Equity considerations for the implementation of health insurance benefit package in Ethiopia: result of expert Delphi exercise.

BACKGROUND: Efficiency, equity and financial risk protection are key health systems objectives. Equitable distribution of health care is among the priority strategic initiative of the government of Ethiopia. However, data on the distribution of interventions benefits or on disease burden disaggregated by subpopulations to guide health care priority setting is not available in Ethiopia. METHODS: Aligned with policy documents, we identified the following groups to be the worse off in the Ethiopian context: under-five children, women of reproductive age, the poor, and rural residents. We used the Delphi technique by a panel of 28 experts to assign a score for 253 diseases/conditions over a period of two days, in phases. The expert panel represented different institutes and professional mix. Experts assigned a score 1 to 4; where 4 indicates disease/condition predominantly affecting the poor and rural residents and 1 indicates a condition more prevalent among the wealthy and urban residents. Subsequently, the average equity score was computed for each disease/condition. RESULTS: The average scores ranged from 1.11 (for vitiligo) to 3.79 (for obstetric fistula). We standardized the scores to be bounded between 1 and 2; 1 the lowest equity score and 2 the highest equity score. The scores for each disease/condition were then assigned to their corresponding interventions. We used these equity scores to adjust the CEA values for each of the interventions. To adjust the CEA values for equity, we multiplied the health benefits (the denominator of the cost-effectiveness value) of each intervention by the corresponding equity scores, resulting in equity adjusted CEA values. The equity adjusted CEA was then used to rank the interventions using a league table. CONCLUSIONS: The Delphi method can be useful in generating equity scores for prioritizing health interventions where disaggregated data on the distribution of diseases or access to interventions by subpopulation groups are not available.

The Ethiopian National Immunization Technical Advisory Group (E-NITAG): Establishment, Achievements and the Future.

The National Immunization Program (NIP) was introduced in Ethiopia in 1980. The NIP has expanded the number of vaccines from six to more than 14 in 2023. However, decisions on new vaccine introduction and other vaccine-related matters were not systematically deliberated nationally. Thus, the need to establish a national body to deliberate on vaccine and vaccination matters, in addition to the global immunization advisory groups, has been emphasized in the last decade. This article presents the establishment and achievements of the Ethiopian NITAG. The E-NITAG was established in 2016 and maintained its active role in providing recommendations for new vaccine introduction and improving the delivery of routine vaccines. The external assessment indicated the E-NITAG was highly functional and played a critical role in enhancing the vaccination practice in Ethiopia, especially during the COVID-19 pandemic. The absence of a dedicated secretariat staff was the major bottleneck to expanding the role of the E-NITAG beyond responding to MOH requests. The E-NITAG must be strengthened by establishing a secretariat that can eventually grow as an independent institution to address complex vaccine-related issues the NIP needs to address.

Estimating immunization coverage at the district level: A case study of measles and diphtheria-pertussis-tetanus-Hib-HepB vaccines in Ethiopia.

Ethiopia has made significant progress in the last two decades in improving the availability and coverage of essential maternal and child health services including childhood immunizations. As Ethiopia keeps momentum towards achieving national immunization goals, methods must be developed to analyze routinely collected health facility data and generate localized coverage estimates. This study leverages the District Health Information Software (DHIS2) platform to estimate immunization coverage for the first dose of measles vaccine (MCV1) and the third dose of diphtheria-pertussis-tetanus-Hib-HepB vaccine (Penta3) across Ethiopian districts ("woredas"). Monthly reported numbers of administered MCV1 and Penta3 immunizations were extracted from public facilities from DHIS2 for 2017/2018-2021/2022 and corrected for quality based on completeness and consistency across time and districts. We then utilized three sources for the target population (infants) to compute administrative coverage estimates: Central Statistical Agency, DHIS2, and WorldPop. The Ethiopian Demographic and Health Surveys were used as benchmarks to which administrative estimates were adjusted at the regional level. Administrative vaccine coverage was estimated for all woredas, and, after adjustments, was bounded within 0-100%. In regions with the highest immunization coverage, MCV1 coverage would range from 83 to 100% and Penta3 coverage from 88 to 100% (Addis Ababa, 2021/2022); MCV1 from 8 to 100% and Penta3 from 4 to 100% (Tigray, 2019/2020). Nationally, the Gini index for MCV1 was 0.37, from 0.13 (Harari) to 0.37 (Somali); for Penta3, it was 0.36, from 0.16 (Harari) to 0.36 (Somali). The use of routine health information systems, such as DHIS2, combined with household surveys permits the generation of local health services coverage estimates. This enables the design of tailored health policies with the capacity to measure progress towards achieving national targets, especially in terms of inequality reductions.

