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

  • Eskinder Eshetu Ali
    Correspondence
    Address correspondence to: Eskinder Eshetu Ali, Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, P.O. Box 110773, Ethiopia.
    Affiliations
    Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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      Abstract

      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.

      Keywords

      Introduction

      The right to the enjoyment of the highest attainable standard of physical and mental health is considered a fundamental human right. Internationally, the right to health was first articulated in the 1946 Constitution of the World Health Organization. The most authoritative interpretation of the right to health is outlined in Article 12 of the International Covenant on Economic, Social and Cultural Rights, which has been ratified by approximately 150 countries including Ethiopia [

      Office of the High Commissioner for Human Rights. International Covenant on Economic, Social and Cultural Rights. Available from: http://www2.ohchr.org/english/law/cescr.htm#art12. [Accessed June 15, 2012].

      ,

      World Health Organization. Human rights-based approach to health. Available from: http://www.who.int/trade/glossary/story054/en/index.html. [Accessed June 15, 2012].

      ,

      Anonymous. The right to health. Available from: www.ohchr.org/Documents/Publications/Factsheet31.pdf. [Accessed June 16, 2012].

      ].
      To realize this right to health, countries are required to ensure availability; nondiscriminating physical, economic, and informational accessibility; cultural and ethical acceptability; and quality of health care [

      World Health Organization. The right to health, Factsheet no. 323. Available from: http://www.who.int/media centre/factsheets/fs323/en/index.html. [Accessed July 15, 2012].

      ]. Generally, health services, goods, and facilities must be provided to all without any discrimination to guarantee that everyone’s right to health is observed [

      Anonymous. The right to health. Available from: www.ohchr.org/Documents/Publications/Factsheet31.pdf. [Accessed June 16, 2012].

      ].
      Ensuring economic access to health care is an essential element of the right to health [
      • Normand C.
      • Thomas S.
      Health care financing and the health system.
      ]. This means, that this fundamental human right cannot be observed in the absence of effective financial protection mechanisms for health care expenditures. This is because the absence of such mechanisms has enormous economic, psychosocial, and medical consequences. For example, out-of-pocket expenditure on health care is known to cause psychological stress on patients and their family. It also aggravates poverty in an already constrained household and leads to severe medical consequences because patients might forgo vital treatment because of unaffordability. Because it consumes the largest portion of households’ health-related expenditure, out-of-pocket expenditure on medicines will have the highest effect, especially on poor households [
      • Wagner A.K.
      • Graves A.J.
      • Reiss S.K.
      • et al.
      Access to care and medicines, burden of health care expenditures, and risk protection: results from the World Health Survey.
      ,
      • Wang H.
      • Zhang L.
      • Hsiao W.
      Ill health and its potential influence on household consumptions in rural China.
      ,
      • Garg C.C.
      • Karan A.K.
      Health and Millennium Development Goal 1: reducing out-of-pocket expenditures to reduce income poverty—evidence from India.
      ,
      • Lexchin J.
      • Grootendorst P.
      The effects of prescription drug user fees on drug and health services use and health status: a review of the evidence.
      ,
      • Liu Y.
      • Rao K.
      • Hsiao W.C.
      Medical expenditure and rural impoverishment in China.
      ].
      Looking at the situation in Ethiopia, the government is in the last phase of implementing a 20-year Health Sector Development Program since 1996-1997 with the objective of improving the country’s health status. So far, remarkable progress had been made, especially in the area of increasing the number of health care facilities and decentralization of the health system [

      Federal Ministry of Health. Health Sector Development Plan (HSDP-III) 2005/6-2009/10. Addis Ababa, Ethiopia: Planning and Programming Department, Federal Ministry of Health, 2005.

      ,

      Federal Ministry of Health. Ethiopia’s Fourth National Health Accounts, 2007/2008. Addis Ababa, Ethiopia: Federal Democratic Republic of Ethiopia, Ministry of Health, 2010.

