Universal health coverage of HIV, TB and malaria interventions in Ethiopia: economic burden, health benefits and financial risk protection

Introduction: Human Immunodeficiency Virus (HIV), Tuberculosis (TB) and malaria remain a major threat to the Ethiopian population. In the past decades, substantial gains have been achieved in reducing morbidity and mortality caused by HIV, TB and malaria diseases. Despite this progress, the coverage of essential health services for these diseases is far below the global targets. The health financing model in Ethiopia heavily relies on out-of-pocket (OOP) spending, which predisposes households to financial hardship. Therefore, high disease burden along with economic barriers have prohibitive consequences on accessing quality health services in the country. In addition, the allocation of scarce healthcare resources needs to be rationed appropriately to improve the health of the population in fair and efficient ways. Furthermore, in Ethiopia, like most low-income countries, apart from the health benefit of interventions to control major communicable diseases, the interventions’ importance in greater household economic returns, financial risk protection (FRP) and distributional consequences has not been fully recognised. Hence, evaluation of patient costs and benefits of the scale-up of HIV, TB and malaria interventions through universal public financing on health, equity and FRP domains are essential for priority setting and resource allocation decisions in Ethiopia. Objectives: This thesis aims to provide evidence on the patient cost, health gains and financial risk protection of HIV, TB and malaria interventions across socio-economic groups in Ethiopia. Methods: This thesis comprises of three interrelated studies. In Paper-I, a nationwide household survey (for HIV) and a separate cross-sectional survey collected from health facilities selected from Oromia and Afar regions (for TB) was used to estimate the magnitude of patient costs, catastrophic health expenditure (CHE) and its determinants for households affected by these diseases. Patient costs and CHE were used as a primary outcome measure in Paper-I. In Paper-II, an Extended Cost-Effectiveness Analysis (ECEA) method was used to estimate the impact of the universal public finance of selected malaria interventions on health benefits and FRP domains across income groups. Paper-III is based on a national level modelling study to estimate the impact of the universal public finance of selected TB interventions on mortality and financial risk reduction across income groups over the period 2018-35. The main outcomes were death averted and CHE in Papers II and III, including private expenditure averted and net government costs for Paper-II. Results: The mean patient cost was USD 78 per year for HIV care and USD 115 per TB episode. Direct patient costs of HIV and TB account for 69% and 46% of the total costs, respectively. The overall incidence of CHE among HIV patients was 20% (43% for the poorest quintile and 4% for the richest quintile) and that of the TB household was 40% (ranging from 58% to 20%, between the poorest and richest income quintiles, respectively). The incidence of CHE is higher in patients with frequent healthcare visits, TB/HIV co-infection, drug-resistant TB and hospitalisation. Inequality in financial risk was present across the different income quintiles, where the lower quintile suffers most. Increasing coverage (by 10%) of artemisinin combination therapy (ACT), long-lasting insecticide-treated bed nets (LLIN), indoor residual spraying (IRS) and malaria vaccines among the population at risk would avert 358, 188, 107, and 38 malaria deaths per year in Ethiopia. The four malaria interventions would avert 440, 220, 125, and 18 cases of CHE, respectively. Similarly, among the four interventions, malaria treatment (ACT) averts approximately USD 4,277,000 in private expenditure. ACT and LLIN interventions were linked to the largest number of deaths and cases of CHE averted. Those people in the lowest income quintiles have the highest health and FRP benefits. For example, the poorest two quintiles accounted for almost half of the deaths averted, compared to one-third in the richest two quintiles. The government cost of the ACT, LLIN, IRS and malaria vaccine interventions is USD 5.7, 16.5, 32.6, and 5.1 million, respectively. Implementing active TB case finding from 2018 to 2035 would lead to reductions of 206,000 (27%) and 193,000 (32%) of the expected TB deaths and CHEs, respectively. Similarly, enhancing DOTS for drug-susceptible TB would avert 192,000 (25%) deaths and 93,000 (15%) CHEs; and improvements in MDR-TB care would avert up to 6,300 (1%) and 33,000 (6%) deaths and CHEs, respectively. Both the health and financial risk benefits would be greatest for the poorest two income quintiles. Conclusion: In Ethiopia, spending on HIV and TB care imposes a major economic burden on households. Healthcare payments for HIV and TB care have adverse impact on equitable access to health services and place the population, especially the poorest, at considerable financial risk. The universal public financing of TB and malaria control interventions saves patient lives and brings higher FRP benefits, particularly among the poorest. Therefore, the Ethiopian Government needs to focus on the universal public finance of health intervention to reduce CHE, foster equity and protect households from the financial risks posed by these diseases. Keywords: HIV, tuberculosis, malaria, economic burden, equity, catastrophic health expenditures, financial risk protection, universal health coverage, extended cost-effectiveness analysis, Ethiopia.Doktorgradsavhandlin