Burden of lower respiratory infections and associated risk factors across regions in Ethiopia: a subnational analysis of the Global Burden of Diseases 2019 study.

OBJECTIVE: This analysis is to present the burden and trends of morbidity and mortality due to lower respiratory infections (LRIs), their contributing risk factors, and the disparity across administrative regions and cities from 1990 to 2019. DESIGN: This analysis used Global Burden of Disease 2019 framework to estimate morbidity and mortality outcomes of LRI and its contributing risk factors. The Global Burden of Disease study uses all available data sources and Cause of Death Ensemble model to estimate deaths from LRI and a meta-regression disease modelling technique to estimate LRI non-fatal outcomes with 95% uncertainty intervals (UI). STUDY SETTING: The study includes nine region states and two chartered cities of Ethiopia. OUTCOME MEASURES: We calculated incidence, death and years of life lost (YLLs) due to LRIs and contributing risk factors using all accessible data sources. We calculated 95% UIs for the point estimates. RESULTS: In 2019, LRIs incidence, death and YLLs among all age groups were 8313.7 (95% UI 7757.6-8918), 59.4 (95% UI 49.8-71.4) and 2404.5 (95% UI 2059.4-2833.3) per 100 000 people, respectively. From 1990, the corresponding decline rates were 39%, 61% and 76%, respectively. Children under the age of 5 years account for 20% of episodes, 42% of mortalities and 70% of the YLL of the total burden of LRIs in 2019. The mortality rate was significantly higher in predominantly pastoralist regions-Benishangul-Gumuz 101.8 (95% UI 84.0-121.7) and Afar 103.7 (95% UI 86.6-122.6). The Somali region showed the least decline in mortality rates. More than three-fourths of under-5 child deaths due to LRIs were attributed to malnutrition. Household air pollution from solid fuel attributed to nearly half of the risk factors for all age mortalities due to LRIs in the country. CONCLUSION: In Ethiopia, LRIs have reduced significantly across the regions over the years (except in elders), however, are still the third-leading cause of mortality, disproportionately affecting children younger than 5 years old and predominantly pastoralist regions. Interventions need to consider leading risk factors, targeted age groups and pastoralist and cross-border communities.

Neglected burden of injuries in Ethiopia, from 1990 to 2019: a systematic analysis of the global burden of diseases study 2019.

Background: The 2030 agenda for sustainable development goals has given injury prevention new attention, including halving road traffic injuries. This study compiled the best available evidence on injury from the global burden of diseases study for Ethiopia from 1990 to 2019. Methods: Injury data on incidence, prevalence, mortality, disability-adjusted life years lost, years lived with disability, and years of life lost were extracted from the 2019 global burden of diseases study for regions and chartered cities in Ethiopia from 1990 to 2019. Rates were estimated per 100,000 population. Results: In 2019, the age-standardized rate of incidence was 7,118 (95% UI: 6,621-7,678), prevalence was 21,735 (95% UI: 19,251-26,302), death was 72 (95% UI: 61-83), disability-adjusted life years lost was 3,265 (95% UI: 2,826-3,783), years of live lost was 2,417 (95% UI: 2,043-2,860), and years lived with disability was 848 [95% UI: (620-1,153)]. Since 1990, there has been a reduction in the age-standardized rate of incidence by 76% (95% UI: 74-78), death by 70% (95% UI: 65-75), and prevalence by 13% (95% UI: 3-18), with noticeable inter-regional variations. Transport injuries, conflict and terrorism, interpersonal violence, self-harm, falls, poisoning, and exposure to mechanical forces were the leading causes of injury-related deaths and long-term disabilities. Since 1990, there has been a decline in the prevalence of transport injuries by 32% (95% UI: 31-33), exposure to mechanical forces by 12% (95% UI: 10-14), and interpersonal violence by 7.4% (95% UI: 5-10). However, there was an increment in falls by 8.4% (95% UI: 7-11) and conflict and terrorism by 1.5% (95% UI: 38-27). Conclusion: Even though the burden of injuries has steadily decreased at national and sub-national levels in Ethiopia over the past 30 years, it still remains to be an area of public health priority. Therefore, injury prevention and control strategies should consider regional disparities in the burden of injuries, promoting transportation safety, developing democratic culture and negotiation skills to solve disputes, using early security-interventions when conflict arises, ensuring workplace safety and improving psychological wellbeing of citizens.