      ].
      However, the progress made in the health care financing system is a little slow. The Ethiopian health care system still suffers from limited availability of health resources, overreliance on out-of pocket payments, and inefficient and inequitable use of resources, which limit universal coverage of health care. The health sector is generally underfinanced by both global and regional standards and is hugely dependent on donors and direct payment by households, contributing about 40% and 37% of the national health expenditure, respectively [

      Federal Ministry of Health. Ethiopia’s Fourth National Health Accounts, 2007/2008. Addis Ababa, Ethiopia: Federal Democratic Republic of Ethiopia, Ministry of Health, 2010.

      ,

      World Health Organization. The World Health Report: Health Systems Financing, the Path to Universal Coverage. Geneva, Switzerland: WHO Press, 2010.

      ]. As an essential component of health care, drug financing is no exception, with households’ out-of-pocket expenditure accounting for 47% of the total drug expenditure [

      Federal Ministry of Health/World Health Organization. Drug Financing in Ethiopia. Addis Ababa, Ethiopia: Federal Ministry of Health/World Health Organization, 2007.

      ].
      In an effort to reduce such limitations in the health care financing system, the Ethiopian government has been implementing different reforms. In 1998, the Federal Ministry of Health (FMOH) developed a health care financing strategy that became a very important policy document for the introduction of health financing reforms. Although a little slow, different regional states of the country started implementing reforms following this strategy. In May 2008, the health insurance strategy was developed by the FMOH. As a result, the government is in the process of initiating health insurance schemes: social health insurance (SHI) for the formal sector and community-based health insurance (CBHI) for citizens in the informal sector (people who are self-employed and a private sector employer with fewer than 10 employees) and agriculture. Currently, the legal and procedural aspects of the SHI system are being instituted, whereas the CBHI system is in its pilot phase of implementation [

      Zelelew H. Health care financing reform in Ethiopia: improving quality and equity. Available from: http://www.healthsystems2020.org/content/resource/detail/85865/function.mysql-connect. [Accessed December 25, 2013].

      ,

      Federal Ministry of Health. Health Insurance Strategy. Addis Ababa, Ethiopia: Planning and Programming Department, Federal Ministry of Health, 2008.

      ].
      On the face of such reforms, the importance of discussions on their implications cannot be overlooked. The implications of these reforms on accessibility of essential medicines to the Ethiopian population is particularly relevant because medicines take a large share of health care expenditure. This review therefore describes the components of the health care financing reform in Ethiopia, with particular emphasis on implications of the reforms on access to essential medicines in the country.

      Methods

      A desk review of government policy documents, guidelines, and manuals from the FMOH was done. Moreover, a PubMed search was conducted on the basis of the following key words: health care financing, drug financing, Ethiopia, health insurance, access to essential medicines. The same key words were used to conduct the search in local journals, which were not indexed in PubMed. No restriction was placed on the date of publication, and all articles related to the issue of health care financing in Ethiopia were reviewed.

      Results

      A total of three proclamations by the house of peoples’ representatives and the council of ministers of the Federal Democratic Republic of Ethiopia, four manuals and guidelines, six evaluation documents by the FMOH and international organizations, and eight research articles published in peer-reviewed local and international journals were found on the issue of health care financing and access to essential medicines in Ethiopia. The author reviewed all the articles.
      The main components of the health care reform that had been implemented by the different regional states of the country are as follows: revenue retention for health service quality improvements in the facility rather than the old system of channeling all revenue to the treasury; systematizing the fee waiver system for the poor; standardizing exemption services; outsourcing of nonclinical services in public hospitals; user fee setting and revision; initiation of health insurance; establishment of a private wing in public hospitals; and health facility autonomy through the establishment of governing bodies [

      Zelelew H. Health care financing reform in Ethiopia: improving quality and equity. Available from: http://www.healthsystems2020.org/content/resource/detail/85865/function.mysql-connect. [Accessed December 25, 2013].

