Defining the Ethiopian Essential Health Service Package : Process, methods and cost-effectiveness evidence for the prioritisation of health interventions

Background: All countries have signed up to the United Nations (UN) Sustainable Development Goals (SDGs), including Target 3.8 on achieving universal health coverage (UHC). UHC is realised when everyone has access to quality essential health services with financial risk protection. Countries should, therefore, measure and track their progress towards UHC over time and take appropriate action. Defining an essential health service package (EHSP) is the first and crucial step towards UHC progress. In defining an EHSP, counties identify the type and mix of health services that respond to their populations’ needs. However, there are gaps in evidence regarding Ethiopia’s current UHC status, and it had been more than 15 years since the EHSP was defined in Ethiopia. Furthermore, there is relatively little national cost-effectiveness evidence available to redefine the EHSP in Ethiopia. Therefore, this study aimed to estimate Ethiopia’s UHC service coverage status, generate relevant cost-effectiveness evidence and synthesise and describe the methods, process and key features of the revised Ethiopian EHSP. Methods: This thesis consists of three studies. In Paper I, 16 individual tracer indicators that measure a health system’s performance in various domains were selected to measure UHC service coverage in Ethiopia. We grouped the tracer indicators into four major programme areas (i.e., reproductive maternal neonatal child health [RMNCH], infectious disease, noncommunicable disease [NCD] and capacity and access), and we constructed an overall UHC service coverage index using geometric means. We also estimated the subnational level of UHC service coverage. In this paper, various surveys and routinely collected administrative data were used. In Paper II, we employed a standardised WHO- CHOICE generalised cost-effectiveness analysis (GCEA) methodology. Average cost- effectiveness ratios (ACERs) for 159 health interventions were calculated. The health benefits of interventions were determined using healthy life years (HLYs) gained. The economic costs of interventions were estimated from the health system perspective. We used the OneHealth tool for data analysis. In the third paper (Paper III), we synthesised and described the methods, process and critical features of the 2019 EHSP. A total of 35consultative workshops were convened with experts and the public to define the revision’s scope, develop a list of health interventions, agree on the prioritisation criteria, gather evidence and compare health interventions. Seven prioritisation criteria were employed: disease burden, cost effectiveness, equity, financial risk protection, budget impact, public acceptability and political acceptability. Results: The overall UHC service coverage for Ethiopia in 2015 was 34.3%, ranging from the highest (52.2%) in Addis Ababa to the lowest (10%) in Afar. The programme area coverage varied from about 53% for infectious diseases to 20% for capacity and access (Paper I). In Paper II, we found ACERs ranging from less than US$1 per HLY gained for family planning intervention to about USD 48,000 for colorectal cancer treatment at stage 4. About 75% of all interventions evaluated had ACERs of less than USD 1,000 per HLY gained. The majority (95%) of RMNCH and infectious disease interventions had an ACER of less than USD 1,000 per HLY while around half of interventions (44%) targeting NCDs had an ACER of less than USD 1,000 per HLY. In Paper III (EHSP revision process), 1,749 interventions were identified in the first phase. These interventions were regrouped and reorganised, and 1,442 interventions were identified as possible candidates for the EHSP. In the second phase, we removed interventions that did not match the burden of disease or were not relevant in the Ethiopian setting, and, therefore, the number of EHSP intervention was reduced to 1,018. We then evaluated and ranked the interventions by the other six criteria. In the final EHSP, 594 (58%) interventions were classified as high priority, 213 (21%) as medium priority and 211 (21%) as low priority. The current policy is to provide 56% of interventions free of charge and to ensure 38% on cost-sharing and 6% on cost-recovery arrangements. Conclusions: In conclusion, the baseline (2015) UHC service coverage index for Ethiopia was low. Furthermore, several potential cost-effective interventions were available that could substantially reduce Ethiopia’s disease burden if scaled up. The revision of Ethiopia’s EHSP followed a comprehensive, participatory, inclusive and evidence-based process, and the EHSP interventions were linked to appropriate health care delivery platforms and financing mechanisms.Doktorgradsavhandlin

Is universal health coverage affordable? Estimated costs and fiscal space analysis for the Ethiopian Essential Health Services Package