Factors Affecting Parent-Adolescent Discussion on Reproductive Health Issues in Harar, Eastern Ethiopia: A Cross-Sectional Study

Background. Open family discussion on reproductive health (RH) issues often leads to increased awareness on RH matters and reduces risky behaviors among adolescents. This study was conducted to assess factors affecting parent-adolescent discussion on RH issues in Harar, Ethiopia. Methods. A cross-sectional survey using face to face interview supplemented with focus group discussion (FGD) was conducted on 751 randomly selected parents of 10–19-year-old adolescents. Data was analyzed using SPSS version 15. Results. More than one-fourth (28.76%) of parents reported discussing RH issues with their adolescents during the last six months. In the logistic regression, parents who have demonstrated good RH knowledge and positive attitude towards RH were almost six times and seventy percent (AOR 5.69, 95% CI: 3.67–8.82; AOR 1.70, 95% CI: 1.08–2.68) higher in discussing RH with their adolescents than their counterparts, respectively. Conclusion. Parent-adolescent discussion about RH issues rarely occurs and is bounded by lack of knowledge, sociocultural norms, and parental concern that discussion would encourage premarital sex. Reproductive health programs should target on improving awareness of parents and addressing sociocultural norms surrounding reproductive health issues

Khat chewing in pregnant women associated with prelabor rupture of membranes, evidence from eastern Ethiopia

Introduction: prelabor rupture of membranes (PROM) is a major factor that affects pregnancy outcome. Results from previous studies have suggested that there is an association between pregnant women, khat chewing and preterm birth, but evidence of association with PROM is sparse. This study therefore aims at identifying association between khat chewing in pregnancy and premature rupture of membranes in eastern Ethiopia. Methods: A health facility-based cross-sectional study was conducted among 1688 pregnant women who came for delivery service in Harar town, Eastern Ethiopia between June to October in 2016. Data were collected using a pre-tested structured questionnaire and checklist to extract data from the medical record. The association between khat and PROM was examined using logistic regression analysis. A statistical significance was declared at p-value < 0.05. Results: Of the 1688 pregnant women who participated in the study, 397 had prelabor rupture of the membranes, representing a proportion of 23.5% [(95% CI: (21.5, 25.6%)]. Of these 397 prelabor rupture of the membranes 198 (31.53%) were from Khat chewing mothers and, 199(18.77%) were from non-khat chewing mothers. After controlling for potential confounders, the multivariable logistic regression analysis revealed the odds of PROM was 1.51 times higher among khat chewed pregnant women [AOR = 1.51; 95% CI; (1.11, 2.07)] were had no khat chewing. Conclusion: this study found a significant association between khat chewing in pregnancy and PROM. Efforts to reduce PROM need to consider prevention of khat chewing in pregnancy. A specific strategy need to protect pregnant women from khat chewing

Anaemia and nutritional status of adolescent girls in Babile District, Eastern Ethiopia

Introduction: Nutritional status during adolescence plays an important role in the human lifecycle that influences growth and development and during this period nutrient needs are the greatest. The objective of this study is to assess anaemia and nutritional status of adolescent girls in the Babile district, Eastern Ethiopia. Methods: Data were collected from 547 adolescent aged 10-19 years by cross sectional study design. WHO Anthro-plus software was used to analyse Nutritional statuses of adolescents and magnitudes were determined using WHO 2007 references point. Haemoglobin was measured on site by hem cue machine. Descriptive and inferential statistical analysis was carried out depending on the nature of variables. Results: The result of the study show that 21.6% thin, 4.8% were over weighted and 1.1% was obese, 32% were anaemic and 15% of adolescents were stunted/ short stature than normal. Nutritional status of adolescent were low both in urban and rural adolescents, but severe thinness were higher among of rural (39.3%) compared to urban (37.5%) adolescents. Factors independently associated with stunting were place of residence, father occupation source of drinking water and age of the adolescents. Conclusion: Nutritional status of adolescent girls contributes to the nutritional status of the community. There is a need to initiate intervention measures to improve the nutritional status of adolescent girls who are the future 'mothers-to-be'. Hence, there is a need to create awareness among adolescents and their family about nutrition and health.Pan African Medical Journal 2016; 2