      ,

      Federal Ministry of Health. Implementation Manual for Health Care Financing Reforms. Addis Ababa, Ethiopia: Federal Ministry of Health, 2005.

      ].
      Since the institution of the health care financing strategy in 1998, user fees were seen to have increased in many parts of the country. Until recently, the fee waiver system was characterized by ineffectiveness in specifically targeting the poor, incompleteness of coverage of services, and lack of proper documentation [
      • Woldie M.
      • Jirra C.
      • Tegegn A.
      An assessment of the free health care provision system in Jimma town, southwest Ethiopia.
      ,
      • Pearson L.
      • Gandhi M.
      • Admasu K.
      • Keyes E.B.
      User fees and maternity services in Ethiopia.
      ,
      • Asfaw A.
      • Braun J.V.
      • Klasen S.
      How big is the crowding-out effect of user fees in the rural areas of Ethiopia? Implications for equity and resources mobilization.
      ]. Although some reports suggest betterment of services with user fees, there is an apparent “crowding out effect” of fee increment by public health facilities, especially on the poor segments of the society in the absence of protective mechanisms [
      • Pearson L.
      • Gandhi M.
      • Admasu K.
      • Keyes E.B.
      User fees and maternity services in Ethiopia.
      ,
      • Asfaw A.
      • Braun J.V.
      • Klasen S.
      How big is the crowding-out effect of user fees in the rural areas of Ethiopia? Implications for equity and resources mobilization.
      ,

      Barnett I, Tefera B. Poor Households’ Experiences and Perception of User Fees for Healthcare: A Mixed-Method Study from Ethiopia. London: Young Lives, 2010.

      ].
      Even though per capita health expenditure in Ethiopia increased from US $7.14 in 2005 to US $16.1 in 2007-2008, households are still burdened with out-of-pocket expenditures at the time they need health care [

      Federal Ministry of Health. Ethiopia’s Fourth National Health Accounts, 2007/2008. Addis Ababa, Ethiopia: Federal Democratic Republic of Ethiopia, Ministry of Health, 2010.

      ]. The major mode of financing the public health sector has thus far been through budget allocation of revenue mobilized from the general tax and donor support [

      Federal Ministry of Health. Health Insurance Strategy. Addis Ababa, Ethiopia: Planning and Programming Department, Federal Ministry of Health, 2008.

      ,

      Barnett I, Tefera B. Poor Households’ Experiences and Perception of User Fees for Healthcare: A Mixed-Method Study from Ethiopia. London: Young Lives, 2010.

      ,
      World Health Organization
      WHO Country Cooperation Strategy 2012-2015.
      ].
      The country’s expenditure on drugs had been increasing by an average of around 28% annually. The per capita government expenditure on drugs was only 32 birr or US $3.80 in 2005-2006 and households’ out-of-pocket payment was 47% of the total drug expenditure. The fee waiver system did not safeguard patients against having to pay for medicines because of the unavailability of drugs in public health facilities. Moreover, the share of employer-provided drug insurance was only 0.2% of the total drug expenditure in 2005-2006 [

      Federal Ministry of Health/World Health Organization. Drug Financing in Ethiopia. Addis Ababa, Ethiopia: Federal Ministry of Health/World Health Organization, 2007.

      ,
      • Carasso B.
      • Lagarde M.
      • Tesfaye A.
      • Palmer N.
      Availability of essential medicines in Ethiopia: an efficiency-equity trade-off?.
      ].
      It was in 2008 that the Ethiopian government issued a health insurance strategy with the aim of achieving universal health service coverage in the country. While maintaining the traditional health financing mechanisms from sources such as the general tax system, development partners, and other alternative sources, the strategy calls for the mobilization of additional resources to the health sector and enhance equity in health service delivery by making health insurance compulsory to both formal and nonformal sectors. Accordingly, the health insurance strategy prescribes compulsory SHI, CBHI, and private health insurance schemes for different parts of the society [

      Federal Ministry of Health. Health Insurance Strategy. Addis Ababa, Ethiopia: Planning and Programming Department, Federal Ministry of Health, 2008.