Cost of childhood cancer treatment in Ethiopia.

BACKGROUND: Despite the recent interest in expanding pediatric oncology units in Ethiopia, reflected in the National Childhood and Adolescent Cancer Control Plan (NCACCP), little is known about the cost of running a pediatric oncology unit and treating childhood cancers. METHODS: We collected historical cost data and quantity of services provided for the pediatric oncology unit and all other departments in Tikur Anbessa Specialized Hospital (TASH) from 8 July 2018 to 7 July 2019, using a provider perspective and mixed (top-down and bottom-up) costing approaches. Direct costs (human resources, drugs, supplies, medical equipment) of the pediatric oncology unit, costs at other relevant clinical departments, and overhead cost share are summed up to estimate the total annual cost of running the unit. Further, unit costs were estimated at specific childhood cancer levels. RESULTS: The estimated annual total cost of running a pediatric oncology unit was USD 776,060 (equivalent to USD 577 per treated child). The cost of running a pediatric oncology unit per treated child ranged from USD 469 to USD 1,085, on the scenario-based sensitivity analysis. Drugs and supplies, and human resources accounted for 33% and 27% of the total cost, respectively. Outpatient department and inpatient department shared 37% and 63% of the cost, respectively. For the pediatric oncology unit, the cost per OPD visit, cost per bed day, and cost per episode of hospital admission were USD 36.9, 39.9, and 373.3, respectively. The annual cost per treated child ranged from USD 322 to USD 1,313 for the specific childhood cancers. CONCLUSION: Running a pediatric oncology unit in Ethiopia is likely to be affordable. Further analysis of cost effectiveness, equity, and financial risk protection impacts of investing in childhood cancer programs could better inform the prioritization of childhood cancer control interventions in the Ethiopia Essential Health Service Package.

Monitoring and evaluating the implementation of essential packages of health services.

Essential packages of health services (EPHS) are a critical tool for achieving universal health coverage, especially in low-income and lower middle-income countries. However, there is a lack of guidance and standards for monitoring and evaluation (M&E) of EPHS implementation. This paper is the final in a series of papers reviewing experiences using evidence from the Disease Control Priorities, third edition publications in EPHS reforms in seven countries. We assess current approaches to EPHS M&E, including case studies of M&E approaches in Ethiopia and Pakistan. We propose a step-by-step process for developing a national EPHS M&E framework. Such a framework would start with a theory of change that links to the specific health system reforms the EPHS is trying to accomplish, including explicit statements about the 'what' and 'for whom' of M&E efforts. Monitoring frameworks need to consider the additional demands that could be placed on weak and already overstretched data systems, and they must ensure that processes are put in place to act quickly on emergent implementation challenges. Evaluation frameworks could learn from the field of implementation science; for example, by adapting the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to policy implementation. While each country will need to develop its own locally relevant M&E indicators, we encourage all countries to include a set of core indicators that are aligned with the Sustainable Development Goal 3 targets and indicators. Our paper concludes with a call to reprioritise M&E more generally and to use the EPHS process as an opportunity for strengthening national health information systems. We call for an international learning network on EPHS M&E to generate new evidence and exchange best practices.

Out-of-pocket expenditures and financial risks associated with treatment of vaccine-preventable diseases in Ethiopia: A cross-sectional costing analysis.