Consumption of animal source food and associated factors among pregnant women in eastern Ethiopia:A community-based study

IntroductionAnimal source foods contain quality nutrients, immunity, and behavioral outcome and are important for growth, and development. However, evidence on the level of animal source food consumption frequency and associated factors among pregnant women in Ethiopia, particularly rural residents are limited. Therefore, this study aimed to assess the consumption frequency of animal source food and to identify associated factors among pregnant women in the Haramaya district. MethodsA community-based cross-sectional study was conducted among 448 pregnant women. Data were collected through face-to-face interviews by trained research assistants, using a validated frequency questionnaire. Consumption of animal food sources was assessed by counting the frequency of each food from animal sources that pregnant women ate over a seven-day reference period. The highest tertile for animal source food consumption was considered as the high frequency of animal source food consumption; whereas the two lower tertiles were taken as the low frequency of animal source food consumption. A binary logistic regression model was used to investigate the association of the independent variables with the animal source food consumption. An adjusted odds ratio with a 95% confidence interval was reported to show an association using a p-value ResultsThe high frequency of animal source food consumption among the study participants was 24.78% (95% CI = 21%-29%). High animal source food consumption was more likely higher among respondents who were literate (AOR = 1.80; 95% CI = 1.048-3.095), and those who owned milk cows (ARO = 1.70; 95% CI = 1.003-2.863). However, respondent who reported chewing khat (AOR = 0.51; 95% CI = 0.313-0.805) (AOR = 0.56; 95% CI = 0.349-0.903), were less likely experienced animal source food consumption. ConclusionWe found low animal source food consumption among pregnant women in this predominantly rural setting. Women's educational level and milk cow ownership were positively associated with animal source food consumption. Additionally, a lower frequency of animal source food consumption was observed among women who reported chewing khat. Therefore, nutrition policy programs and interventions aimed at encouraging maternal nutritional guidance and counseling are recommended

Prevalence and determinants of dietary practices among pregnant women in eastern Ethiopia

INTRODUCTION: Appropriate dietary practices in pregnancy are critical to meet the increased metabolic and physiological demands; however, information about dietary practices among pregnant women, particularly rural residents, is limited. The study aimed to assess the level of appropriate dietary practices and associated determinants among pregnant women in Haramaya District, eastern Ethiopia, 2021. METHODS: A community-based cross-sectional study was conducted among 448 pregnant women in Haramaya District, Eastern Ethiopia. Data was collected through face-to-face interviews by trained research assistants, using a validated frequency questionnaire. The pregnant women were labeled as “appropriate dietary practice” when they consumed at least four meals daily, had a good food variety score, high dietary diversity score, and high consumption of animal source foods during the reference period. Otherwise, they were defined as “inappropriate.” A Poisson regression model with robust variance estimation was used to investigate the association of the independent variables with the dietary practice. An adjusted prevalence ratio with a 95% confidence interval was reported to show an association using a p-value < 0.05. RESULTS: The appropriate dietary practice among the study participants was 15.2% (95% CI = 12–18%). Of the respondents, 29.46, 37.5, and 24.7% had a high dietary diversity, high food variety score, and high consumption of animal source foods. The appropriate dietary practice was more prevalent among merchant women (APR = 2.07; 95% CI 1.07–4.02) and those whose husbands have at least a high school educational level (APR = 1.96; 95% CI 1.06–3.46). However, the prevalence of appropriate dietary practice was significantly lower among those who chewed khat (APR = 0.58; 95% CI 0.37–0.90) and among respondents who reported restriction of the intake of some foods (APR = 0.36; 95% CI 0.20–0.65). CONCLUSION: We found sup-optimal appropriate dietary practice among pregnant women in this predominantly rural setting. Additionally, the lower appropriate dietary practice was observed among women who reported chewing khat and experienced restriction of dietary consumption during pregnancy. Therefore, nutrition policy programs and interventions aimed at encouraging maternal nutritional guidance and counseling are recommended. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s40795-021-00494-4