      ].
      The proclamation that provided for the SHI scheme was issued on August 2010, and the SHI agency was established accountable to the ministry of health [

      Council of Ministers. The Ethiopian Health Insurance Agency Council of Ministers Regulation No. 191/2010. Federal Negarit Gazeta of the Federal Democratic Republic of Ethiopia, Page 5673, Addis Ababa, 2010.

      ]. Although the implementation of the scheme has been postponed to July 2014, members of the scheme will be pensioners and employees of a public office, a public enterprise, or any person who employs at least 10 employees with the exception of the defense forces. The sources of finance for this scheme are contributions by employees/pensioners and employers, investment income, and other related sources. Members and their families (spouse and children) will be beneficiaries of this scheme [
      2010: Social Health Insurance Proclamation. Federal Negarit Gazeta of the Federal Democratic Republic of Ethiopia, page 5494,.
      ].
      According to a November 2012 council of ministers regulation, any beneficiary of the SHI scheme shall have the right to access inpatient, outpatient, delivery, and surgical services. The scheme will also cover diagnostic services and generic drugs included in the agency’s drug list, which is currently under preparation. However, the following services are not covered: any treatment outside Ethiopia; treatment of injuries resulting from natural disasters, social unrest, epidemics, and high-risk sports; problems related to drug abuse or addiction; periodic medical checkup unrelated to illness; occupational injuries, traffic accidents, and other injuries covered by other laws; cosmetic surgeries; organ transplants; dialysis except in case of acute renal failure; eye glasses and contact lenses; in vitro fertilization; hip replacement; dentures, crowns, bridges, implants, and root canal treatments except those required because of infections; and provision of hearing aids and those services that are anyway provided to patients free of charge. Solidarity-based contributions are adapted. Accordingly, each member of the SHI scheme is supposed to contribute 3% of the monthly salary if the person is an employee of the formal sector or 1% of the pension if he or she is a pensioner. The employer will contribute the other 3% of the employee’s salary. For pensioners, the government will cover the other 1% of the pension. The agency will require 5% co-payment for any outpatient visit, and the member will be required to cover 50% of the cost if he or she chooses to bypass the referral system except in emergencies [

      Council of Ministers. Social Health Insurance Council of Ministers Regulation No. 271/2012. Federal Negarit Gazeta of the Federal Democratic Republic of Ethiopia, Page 6641, Addis Ababa, 2012.

      ].
      However, CBHI schemes are to be established at the woreda and kebele level and are subsidized by the government. The scheme was bound to be implemented in two phases, pilot and scale up. It is in the pilot phase of implementation in 13 districts since 2011. Starting in the year 2013-2014, the CBHI scheme is expected to be scaled-up covering about 40% of the population by the end of the 2014-2015 fiscal year [

      Ministry of Labor and Social Affairs. National Social Protection Policy of Ethiopia. Addis Ababa, Ethiopia: Federal Democratic Republic of Ethiopia, Ministry of Labor and Social Affairs, 2012.

      ].
      The CBHI system is based on membership on a household level, and all the members of the household are beneficiaries of the scheme. The premiums could be different in different kebeles and are decided depending on the ability of the community to pay and will be dependent on the number of members of the household. The scheme covers expenses for outpatient and inpatient services, surgery, and medicines. Generally, the services that are covered and those that are not are similar to those of the SHI scheme [

      Tehuledere Woreda. Tehuledere Woreda Community Based Health Insurance Institution. South Wollo, Haik: Federal Ministry of Health and Amhara Regional Health Bureau, 2011.

      ].
      In a little more than a year’s time after its pilot implementation, the CBHI scheme uptake had reached an impressive 45.5% of target households and studies show that there is a very high demand for the scheme [

      Derseh A, Sparrow RA, Debebe ZY, et al. Enrolment in Ethiopia’s community based health insurance scheme. ISS Working Paper Series/General Series 2013. Available from: http://hdl.handle.net/1765/50221 [Accessed March 12, 2014].

