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

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

Economic evaluation of Health Extension Program packages in Ethiopia

Background Ethiopia launched the Health Extension Program (HEP) in 2004, aimed at ensuring equitable community-level healthcare services through Health Extension Workers. Despite the program’s being a flagship initiative, there is limited evidence on whether investment in the program represents good value for money. This study assessed the cost and cost-effectiveness of HEP interventions to inform policy decisions for resource allocation and priority setting in Ethiopia. Methods Twenty-one health care interventions were selected under the hygiene and sanitation, family health services, and disease prevention and control sub-domains. The ingredient bottom-up and top-down costing method was employed. Cost and cost-effectiveness were assessed from the provider perspective. Health outcomes were measured using life years gained (LYG). Incremental cost per LYG in relation to the gross domestic product (GDP) per capita of Ethiopia (US$852.80) was used to ascertain the cost-effectiveness. All costs were collected in Ethiopian birr and converted to United States dollars (US$) using the average exchange rate for 2018 (US$1 = 27.67 birr). Both costs and health outcomes were discounted by 3 Result The average unit cost of providing selected hygiene and sanitation, family health, and disease prevention and control services with the HEP was US$0.70, US$4.90, and US$7.40, respectively. The major cost driver was drugs and supplies, accounting for 53% and 68%, respectively, of the total cost. The average annual cost of delivering all the selected interventions was US$9,897. All interventions fall within 1 times GDP per capita per LYG, indicating that they are very cost-effective (ranges: US$22–$295 per LYG). Overall, the HEP is cost-effective by investing US$77.40 for every LYG. Conclusion The unit cost estimates of HEP interventions are crucial for priority-setting, resource mobilization, and program planning. This study found that the program is very cost-effective in delivering community health services.publishedVersio

Health gains and financial risk protection afforded by public financing of selected malaria interventions in Ethiopia: an extended cost-effectiveness analysis

Background Malaria is a public health burden and a major cause for morbidity and mortality in Ethiopia. Malaria also places a substantial financial burden on families and Ethiopia’s national economy. Economic evaluations, with evidence on equity and financial risk protection (FRP), are therefore essential to support decision-making for policymakers to identify best buys amongst possible malaria interventions. The aim of this study is to estimate the expected health and FRP benefits of universal public financing of key malaria interventions in Ethiopia. Methods Using extended cost-effectiveness analysis (ECEA), the potential health and FRP benefits were estimated, and their distributions across socio-economic groups, of publicly financing a 10% coverage increase in artemisinin-based combination therapy (ACT), long-lasting insecticide-treated bed nets (LLIN), indoor residual spraying (IRS), and malaria vaccine (hypothetical). Results ACT, LLIN, IRS, and vaccine would avert 358, 188, 107 and 38 deaths, respectively, each year at a net government cost of USD 5.7, 16.5, 32.6, and 5.1 million, respectively. The annual cost of implementing IRS would be two times higher than that of the LLIN interventions, and would be the main driver of the total costs. The averted deaths would be mainly concentrated in the poorest two income quintiles. The four interventions would eliminate about USD 4,627,800 of private health expenditures, and the poorest income quintiles would see the greatest FRP benefits. ACT and LLINs would have the largest impact on malaria-related deaths averted and FRP benefits. Conclusions ACT, LLIN, IRS, and vaccine interventions would bring large health and financial benefits to the poorest households in Ethiopia.publishedVersio

Distributional impact of infectious disease interventions in the Ethiopian Essential Health Service Package: a modelling study

Objectives Reducing inequalities in health and financial risk are key goals on the path toward universal health coverage, particularly in low-income and middle-income countries. The design of the health benefit package creates an opportunity to select interventions through established criteria. The aim of this study is to examine the health equity and financial protection impact of selected interventions, along with their costs, at the national level in Ethiopia.Design Distributional cost-effectiveness analysis.Population The eligible population for all selected interventions is assumed to be 10 million.Data sources Data on disease prevalence and population size were gathered from the Global Burden of Disease database, and average health benefits and program costs are sourced from the Ethiopian Essential Health Service Package (EHSP) database, national surveys and other publicly available sources.Intervention A total of 30 interventions were selected from the latest EHSP revision and analysed over a 1-year period.Outcome measures Health benefits, social welfare indices and financial protection metrics across income quintiles were reported.Results We found 23 interventions that improve population health and reduce health inequality and four interventions reduce both population health and health inequality. Additionally, three interventions improve population health while increasing health inequality. Overall, the EHSP interventions provide a 0.021 improvement in health-adjusted life expectancy (HALE) per person, with a positive distributional equity impact: 0.029 (26.9%) HALE gained in the poorest and 0.015 (14.0%) in the richest quintile. Similarly, a total of 1 79 475 cases of catastrophic health expenditure were averted, including 82 100 (46.0%) cases in the poorest and 17 900 (10.0%) in the richest quintile.Conclusion Increasing access to the EHSP improves health equity and financial protection. Improved access to selected EHSP interventions also has the potential to provide greater benefits to the poorest and thereby improve social welfare

Association between Women’s Empowerment and Other Socio-Demographic and Nutritional Factors on Stunting among Children Aged 6 to 59 Months: Data from 2016 EDHS

