The impact of community-based health insurance on health service utilization and financial risk protection in Ethiopia.

BACKGROUND: Evidence on the effectiveness of community-based health insurance (CBHI) in low-income countries is inconclusive. This study assessed the impact of CBHI on health service utilization and financial risk protection in Ethiopia. METHODS: We conducted a comparative cross-sectional study nested within a larger national household survey in 2020. Data was collected from three groups of households-CBHI member households (n = 1586), non-member households from CBHI implementing woredas (n = 1863), and non-member households from non-CBHI implementing woredas (n = 789). Indicators of health service utilization, out-of-pocket health spending, catastrophic health expenditure, and impoverishment due to health spending among CBHI members were compared with non-members from CBHI implementing woredas and households from non-CBHI implementing woredas. Propensity score matching (PSM) was used to account for possible selection bias. RESULTS: The annual number of OPD visits per capita among CBHI member households was 2.09, compared to 1.53 among non-member households from CBHI woredas and 1.75 among households from non-CBHI woredas. PSM estimates indicated that CBHI members had 0.36 (95% CI: 0.25, 0.44) and 0.17 (95% CI: -0.04, 0.19) more outpatient department (OPD) visits per capita per year than their matched non-member households from CBHI-implementing and non-CBHI implementing woredas, respectively. CBHI membership resulted in a 28-43% reduction in annual OOP payments as compared to non-member households. CBHI member households were significantly less likely to incur catastrophic health expenditures (measured as annual OOP payments of more than 10% of the household's total expenditure) compared to non-members (p < 0.01). CONCLUSION: CBHI membership increases health service utilization and financial protection. CBHI proves to be an important strategy for promoting universal health coverage. Implementing CBHI in all woredas and increasing membership among households in woredas that are already implementing CBHI will further expand its benefits.

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

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

Equitable Distribution of Poor Quality of Care? Equity in Quality of Reproductive Health Services in Ethiopia.

The Ethiopian health system faces persistent inequities in health-care utilization and outcomes, despite continued efforts to expand health service coverage. There is little evidence in the literature describing the status of equity in the quality of healthcare. This paper aims to understand the disparities in quality of antenatal care (ANC) and family planning (FP) among the poor and non-poor communities. We used the 2016 Ethiopia Demographic and Health Survey (DHS) data to compute a Multidimensional Poverty Index (MPI), and the 2014 Service Provision Assessment (SPA) data to assess quality of ANC and FP services-defined as the level of adherence to World Health Organization (WHO) clinical and service guidelines. We merged the two datasets using geographical coordinates, and aggregated service users into facility catchment area clusters using a 2-km radius for urban and 10-km radius for rural facilities. We computed ANC and FP quality and MPI indices for each facility and assigned these to catchment areas. Using the international cutoff point for deprivation (MPI = 33.3%), we evaluated whether the quality of ANC and FP services varies by poor and non-poor catchment areas. We found that most of catchment areas (75.7%) were deprived. While the overall quality of ANC and FP services are low (33% and 34% respectively), we found little variation in the distribution of the quality of these services between poor and non-poor areas, urban and rural settings, or regionally. The short-term focus needs to be on improving the overall quality of services rather than on its distribution.

The burden of household out-of-pocket health expenditures in Ethiopia: estimates from a nationally representative survey (2015-16).

In Ethiopia, little is known about the extent of out-of-pocket health expenditures and the associated financial hardships at national and regional levels. We estimated the incidence of both catastrophic and impoverishing health expenditures using data from the 2015/16 Ethiopian household consumption and expenditure and welfare monitoring surveys. We computed incidence of catastrophic health expenditures (CHE) at 10% and 25% thresholds of total household consumption and 40% threshold of household capacity to pay, and impoverishing health expenditures (IHE) using Ethiopia's national poverty line (ETB 7184 per adult per year). Around 2.1% (SE: 0.2, P < 0.001) of households would face CHE with a 10% threshold of total consumption, and 0.9% (SE: 0.1, P < 0.001) of households would encounter IHE, annually in Ethiopia. CHE rates were high in the regions of Afar (5.8%, SE: 1.0, P < 0.001) and Benshangul-Gumuz (4.0%, SE: 0.8, P < 0.001). Oromia (n = 902 000), Amhara (n = 275 000) and Southern Nations Nationalities and Peoples (SNNP) (n = 268 000) regions would have the largest numbers of affected households, due to large population size. The IHE rates would also show similar patterns: high rates in Afar (5.0%, SE: 0.96, P < 0.001), Oromia (1.1%, SE: 0.22, P < 0.001) and Benshangul-Gumuz (0.9%, SE: 0.4, P = 0.02); a large number of households would be impoverished in Oromia (n = 356 000) and Amhara (n = 202 000) regions. In summary, a large number of households is facing financial hardship in Ethiopia, particularly in Afar, Benshangul-Gumuz, Oromia, Amhara and SNNP regions and this number would likely increase with greater health services utilization. We recommend regional-level analyses on services coverage to be conducted as some of the estimated low CHE/IHE regional values might be due to low services coverage. Periodic analyses on the financial hardship status of households could also be monitored to infer progress towards universal health coverage.