Prevalence, predictors of low birth weight and its association with maternal iron status using serum ferritin concentration in rural Eastern Ethiopia:a prospective cohort study

Introduction Low birth weight (LBW) is one of the major predictors of perinatal survival, infant morbidity, and mortality, as well as the risk of developmental disabilities and illnesses in future lives. The effect of the nutritional status of pregnant women on birth outcomes is becoming a common research agenda, but evidence on the level of low birth weight (LBW) and its association with prenatal iron status in Ethiopia, particularly among rural residents, is limited. Thus, this study aimed to assess the prevalence, predictors of LBW, and its association with maternal iron status using serum ferritin concentration in Haramaya district, eastern Ethiopia, 2021. Methods A community-based prospective cohort study design was conducted. Of a total of 427 eligible pregnant women followed until birth, 412 (96.48%) were included in the final analysis. Iron status was determined using serum ferritin (SF) concentration from venous blood collected aseptically from the ante-cubital veins analyzed on a fully automated Cobas e411 (German, Japan Cobas 4000 analyzer series) immunoassay analyzer. Iron deficiency(ID) and iron deficiency anemia (IDA) were classified as having SF less than 15 mu g/L and SF less than 15 mu g/L and Hb level of < 11.0 g/dl during the first or third trimester or < 10.5 g/dl during the second trimester as well, respectively. Birthweight was measured within 72 h of birth and < 2500 g was considered LBW. Birthweight was measured within 72 h of birth and < 2500 g was considered as LBW. A Poisson regression model with robust variance estimation was used to investigate the factors associated with LBW and the association between maternal iron status and LBW. An adjusted prevalence ratio with a 95% confidence interval was reported to show an association using a p-value < 0.05. Results About 20.2% (95% CI: 16%-24%) of neonates were born with LBW. The prevalence of LBW was 5.04 (95% CI = 2.78-9.14) times higher among women who were iron deficient during pregnancy compared to those who were normal. The neonates of women who were iron deficient during pregnancy had lower birth weight (aPR=5.04; 95% CI = 2.78-9.14) than the neonates of women who were normal. Prevalence of LBW was higher among mothers who were undernourished (MUAC < 23cm) (aPR = 1.92; 95% CI= 1.33-2.27), stunted (heigh

Spatial pattern of perinatal mortality and its determinants in Ethiopia: Data from Ethiopian Demographic and Health Survey 2016.

BACKGROUND: The perinatal mortality rate in Ethiopia is among the highest in Sub Saharan Africa. The aim of this study was to identify the spatial patterns and determinants of perinatal mortality in the country using a national representative 2016 Ethiopia Demographic and Health Survey (EDHS) data. METHODS: The analysis was completed utilizing data from 2016 Ethiopian Demographic and Health Survey. This data captured the information of 5 years preceding the survey period. A total of 7230 women who at delivered at seven or more months gestational age nested within 622 enumeration areas (EAs) were used. Statistical analysis was performed by using STATA version 14.1, by considering the hierarchical nature of the data. Multilevel logistic regression models were fitted to identify community and individual-level factors associated with perinatal mortality. ArcGIS version 10.1 was used for spatial analysis. Moran's, I statistics fitted to identify global autocorrelation and local autocorrelation was identified using SatSCan version 9.6. RESULTS: The spatial distribution of perinatal mortality in Ethiopia revealed a clustering pattern. The global Moran's I value was 0.047 with p-value <0.001. Perinatal mortality was positively associated with the maternal age, being from rural residence, history of terminating a pregnancy, and place of delivery, while negatively associated with partners' educational level, higher wealth index, longer birth interval, female being head of household and the number of antenatal care (ANC) follow up. CONCLUSIONS: In Ethiopia, the perinatal mortality is high and had spatial variations across the country. Strengthening partner's education, family planning for longer birth interval, ANC, and delivery services are essential to reduce perinatal mortality and achieve sustainable development goals in Ethiopia. Disparities in perinatal mortality rates should be addressed alongside efforts to address inequities in maternal and neonatal healthcare services all over the country