      ]. Different administrative reports indicate that implementation of the reforms increased the availability of essential medicines, diagnostic capacity of health facilities, accessibility of health care to the poor, and quality of care [

      Zelelew H. Health care financing reform in Ethiopia: improving quality and equity. Available from: http://www.healthsystems2020.org/content/resource/detail/85865/function.mysql-connect. [Accessed December 25, 2013].

      ,
      • Mebratie A.D.
      • Sparrow R.
      • Yilma Z.
      • et al.
      Impact of Ethiopian pilot community-based health insurance scheme on health-care utilization: a household panel data analysis.
      ]. There is very limited evidence, however, of these achievements in peer-reviewed scientific journals. Evaluations of the progress of the health care financing reform praised the increased availability of essential medicines due to better health facility autonomy to use the retained revenue to purchase medicines [

      Purvis G, Alebachew A, Feleke W. Ethiopia health sector financing reform midterm project evaluation. Available from: http://pdf.usaid.gov/pdf_docs/pdact293.pdf. [Accessed December 22, 2013]

      ,

      Health System Financing Reform Project. Assessment of User Fee Revisions in Public Health Facilities in Ethiopia: SNNP Regional Report. Hawassa, Ethiopia: USAID - Health System Financing Reform Project, 2011.

      ]. In contrast, there are cases in which beneficiaries of the fee waiver system complain of shortage of medicines in the health facilities, exposing them to financial burdens due to buying medicines from expensive private sources [

      Health System Financing Reform Project. Assessment of the Implementation of the Fee Waiver System: SNNP Regional Report. Hawassa, Ethiopia: USAID - Health System Financing Reform Project, 2011.

      ].

      Discussion

      Majority of the evidence found in this review is based on regulations and other administrative documents. There was very limited evidence of the status and achievements of health care financing reforms in Ethiopia in peer-reviewed scientific journals. Generally, the reviewed sources showed that the Ethiopian society is highly exposed to increasing user fees for health care services and adverse effects of out-of-pocket expenditures for health care. Risk protection systems are at their level of infancy in Ethiopia [

      Federal Ministry of Health. Health Insurance Strategy. Addis Ababa, Ethiopia: Planning and Programming Department, Federal Ministry of Health, 2008.

      ,
      • Woldie M.
      • Jirra C.
      • Tegegn A.
      An assessment of the free health care provision system in Jimma town, southwest Ethiopia.
      ,
      • Pearson L.
      • Gandhi M.
      • Admasu K.
      • Keyes E.B.
      User fees and maternity services in Ethiopia.
      ,
      • Asfaw A.
      • Braun J.V.
      • Klasen S.
      How big is the crowding-out effect of user fees in the rural areas of Ethiopia? Implications for equity and resources mobilization.
      ,
      • Engida E.
      • Haile-Mariam D.
      Assessment of the free health care provision system in Bahir Dar area, northern Ethiopia.
      ].
      The annual per capita health care expenditure of US $16.1 in 2007-2008 by the government is very low compared with that in other parts of the world. It is incomparable relative to the US $225 in upper middle–income countries and US $2500 in high-income countries [
      World Health Organization/Management Science for Health
      ]. Moreover, the per capita government drug expenditure of only 32 birr or US $3.80 in 2005-2006 was only 45% of the average per capita for low-income countries at the time [

      Federal Ministry of Health/World Health Organization. Drug Financing in Ethiopia. Addis Ababa, Ethiopia: Federal Ministry of Health/World Health Organization, 2007.