BACKGROUND: Vaccine-preventable diseases (VPDs) remain major causes of morbidity and mortality in low- and middle-income countries (LMICs). Universal access to vaccination, besides improved health outcomes, would substantially reduce VPD-related out-of-pocket (OOP) expenditures and associated financial risks. This paper aims to estimate the extent of OOP expenditures and the magnitude of the associated catastrophic health expenditures (CHEs) for selected VPDs in Ethiopia. METHODS AND FINDINGS: We conducted a cross-sectional costing analysis, from the household (patient) perspective, of care-seeking for VPDs in children aged under 5 years for pneumonia, diarrhea, measles, and pertussis, and in children aged under 15 years for meningitis. Data on OOP direct medical and nonmedical expenditures (2021 USD) and household consumption expenditures were collected from 995 households (1 child per household) in 54 health facilities nationwide between May 1 and July 31, 2021. We used descriptive statistics to measure the main outcomes: magnitude of OOP expenditures, along with the associated CHE within households. Drivers of CHE were assessed using a logistic regression model. The mean OOP expenditures per disease episode for outpatient care for diarrhea, pneumonia, pertussis, and measles were $5·6 (95% confidence interval (CI): $4·3, 6·8), $7·8 ($5·3, 10·3), $9·0 ($6·4, 11·6), and $7·4 ($3·0, 11·9), respectively. The mean OOP expenditures were higher for inpatient care, ranging from $40·6 (95% CI: $12·9, 68·3) for severe measles to $101·7 ($88·5, 114·8) for meningitis. Direct medical expenditures, particularly drug and supply expenses, were the major cost drivers. Among those who sought inpatient care (345 households), about 13·3% suffered CHE, at a 10% threshold of annual consumption expenditures. The type of facility visited, receiving inpatient care, and wealth were significant predictors of CHE (p-value < 0·001) while adjusting for area of residence (urban/rural), diagnosis, age of respondent, and household family size. Limitations include inadequate number of measles and pertussis cases. CONCLUSIONS: The OOP expenditures induced by VPDs are substantial in Ethiopia and disproportionately impact those with low income and those requiring inpatient care. Expanding equitable access to vaccines cannot be overemphasized, for both health and economic reasons. Such realization requires the government's commitment toward increasing and sustaining vaccine financing in Ethiopia.

Cost-effectiveness of running a paediatric oncology unit in Ethiopia.

OBJECTIVE: To estimate the cost-effectiveness of running a paediatric oncology unit in Ethiopia to inform the revision of the Ethiopia Essential Health Service Package (EEHSP), which ranks the treatment of childhood cancers at a low and medium priority. METHODS: We built a decision analytical model-a decision tree-to estimate the cost-effectiveness of running a paediatric oncology unit compared with a do-nothing scenario (no paediatric oncology care) from a healthcare provider perspective. We used the recently (2018-2019) conducted costing estimate for running the paediatric oncology unit at Tikur Anbessa Specialized Hospital (TASH) and employed a mixed costing approach (top-down and bottom-up). We used data on health outcomes from other studies in similar settings to estimate the disability-adjusted life years (DALYs) averted of running a paediatric oncology unit compared with a do-nothing scenario over a lifetime horizon. Both costs and effects were discounted (3%) to the present value. The primary outcome was incremental cost in US dollars (USDs) per DALY averted, and we used a willingness-to-pay (WTP) threshold of 50% of the Ethiopian gross domestic product per capita (USD 477 in 2019). Uncertainty was tested using one-way and probabilistic sensitivity analyses. RESULTS: The incremental cost and DALYs averted per child treated in the paediatric oncology unit at TASH were USD 876 and 2.4, respectively, compared with no paediatric oncology care. The incremental cost-effectiveness ratio of running a paediatric oncology unit was USD 361 per DALY averted, and it was cost-effective in 90% of 100 000 Monte Carlo iterations at a USD 477 WTP threshold. CONCLUSIONS: The provision of paediatric cancer services using a specialised oncology unit is most likely cost-effective in Ethiopia, at least for easily treatable cancer types in centres with minimal to moderate capability. We recommend reassessing the priority-level decision of childhood cancer treatment in the current EEHSP.

Joint distribution of child mortality and wealth across 30 sub-Saharan African countries over 2000-2019.

Background: While reductions in child mortality have been observed across sub-Saharan African countries in the last 30 years, narrowing the gaps in under-five mortality across socioeconomic groups also requires an understanding of the multiple associations between health and welfare and socioeconomic drivers. We examined the probability density distributions in under-five mortality within countries and joint pathways of under-five mortality and wealth over time. Methods: We used 69 Demographic and Health Surveys and 19 Malaria Indicator Surveys from 30 sub-Saharan African countries, with each country having at least two surveys conducted since 2000. We constructed a cross-country wealth index and estimated under-five death prevalence. We examined the pure distribution in under-five mortality prevalence and the joint probability distribution of wealth and under-five mortality prevalence over time, including the area of confidence ellipse which spanned the two dimensions of mortality and wealth and covered 75% of the mass of the joint distribution. Results: Most countries experienced decreases in under-five mortality along with increases in wealth over time. However, we observed great variations in the evolution of the joint distributions across countries over time. For instance, the areas of confidence ellipse ranged from 0.178 in Ethiopia (2000) to 1.119 in Angola (2006). The change (over time) in the area of confidence ellipses ranged from 0.010 in Tanzania to 0.844 in Angola between the 2000s and 2010s. The ranking of country performance on under-five mortality varied greatly, depending on whether performance summary indicators were based on disaggregation by wealth or on full non-disaggregated distributions. Conclusions: Our analysis points to the relevance of full distributions of health and joint distributions of health and wealth as complementary indicators of distributions of health across socioeconomic status, in assessing country performance on health.

