contracts.

Healthcare-seeking behaviour in rural Ethiopia: evidence from clinical vignettes.

OBJECTIVES: To investigate the determinants of healthcare-seeking behaviour using five context-relevant clinical vignettes. The analysis deals with three issues: whether and where to seek modern care and when to seek care. SETTING: This study is set in 96 villages located in four main regions of Ethiopia. The participants of this study are 1632 rural households comprising 9455 individuals. PRIMARY AND SECONDARY OUTCOME MEASURES: Probability of seeking modern care for symptoms related to acute respiratory infections/pneumonia, diarrhoea, malaria, tetanus and tuberculosis. Conditional on choosing modern healthcare, where to seek care (health post, health centre, clinic and hospital). Conditional on choosing modern healthcare, when to seek care (seek care immediately, the next day, after 2 days, between 3 days to 1 week, a week or more). RESULTS: We find almost universal preference for modern care. Foregone care ranges from 0.6% for diarrhoea to 2.5% for tetanus. There is a systematic relationship between socioeconomic status and choice of providers mainly for adult-related conditions with households in higher consumption quintiles more likely to seek care in health centres, private/Non-Government Organization (NGO) clinics as opposed to health posts. Delays in care-seeking behaviour are apparent mainly for adult-related conditions and among poorer households. CONCLUSIONS: The analysis suggests that the lack of healthcare utilisation is not driven by the inability to recognise health problems or due to a low perceived need for modern care.