Estimating the required resources for implementing an essential health services package (EHSP) is vital to examine its feasibility and affordability. This study aimed to estimate the financial resources required to implement the Ethiopian EHSP from 2020 to 2030. Furthermore, we explored potential alternatives to increase the fiscal space for health in Ethiopia. We used the OneHealth Tool (OHT) to estimate the costs of expanding the EHSP service provision in the public sector in Ethiopia. Combinations of ingredient-based bottom-up and program-based summary costing approaches were applied. We predicted the fiscal space using assumptions for economic growth, government resource allocations to health, external aid for health, the magnitude of out-of-pocket expenditure, and other private health expenditures as critical factors affecting available resources devoted to health. All costs were valued using 2020 US dollars (USD). To implement the EHSP, 13.0 billion USD (per capita: 94 USD) would be required in 2030. The largest (50–70%) share of estimated costs was for medicines, commodities, and supplies, followed by human resources costs (10–17%). However, the expected available resources based on a business-as-usual fiscal space estimate would be 63 USD per capita for the same year. Therefore, the gap as a percentage of the required resources would be 33% in 2030. The resources needed to implement the EHSP would increase steadily over the projection period due mainly to increases in service coverage targets over time. Allocating gains from economic growth to increase the total government health expenditure could partly address the gap.publishedVersio

Measuring progress towards universal health coverage: National and subnational analysis in Ethiopia

Introduction: Aiming for universal health coverage (UHC) as a country-level goal requires that progress is measured and tracked over time. However, few national and subnational studies monitor UHC in low-income countries and there is none for Ethiopia. This study aimed to estimate the 2015 national and subnational UHC service coverage status for Ethiopia. Methods: The UHC service coverage index was constructed from the geometric means of component indicators: first, within each of four major categories and then across all components to obtain the final summary index. Also, we estimated the subnational level UHC service coverage. We used a variety of surveys data and routinely collected administrative data. Results: Nationally, the overall Ethiopian UHC service coverage for the year 2015 was 34.3%, ranging from 52.2% in the Addis Ababa city administration to 10% in the Afar region. The coverage for non-communicable diseases, reproductive, maternal, neonatal and child health and infectious diseases were 35%, 37.5% and 52.8%, respectively. The national UHC service capacity and access coverage was only 20% with large variations across regions, ranging from 3.7% in the Somali region to 41.1% in the Harari region. Conclusion: The 2015 overall UHC service coverage for Ethiopia was low compared with most of the other countries in the region. Also, there was a substantial variation among regions. Therefore, Ethiopia should rapidly scale up promotive, preventive and curative health services through increasing investment in primary healthcare if Ethiopia aims to reach the UHC service coverage goals. Also, policymakers at the regional and federal levels should take corrective measures to narrow the gap across regions, such as redistribution of the health workforce, increase resources allocated to health and provide focused technical and financial support to low-performing regions.publishedVersio

Cost-effectiveness of facility-based, stand-alone and mobile-based voluntary counseling and testing for HIV in Addis Ababa, Ethiopia

Background: Globally, there is a consensus to end the HIV/AIDS epidemic by 2030, and one of the strategies to achieve this target is that 90% of people living with HIV should know their HIV status. Even if there is strong evidence of clients’ preference for testing in the community, HIV voluntary counseling and testing (VCT) continue to be undertaken predominantly in health facilities. Hence, empirical cost-effectiveness evidence about different HIV counseling and testing models is essential to inform whether such community-based testing are justifiable compared with additional resources required. Therefore, the purpose of this study was to compare the cost-effectiveness of facility-based, stand-alone and mobile-based HIV voluntary counseling and testing methods in Addis Ababa, Ethiopia. Methods: Annual economic costs of counseling and testing methods were collected from the providers’ perspective from July 2016 to June 2017. Ingredients based bottom-up costing approach was applied. The effectiveness of the interventions was measured in terms of the number of HIV seropositive clients identified. Decision tree modeling was built using TreeAge Pro 2018 software, and one-way and probabilistic sensitivity analyses were conducted by varying HIV positivity rate, costs, and probabilities. Results: The cost of test per client for facility-based, stand-alone and mobile-based VCT was USD 5.06, USD 6.55 and USD 3.35, respectively. The unit costs of test per HIV seropositive client for the corresponding models were USD 158.82, USD 150.97 and USD 135.82, respectively. Of the three models, stand-alone-based VCT was extendedly dominated. Mobile-based VCT costs, an additional cost of USD 239 for every HIV positive client identified when compared to facility-based VCT. Conclusion: Using a mobile-based VCT approach costs less than both the facility-based and stand-alone approaches, in terms of both unit cost per tested individual and unit cost per HIV seropositive cases identified. The stand-alone VCT approach was not cost-effective compared to facility-based and mobile-based VCT. The incremental cost-effectiveness ratio for mobile-based VCT compared with facility-based VCT was USD 239 per HIV positive case.publishedVersio