Estimated travel time and staffing constraints to accessing the Ethiopian health care system: A two-step floating catchment area analysis.

Background: Despite large investments in the public health care system, disparities in health outcomes persist between lower- and upper-income individuals, as well as rural vs urban dwellers in Ethiopia. Evidence from Ethiopia and other low- and middle-income countries suggests that challenges in health care access may contribute to poverty in these settings. Methods: We employed a two-step floating catchment area to estimate variations in spatial access to health care and in staffing levels at health care facilities. We estimated the average travel time from the population centers of administrative areas and adjusted them with provider-to-population ratios. To test hypotheses about the role of travel time vs staffing, we applied Spearman's rank tests to these two variables against the access score to assess the significance of observed variations. Results: Among Ethiopia's 11 first-level administrative units, Addis Ababa, Dire Dawa, and Harari had the best access scores. Regions with the lowest access scores were generally poorer and more rural/pastoral. Approximately 18% of the country did not have access to a public health care facility within a two-hour walk. Our results suggest that spatial access and staffing issues both contribute to access challenges. Conclusion: Investments both in new health facilities and staffing in existing facilities will be necessary to improve health care access within Ethiopia. Because rural and low-income areas are more likely to have poor access, future strategies for expanding and strengthening the health care system should strongly emphasize equity and the role of improved access in reducing poverty.

Equitable Prioritization of Health Interventions by Incorporating Financial Risk Protection Weights Into Economic Evaluations.

OBJECTIVES: Financial risk protection (FRP), or the prevention of medical impoverishment, is a major objective of health systems, particularly in low- and middle-income countries where the extent of out-of-pocket (OOP) health expenditures can be substantial. We sought to develop a method that allows decision makers to explicitly integrate FRP outcomes into their priority-setting activities. METHODS: We used literature review to identify 31 interventions in low- and middle-income countries, each of which provided measures of health outcomes, costs, OOP health expenditures averted, and FRP (proxied by OOP health expenditures averted as a percentage of income), all disaggregated by income quintile. We developed weights drawn from the Z-score of each quintile-intervention pair based on the distribution of FRP of all quintile-intervention pairs. We next ranked the interventions by unweighted and weighted health outcomes for each income quintile. We also evaluated how pro-poor they were by, first, ordering the interventions by cost-effectiveness for each quintile and, next, calculating the proportion of interventions each income quintile would be targeted for a given random budget. A ranking was said to be pro-poor if each quintile received the same or higher proportion of interventions than richer quintiles. RESULTS: Using FRP weights produced a more pro-poor priority setting than unweighted outcomes. Most of the reordering produced by the inclusion of FRP weights occurred in interventions of moderate cost-effectiveness, suggesting that these weights would be most useful as a way of distinguishing moderately cost-effective interventions with relatively high potential FRP. CONCLUSIONS: This preliminary method of integrating FRP into priority-setting would likely be most suitable to deciding between health interventions with intermediate cost-effectiveness.

The magnitude and perceived reasons for childhood cancer treatment abandonment in Ethiopia: from health care providers' perspective.