Background: Stunting is the most prevalent form of malnutrition in children under five years of age in Ethiopia. Evidence supporting women’s impact on reducing child stunting is limited. Ithis study aimed to examine the association between women’s empowerment and socio-demographic factors on stunting among children aged 6 to 59 months.Subjects and Method: The study used the EDHS 2016 dataset. Children aged 6-59 months whose mothers (aged 15-49 years) were living with their husbands at the time of the survey were included. We enrolled 8,496 mother and child pairs. Complex sample logistic regression analysis was employed to determine the association between child stunting and the predictors. Data analyses were employed using SPSS Version 22.Results: Around 2,624 (31%) of the mothers were 25 to 29 years old. In the 12 months before the survey, around 45% (3,806) of the mothers were employed; 2,072 (54%) of them had seasonal jobs, and the 1,734 (45%) remaining mothers had full-time employment. Among employed mothers, about 50.5% (1,921) had not received payment for their work. Household wealth index (AOR= 1.9; 95% CI= 1.44 to 2.73) and maternal height (AOR= 1.9; 95% CI= 1.28 to 2.82), and having a boy child (AOR= 1.3; 95%CI= 1.08 to 1.46) is more liked associating with stunting. But maternal attitude towards wife-beating (AOR= 1.1; 95% CI= 0.89 to 1.26) had no association with it.Conclusion: children born from the poorest households, low maternal height (<145cm), and male sex have increased risk of stunting. Lastly, Mothers' economic and socio-familial empowerment do not predict the risk of child stunting.Keywords: stunting, empowerment, women, Ethiopian demographic health survey.Correspondence: Yirgalem Shibiru Baruda. School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia. Email: [email protected] of Maternal and Child Health (2022), 07(06): 630-641https://doi.org/10.26911/thejmch.2022.07.06.02

Financial burden of HIV and TB among patients in Ethiopia: a cross-sectional survey

Objectives HIV and tuberculosis (TB) are major global health threats and can result in household financial hardships. Here, we aim to estimate the household economic burden and the incidence of catastrophic health expenditures (CHE) incurred by HIV and TB care across income quintiles in Ethiopia. Design A cross-sectional survey. Setting 27 health facilities in Afar and Oromia regions for TB, and nationwide household survey for HIV. Participants A total of 1006 and 787 individuals seeking HIV and TB care were enrolled, respectively. Outcome measures The economic burden (ie, direct and indirect cost) of HIV and TB care was estimated. In addition, the CHE incidence and intensity were determined using direct costs exceeding 10% of the household income threshold. Results The mean (SD) age of HIV and TB patient was 40 (10), and 30 (14) years, respectively. The mean (SD) patient cost of HIV was $78 ($170) per year and $115 ($118) per TB episode. Out of the total cost, the direct cost of HIV and TB constituted 69% and 46%, respectively. The mean (SD) indirect cost was $24 ($66) per year for HIV and $63 ($83) per TB episode. The incidence of CHE for HIV was 20%; ranges from 43% in the poorest to 4% in the richest income quintile (p<0.001). Similarly, for TB, the CHE incidence was 40% and ranged between 58% and 20% among the poorest and richest income quintiles, respectively (p<0.001). This figure was higher for drug-resistant TB (62%). Conclusions HIV and TB are causes of substantial economic burden and CHE, inequitably, affecting those in the poorest income quintile. Broadening the health policies to encompass interventions that reduce the high cost of HIV and TB care, particularly for the poor, is urgently needed

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

Economic evaluation of Health Extension Program packages in Ethiopia

Background Ethiopia launched the Health Extension Program (HEP) in 2004, aimed at ensuring equitable community-level healthcare services through Health Extension Workers. Despite the program’s being a flagship initiative, there is limited evidence on whether investment in the program represents good value for money. This study assessed the cost and cost-effectiveness of HEP interventions to inform policy decisions for resource allocation and priority setting in Ethiopia. Methods Twenty-one health care interventions were selected under the hygiene and sanitation, family health services, and disease prevention and control sub-domains. The ingredient bottom-up and top-down costing method was employed. Cost and cost-effectiveness were assessed from the provider perspective. Health outcomes were measured using life years gained (LYG). Incremental cost per LYG in relation to the gross domestic product (GDP) per capita of Ethiopia (US$852.80) was used to ascertain the cost-effectiveness. All costs were collected in Ethiopian birr and converted to United States dollars (US$) using the average exchange rate for 2018 (US$1 = 27.67 birr). Both costs and health outcomes were discounted by 3 Result The average unit cost of providing selected hygiene and sanitation, family health, and disease prevention and control services with the HEP was US$0.70, US$4.90, and US$7.40, respectively. The major cost driver was drugs and supplies, accounting for 53% and 68%, respectively, of the total cost. The average annual cost of delivering all the selected interventions was US$9,897. All interventions fall within 1 times GDP per capita per LYG, indicating that they are very cost-effective (ranges: US$22–$295 per LYG). Overall, the HEP is cost-effective by investing US$77.40 for every LYG. Conclusion The unit cost estimates of HEP interventions are crucial for priority-setting, resource mobilization, and program planning. This study found that the program is very cost-effective in delivering community health services