Contextualization of cost-efectiveness evidence from literature for 382 health interventions for the Ethiopian essential health services package revision

Background Cost-effectiveness of interventions was a criterion decided to guide priority setting in the latest revision of Ethiopia’s essential health services package (EHSP) in 2019. However, conducting an economic evaluation study for a broad set of health interventions simultaneously is challenging in terms of cost, timeliness, input data demanded, and analytic competency. Therefore, this study aimed to synthesize and contextualize cost-effectiveness evidence for the Ethiopian EHSP interventions from the literature. Methods The evidence synthesis was conducted in five key steps: search, screen, evaluate, extract, and contextualize. We searched MEDLINE and EMBASE research databases for peer-reviewed published articles to identify average cost-effectiveness ratios (ACERs). Only studies reporting cost per disability-adjusted life year (DALY), quality-adjusted life year (QALY), or life years gained (LYG) were included. All the articles were evaluated using the Drummond checklist for quality, and those with a score of at least 7 out of 10 were included. Information on cost, effectiveness, and ACER was extracted. All the ACERs were converted into 2019 US dollars using appropriate exchange rates and the GDP deflator. Results In this study, we synthesized ACERs for 382 interventions from seven major program areas, ranging from US$3 per DALY averted (for the provision of hepatitis B vaccination at birth) to US$242,880 per DALY averted (for late-stage liver cancer treatment). Overall, 56% of the interventions have an ACER of less than US$1000 per DALY, and 80$10,000 per DALY. Conclusion We conclude that it is possible to identify relevant economic evaluations using evidence from the literature, even if transferability remains a challenge. The present study identified several cost-effective candidate interventions that could, if scaled up, substantially reduce Ethiopia’s disease burden.publishedVersio

Defining the Ethiopian Essential Health Service Package : Process, methods and cost-effectiveness evidence for the prioritisation of health interventions

Background: All countries have signed up to the United Nations (UN) Sustainable Development Goals (SDGs), including Target 3.8 on achieving universal health coverage (UHC). UHC is realised when everyone has access to quality essential health services with financial risk protection. Countries should, therefore, measure and track their progress towards UHC over time and take appropriate action. Defining an essential health service package (EHSP) is the first and crucial step towards UHC progress. In defining an EHSP, counties identify the type and mix of health services that respond to their populations’ needs. However, there are gaps in evidence regarding Ethiopia’s current UHC status, and it had been more than 15 years since the EHSP was defined in Ethiopia. Furthermore, there is relatively little national cost-effectiveness evidence available to redefine the EHSP in Ethiopia. Therefore, this study aimed to estimate Ethiopia’s UHC service coverage status, generate relevant cost-effectiveness evidence and synthesise and describe the methods, process and key features of the revised Ethiopian EHSP. Methods: This thesis consists of three studies. In Paper I, 16 individual tracer indicators that measure a health system’s performance in various domains were selected to measure UHC service coverage in Ethiopia. We grouped the tracer indicators into four major programme areas (i.e., reproductive maternal neonatal child health [RMNCH], infectious disease, noncommunicable disease [NCD] and capacity and access), and we constructed an overall UHC service coverage index using geometric means. We also estimated the subnational level of UHC service coverage. In this paper, various surveys and routinely collected administrative data were used. In Paper II, we employed a standardised WHO- CHOICE generalised cost-effectiveness analysis (GCEA) methodology. Average cost- effectiveness ratios (ACERs) for 159 health interventions were calculated. The health benefits of interventions were determined using healthy life years (HLYs) gained. The economic costs of interventions were estimated from the health system perspective. We used the OneHealth tool for data analysis. In the third paper (Paper III), we synthesised and described the methods, process and critical features of the 2019 EHSP. A total of 35consultative workshops were convened with experts and the public to define the revision’s scope, develop a list of health interventions, agree on the prioritisation criteria, gather evidence and compare health interventions. Seven prioritisation criteria were employed: disease burden, cost effectiveness, equity, financial risk protection, budget impact, public acceptability and political acceptability. Results: The overall UHC service coverage for Ethiopia in 2015 was 34.3%, ranging from the highest (52.2%) in Addis Ababa to the lowest (10%) in Afar. The programme area coverage varied from about 53% for infectious diseases to 20% for capacity and access (Paper I). In Paper II, we found ACERs ranging from less than US$1 per HLY gained for family planning intervention to about USD 48,000 for colorectal cancer treatment at stage 4. About 75% of all interventions evaluated had ACERs of less than USD 1,000 per HLY gained. The majority (95%) of RMNCH and infectious disease interventions had an ACER of less than USD 1,000 per HLY while around half of interventions (44%) targeting NCDs had an ACER of less than USD 1,000 per HLY. In Paper III (EHSP revision process), 1,749 interventions were identified in the first phase. These interventions were regrouped and reorganised, and 1,442 interventions were identified as possible candidates for the EHSP. In the second phase, we removed interventions that did not match the burden of disease or were not relevant in the Ethiopian setting, and, therefore, the number of EHSP intervention was reduced to 1,018. We then evaluated and ranked the interventions by the other six criteria. In the final EHSP, 594 (58%) interventions were classified as high priority, 213 (21%) as medium priority and 211 (21%) as low priority. The current policy is to provide 56% of interventions free of charge and to ensure 38% on cost-sharing and 6% on cost-recovery arrangements. Conclusions: In conclusion, the baseline (2015) UHC service coverage index for Ethiopia was low. Furthermore, several potential cost-effective interventions were available that could substantially reduce Ethiopia’s disease burden if scaled up. The revision of Ethiopia’s EHSP followed a comprehensive, participatory, inclusive and evidence-based process, and the EHSP interventions were linked to appropriate health care delivery platforms and financing mechanisms