BACKGROUND: Treatment abandonment is one of major reasons for childhood cancer treatment failure and low survival rate in low- and middle-income countries. Ethiopia plans to reduce abandonment rate by 60% (2019-2023), but baseline data and information about the contextual risk factors that influence treatment abandonment are scarce. METHODS: This cross-sectional study was conducted from September 5 to 22, 2021, on the three major pediatric oncology centers in Ethiopia. Data on the incidence and reasons for treatment abandonment were obtained from healthcare professionals. We were unable to obtain data about the patients' or guardians' perspective because the information available in the cancer registry was incomplete to contact adequate number of respondents. We used a validated, semi-structured questionnaire developed by the International Society of Pediatric Oncology Abandonment Technical Working Group. We included all (N = 38) health care professionals (physicians, nurses, and social workers) working at these centers who had more than one year of experience in childhood cancer service provision (a universal sampling and 100% response rate). RESULTS: The perceived mean abandonment rate in Ethiopia is 34% (SE 2.5%). The risk of treatment abandonment is dependent on the type of cancer (high for bone sarcoma and brain tumor), the phase of treatment and treatment outcome. The highest risk is during maintenance and treatment failure or relapse for acute lymphoblastic leukemia, and during pre- or post-surgical phase for Wilms tumor and bone sarcoma. The major influencing risk factors in Ethiopia includes high cost of care, low economic status, long travel time to treatment centers, long waiting time, belief in the incurability of cancer and poor public awareness about childhood cancer. CONCLUSIONS: The perceived abandonment rate in Ethiopia is high, and the risk of abandonment varies according to the type of cancer, phase of treatment or treatment outcome. Therefore, mitigation strategies to reduce the abandonment rate should include identifying specific risk factors and prioritizing strategies based on their level of influence, effectiveness, feasibility, and affordability.

Care of Older Persons in Eastern Africa: A Scoping Review of Ethical Issues.

Introduction: The aging population is rapidly increasing globally, with 80% of the older population living in low- and middle-income countries. In Eastern African countries, there exists an incongruence between readiness-economically, structurally, politically, and culturally-to create a conducive environment for healthy aging, which implies public health as well as ethical concerns. The aim of this scoping review was to explore existing evidence addressing the various ethical issues in connection with elder care in the region of Eastern Africa. Methods: We searched six databases (Africa-Wide Information, AgeLine, CINHAL, MEDLINE, APA PsycInfo, and SocINDEX) to identify peer-reviewed journal articles that could meet some eligibility criteria such as being a peer-reviewed journal article written in English, having been published in any year until July 2020, and focusing on ethical issues in the care of older people aged 60 years and older from Eastern Africa. We also searched for additional evidence in the references of included papers and web-based platforms. We included 24 journal articles and analyzed them using the inductive content analysis approach. Results: The included articles represent seven (38.9%) of the 18 countries in the Eastern African region. The articles covered six ethical concerns: lack of government attention to older persons (n = 14, 58.3%), inaccessibility of health care services (n = 13, 54.2%), loneliness and isolation (n = 11, 45.8%), gender inequalities in old age (n = 9, 37.5%), mistreatment and victimization (n = 8, 33.3%), and medical errors (n = 2, 8.3%). Conclusion: This scoping review summarized ethical issues arising in relation to providing care for older persons in the Eastern African context. In light of the rapid increase in the number of older persons in this region, it is critical for governments and responsible bodies to implement and accelerate efforts promptly to generate more evidence to inform programs and policies that improve the health and wellbeing of older persons. Further research is needed to inform global health efforts that aim at improving the lives of older persons, particularly in low- and middle-income countries. Clinical Trial Registration: https://osf.io/sb8gw, identifier: 10.17605/OSF.IO/SB8GW.

Cost-analysis of COVID-19 sample collection, diagnosis, and contact tracing in low resource setting: The case of Addis Ababa, Ethiopia.

BACKGROUND: Ethiopia has been responding to the COVID-19 pandemic through a combination of interventions, including non-pharmaceutical interventions, quarantine, testing, isolation, contact tracing, and clinical management. Estimating the resources consumed for COVID-19 prevention and control could inform efficient decision-making for epidemic/pandemic-prone diseases in the future. This study aims to estimate the unit cost of COVID-19 sample collection, laboratory diagnosis, and contact tracing in Addis Ababa, Ethiopia. METHODS: Primary and secondary data were collected to estimate the costs of COVID-19 sample collection, diagnosis, and contact tracing. A healthcare system perspective was used. We used a combination of micro-costing (bottom-up) and top-down approaches to estimate resources consumed and the unit costs of the interventions. We used available cost and outcome data between May and December 2020. The costs were classified into capital and recurrent inputs to estimate unit and total costs. We identified the cost drivers of the interventions. We reported the cost for the following outcome measures: (1) cost per sample collected, (2) cost per laboratory diagnosis, (3) cost per sample collected and laboratory diagnosis, (4) cost per contact traced, and (5) cost per COVID-19 positive test identified. We conducted one-way sensitivity analysis by varying the input parameters. All costs were reported in US dollars (USD). RESULTS: The unit cost per sample collected was USD 1.33. The unit cost of tracing a contact of an index case was USD 0.66. The unit cost of COVID-19 diagnosis, excluding the cost for sample collection was USD 3.91. The unit cost of sample collection per COVID-19 positive individual was USD 11.63. The unit cost for COVID-19 positive test through contact tracing was USD 54.00. The unit cost COVID-19 DNA PCR diagnosis for identifying COVID-19 positive individuals, excluding the sample collection and transport cost, was USD 37.70. The cost per COVID-19 positive case identified was USD 49.33 including both sample collection and laboratory diagnosis costs. Among the cost drivers, personnel cost (salary and food cost) takes the highest share for all interventions, ranging from 51-76% of the total cost. CONCLUSION: The costs of sample collection, diagnosis, and contact tracing for COVID-19 were high given the low per capita health expenditure in Ethiopia and other low-income settings. Since the personnel cost accounts for the highest cost, decision-makers should focus on minimizing this cost when faced with pandemic-prone diseases by strengthening the health system and using digital platforms. The findings of this study can help decision-makers prioritize and allocate resources for effective public health emergency response.