      ]. The reliance of the financing system on tax revenue, donor financing, and households’ out-of-pocket expenditure has proven to be unsustainable.
      Although limited, the evidence shows that a significant amount of fund can be mobilized using community health insurance schemes. On the basis of willingness-to-pay studies, some researchers estimated that the amount of fund that can be mobilized using CBHI systems could be up to three times higher than the recurrent budget allocated by the government for the health sector. This will ensure better access to health care with minimal financial hardships [
      • Asfaw A.
      • Braun J.V.
      • Klasen S.
      How big is the crowding-out effect of user fees in the rural areas of Ethiopia? Implications for equity and resources mobilization.
      ,
      • Asfaw A.
      • Braun J.V.
      Innovations in healthcare financing: new evidence on the prospect of community health insurance schemes in the rural areas of Ethiopia.
      ].
      Generally, limited data exist on the effects of financing reforms on access to essential medicines in different parts of Ethiopia. The already available ones focus on general health-related effects and are largely managerial supervision reports. This paucity of published evidence on the effect of health insurance on improving the accessibility to medicines is also the case in the rest of the world. Many of the already available publications are criticized for using weak study designs, and there are conflicting results by different authors. However, the reports generally suggest that accessibility to medicines depends more on the functioning of the public health care system and quality of services than on the availability of health insurance. Moreover, the level of comprehensiveness of the medicines benefit package affects the protective effect of health insurance on out-of-packet expenditure for medicines [
      • Robyn P.J.
      • Fink G.
      • Sié A.
      • Sauerborn R.
      Health insurance and health-seeking behavior: evidence from a randomized community-based insurance rollout in rural Burkina Faso.
      ,
      • Wirtz V.J.
      • Santa-Ana-Tellez Y.
      • Servan-Mori E.
      • Avila-Burgos L.
      Heterogeneous effects of health insurance on out-of-pocket expenditure on medicines in Mexico.
      ,
      • Faden L.
      • Vialle-Valentin C.
      • Ross-Degnan D.
      • Wagner A.
      Active pharmaceutical management strategies of health insurance systems to improve cost-effective use of medicines in low- and middle-income countries: a systematic review of current evidence.
      ,
      • King G.
      • Gakidou E.
      • Imai K.
      • et al.
      Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme.
      ,
      • Sepehri A.
      • Sarma S.
      • Serieux J.
      Who is giving up the free lunch? The insured patients’ decision to access health insurance benefits and its determinants: evidence from a low-income country.
      ,
      • Chankova S.
      • Sulzbach S.
      • Diop F.
      Impact of mutual health organizations: evidence from West Africa.
      ]. Thus, the need for well-designed studies on the subject is of paramount significance [
      • King G.
      • Gakidou E.
      • Imai K.
      • et al.
      Public policy for the poor? A randomised assessment of the Mexican universal health insurance programme.
      ,
      • Bigdeli M.
      • Javadi D.
      • Hoebert J.
      Health policy and systems research in access to medicines: a prioritized agenda for low- and middle-income countries.
      ].
      An implication of the induction of the social health insurance system in Ethiopia could be a surge of very high health care utilization and creation of a big gap of supply of medicines and services as witnessed in other parts of the world [
      • Kondo A.
      • Shigeoka H.
      Effects of universal health insurance on health care utilization, and supply-side responses: evidence from Japan.
      ]. Moreover, the potential negative effects of the institution of health insurance on the rational use of medicines seen in some countries should not be overlooked [
      • Dong H.
      • Bogg L.
      • Wang K.
      • et al.
      A description of outpatient drug use in rural China: evidence of differences due to insurance coverage.
      ].

      Conclusions

      Although a little slow, the progress made in the implementation of health care financing reforms in Ethiopia is encouraging. The government’s effort to institute health insurance schemes should be supported by the incorporation of important principles of pharmacoeconomics and health technology assessment. Generally, there is no clear evidence on the effect of health care financing reforms on access to essential medicines in Ethiopia. This could be because health care financing reforms, especially health insurance, are a new phenomenon for the country’s health care system. Thus, there is a clear need for well-organized research on the issue.
      Source of financial support: The authors have no other financial relationships to disclose.

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