Financial risks of care seeking for malaria by rural households in Jimma Zone, Oromia Region, Southwest Ethiopia: a cross-sectional study

Objectives Despite major progress in the prevention and control of malaria in recent years, the disease remains a major cause of morbidity in Ethiopia. Malaria also imposes substantial socioeconomic costs on households. The aim of this study is to estimate the financial risk of seeking malaria service for rural households across socioeconomic statuses in the Jimma Zone, Oromia Region. Design A facility-based cross-sectional survey. Setting Jimma Zone, Oromia Region, Southwest Ethiopia. Participants A total of 221 patients with malaria from 10 public health facilities were interviewed between September 2018 and December 2019. Primary and secondary outcome measures The main outcome measures capture the financial risks associated with malaria services, specifically catastrophic and impoverishing health expenditures. Catastrophic health expenditure (CHE) occurs when healthcare costs reach 10% of a household’s monthly income, whereas impoverishment occurs when a household’s monthly income falls below the national poverty level after paying for health service. Descriptive statistics were used to summarise the expenditure patterns associated with malaria services. All costs were gathered in Ethiopian birr and reported in 2019 US$. Results The average cost of receiving malaria services was US$4.40 (bootstrap 95% CI: 3.6 to 5.3), with indirect costs accounting for 52% of total costs. Overall, at the 10% threshold, 12% (bootstrap 95% CI: 8.1% to 16.7%) of patients with malaria incurred CHE: 40% (bootstrap 95% CI: 26.7% to 55.6%) of the household in the poorest quintile experienced CHE, but none from the richest quintile did. The proportion of households living in poverty increased by more than 2-3% after spending on malaria-specific health services. Conclusion Healthcare seeking for malaria imposes a substantial financial risk on rural households, particularly for the poorest and most vulnerable. Malaria policies and interventions should therefore seek to alleviate both the direct costs and productivity losses associated with the disease, especially among the poor.publishedVersio

Beyond hemoglobin:uncovering iron deficiency and iron deficiency anemia using serum ferritin concentration among pregnant women in eastern Ethiopia: a community-based study

Background Although the high burden of anemia among pregnant women in low-resource settings like Ethiopia is well documented, evidence is scarce on the underlying causes using biochemical tests. Therefore, this study assessed the iron status and factors associated with iron deficiency (ID) using serum ferritin concentration among pregnant women in Haramaya district, eastern Ethiopia. Methods A community-based cross-sectional study was conducted among randomly selected pregnant women in Haramaya district, eastern Ethiopia. The serum ferritin (SF) concentration was measured in the National Biochemical Laboratory of Ethiopia on a fully automated Cobas e411 (German, Japan Cobas 4000 analyzer series) immunoassay analyzer using the electro-chemiluminescence (ECL) method and standard procedures. A log-binomial regression analysis identified variables associated with iron deficiency, and defined as serum ferritin concentration < 15 mu g/L (per the World Health Organization recommendation in developing countries). An adjusted risk ratio (aRR), and a 95% confidence interval (CI), were used to report associations. Finally, the p-value < 0.05 was the cut-off point for the significant association. Results A total of 446 pregnant women with a mean age of 24.78 (+ 5.20) were included in the study. A total of 236 (52.91%; 95% CI: 48.16-57.63) had iron deficiency. The overall prevalence of anemia and iron deficiency anemia (IDA) was 45.96% (95% CI: 41.32-50.71) and 28.03% (95% CI: 21.27-32.44), respectively. The risk of iron deficiency was more likely among women with low dietary diversity (aRR = 1.36; 95% CI = 1.07-1.72) and those who skipped meals (aRR = 1.29; 95% CI = 1.05-1.57), but less among women who had antenatal care (aRR = 0.73 (95% CI = 0.61-0.88). Conclusion More than half of the pregnant women in eastern Ethiopia had iron deficiency. Improving dietary diversity, meal frequency, and prenatal follow-up is essential to improve the high burden of ID and the adverse effect on pregnant women and the fetus. Moreover, a prospective study comparing maternal and perinatal outcomes among these spectra-iron depletion, ID, and IDA-is crucial for understanding their impact on maternal and perinatal mortality and morbidity