The potential distributional health and financial benefits of increased tobacco taxes in Ethiopia: Findings from a modeling study.

Ethiopia raised taxes on tobacco products in early 2020, increasing the overall price of the typical pack of cigarettes by about 67%. We quantify the potential impacts of Ethiopia's tobacco tax hike on various outcomes-life years, tax revenues, cigarette expenditures and catastrophic health expenditures (CHE). Using parameters like price elasticity of demand for cigarettes and smoking prevalence in Ethiopia from the existing literature and secondary data sources, we model the potential implications of the reform at the population level and for different wealth quintiles. We focus only on men since a small proportion of Ethiopian women smoke. Results indicate that Ethiopia's tax hike could induce a significant proportion of current smokers to quit smoking and thereby save almost eight million years of life in the current population. The reform is also likely to increase tax revenues by USD26 million in the first year after its introduction. The richest quintile will bear the greatest share of this higher tax burden and the poorest will bear the least. Additionally, deaths due to the main diseases associated with smoking will fall. This is expected to avert up to 173,000 CHE cases due to the out-of-pocket costs that would have been incurred in obtaining medical treatment. This analysis highlights that cigarette tax hikes in countries that have low smoking prevalence can reduce smoking even further, and thereby protect against the future health and financial costs of smoking. Importantly, the effects of these policies can be progressive across the income spectrum.

Economic evaluations of health system strengthening activities in low-income and middle-income country settings: a methodological systematic review.

OBJECTIVE: Health system strengthening (HSS) activities should accompany disease-targeting interventions in low/middle-income countries (LMICs). Economic evaluations provide information on how these types of investment might best be balanced but can be challenging. We conducted a systematic review to evaluate how researchers address these economic evaluation challenges. METHODS: We identified studies about economic evaluation of HSS activities in LMICs using a two-stage approach. First, we conducted a broad search to identify areas where economic evaluations of HSS activities were being conducted. Next, we selected specific interventions for more targeted literature review. We extracted study characteristics using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Finally, we summarised authors' modelling decisions using a framework that examines how models are developed to emphasise generalisability, precision, or realism. FINDINGS: Our searches produced 1978 studies, out of which we included 36. Most studies used data from prospective trials and calculated cost-effectiveness directly from these trial inputs, rather than using simulation methods. As a group, these studies primarily emphasised precision and realism over generalisability, meaning that their results were best suited to specific settings. CONCLUSIONS: The number of included studies was small. Our findings suggest that most economic evaluations of HSS do not leverage methods like sensitivity analyses or inputs from literature review that would produce more generalisable (but potentially less precise) results. More research into how decision-makers would use economic evaluations to define the expansion path to strengthening health systems would allow for conceptualising impactful work on the economic value of HSS.

Addressing the Impact of Noncommunicable Diseases and Injuries (NCDIs) in Ethiopia: Findings and Recommendations from the Ethiopia NCDI Commission.

BACKGROUND: Noncommunicable diseases and injuries (NCDIs) are the leading causes of premature mortality globally. Ethiopia is experiencing a rapid increase in NCDI burden. The Ethiopia NCDI Commission aimed to determine the burden of NCDIs, prioritize health sector interventions for NCDIs and estimate the cost and available fiscal-space for NCDI interventions. METHODS: We retrieved data on NCDI disease burden and concomitant risk factors from the Global Burden of Disease (GBD) Study, complemented by systematic review of published literature from Ethiopia. Cost-effective interventions were identified through a structured priority-setting process and costed using the One Health tool. We conducted fiscal-space analysis to identify an affordable package of NCDI services in Ethiopia. RESULTS: We find that there is a large and diverse NCDI disease burden and their risk factors such as hypertension and diabetes (these conditions are NCDIs themselves and could be risk factors to other NCDIs), including less common but more severe NCDIs such as rheumatic heart disease and cancers in women. Mental, neurological, chronic respiratory and surgical conditions also contribute to a substantial proportion of NCDI disease burden in Ethiopia. Among an initial list of 235 interventions, the commission recommended 90 top-priority NCDI interventions (including essential surgery) for implementation. The additional annual cost for scaling up of these interventions was estimated at US$550m (about US$4.7 per capita). CONCLUSIONS: A targeted investment in cost-effective interventions could result in substantial reduction in premature mortality and may be within the projected fiscal space of Ethiopia. Innovative financing mechanisms, multi-sectoral governance, regional implementation, and an integrated service delivery approach mainly using primary health care are required to achieve these goals.

Hospitalization costs for COVID-19 in Ethiopia: Empirical data and analysis from Addis Ababa's largest dedicated treatment center.

BACKGROUND: The COVID-19 pandemic has caused profound health, economic, and social disruptions globally. We assessed the full costs of hospitalization for COVID-19 disease at Ekka Kotebe COVID-19 treatment center in Addis Ababa, the largest hospital dedicated to COVID-19 patient care in Ethiopia. METHODS AND FINDINGS: We retrospectively collected and analysed clinical and cost data on patients admitted to Ekka Kotebe with laboratory-confirmed COVID-19 infections. Cost data included personnel time and salaries, drugs, medical supplies and equipment, facility utilities, and capital costs. Facility medical records were reviewed to assess the average duration of stay by disease severity (either moderate, severe, or critical). The data collected covered the time-period March-November 2020. We then estimated the cost per treated COVID-19 episode, stratified by disease severity, from the perspective of the provider. Over the study period there were 2,543 COVID-19 cases treated at Ekka Kotebe, of which, 235 were critical, 515 were severe, and 1,841 were moderate. The mean patient duration of stay varied from 9.2 days (95% CI: 7.6-10.9; for moderate cases) to 19.2 days (17.9-20.6; for critical cases). The mean cost per treated episode was USD 1,473 (95% CI: 1,197-1,750), but cost varied by disease severity: the mean cost for moderate, severe, and critical cases were USD 1,266 (998-1,534), USD 1,545 (1,413-1,677), and USD 2,637 (1,788-3,486), respectively. CONCLUSIONS: Clinical management and treatment of COVID-19 patients poses an enormous economic burden to the Ethiopian health system. Such estimates of COVID-19 treatment costs inform financial implications for resource-constrained health systems and reinforce the urgency of implementing effective infection prevention and control policies, including the rapid rollout of COVID-19 vaccines, in low-income countries like Ethiopia.

Modeling the relative risk of incidence and mortality of select vaccine-preventable diseases by wealth group and geographic region in Ethiopia.

Immunization is one of the most effective public health interventions, saving millions of lives every year. Ethiopia has seen gradual improvements in immunization coverage and access to child health care services; however, inequalities in child mortality across wealth quintiles and regions remain persistent. We model the relative distributional incidence and mortality of four vaccine-preventable diseases (VPDs) (rotavirus diarrhea, human papillomavirus, measles, and pneumonia) by wealth quintile and geographic region in Ethiopia. Our approach significantly extends an earlier methodology, which utilizes the population attributable fraction and differences in the prevalence of risk and prognostic factors by population subgroup to estimate the relative distribution of VPD incidence and mortality. We use a linear system of equations to estimate the joint distribution of risk and prognostic factors in population subgroups, treating each possible combination of risk or prognostic factors as computationally distinct, thereby allowing us to account for individuals with multiple risk factors. Across all modeling scenarios, our analysis found that the poor and those living in rural and primarily pastoralist or agrarian regions have a greater risk than the rich and those living in urban regions of becoming infected with or dying from a VPD. While in absolute terms all population subgroups benefit from health interventions (e.g., vaccination and treatment), current unequal levels and pro-rich gradients of vaccination and treatment-seeking patterns should be redressed so to significantly improve health equity across wealth quintiles and geographic regions in Ethiopia.