Is universal health coverage affordable? Estimated costs and fiscal space analysis for the Ethiopian Essential Health Services Package

Estimating the required resources for implementing an essential health services package (EHSP) is vital to examine its feasibility and affordability. This study aimed to estimate the financial resources required to implement the Ethiopian EHSP from 2020 to 2030. Furthermore, we explored potential alternatives to increase the fiscal space for health in Ethiopia. We used the OneHealth Tool (OHT) to estimate the costs of expanding the EHSP service provision in the public sector in Ethiopia. Combinations of ingredient-based bottom-up and program-based summary costing approaches were applied. We predicted the fiscal space using assumptions for economic growth, government resource allocations to health, external aid for health, the magnitude of out-of-pocket expenditure, and other private health expenditures as critical factors affecting available resources devoted to health. All costs were valued using 2020 US dollars (USD). To implement the EHSP, 13.0 billion USD (per capita: 94 USD) would be required in 2030. The largest (50–70%) share of estimated costs was for medicines, commodities, and supplies, followed by human resources costs (10–17%). However, the expected available resources based on a business-as-usual fiscal space estimate would be 63 USD per capita for the same year. Therefore, the gap as a percentage of the required resources would be 33% in 2030. The resources needed to implement the EHSP would increase steadily over the projection period due mainly to increases in service coverage targets over time. Allocating gains from economic growth to increase the total government health expenditure could partly address the gap

Cost-effectiveness of facility-based, stand-alone and mobile-based voluntary counseling and testing for HIV in Addis Ababa, Ethiopia

Background: Globally, there is a consensus to end the HIV/AIDS epidemic by 2030, and one of the strategies to achieve this target is that 90% of people living with HIV should know their HIV status. Even if there is strong evidence of clients’ preference for testing in the community, HIV voluntary counseling and testing (VCT) continue to be undertaken predominantly in health facilities. Hence, empirical cost-effectiveness evidence about different HIV counseling and testing models is essential to inform whether such community-based testing are justifiable compared with additional resources required. Therefore, the purpose of this study was to compare the cost-effectiveness of facility-based, stand-alone and mobile-based HIV voluntary counseling and testing methods in Addis Ababa, Ethiopia. Methods: Annual economic costs of counseling and testing methods were collected from the providers’ perspective from July 2016 to June 2017. Ingredients based bottom-up costing approach was applied. The effectiveness of the interventions was measured in terms of the number of HIV seropositive clients identified. Decision tree modeling was built using TreeAge Pro 2018 software, and one-way and probabilistic sensitivity analyses were conducted by varying HIV positivity rate, costs, and probabilities. Results: The cost of test per client for facility-based, stand-alone and mobile-based VCT was USD 5.06, USD 6.55 and USD 3.35, respectively. The unit costs of test per HIV seropositive client for the corresponding models were USD 158.82, USD 150.97 and USD 135.82, respectively. Of the three models, stand-alone-based VCT was extendedly dominated. Mobile-based VCT costs, an additional cost of USD 239 for every HIV positive client identified when compared to facility-based VCT. Conclusion: Using a mobile-based VCT approach costs less than both the facility-based and stand-alone approaches, in terms of both unit cost per tested individual and unit cost per HIV seropositive cases identified. The stand-alone VCT approach was not cost-effective compared to facility-based and mobile-based VCT. The incremental cost-effectiveness ratio for mobile-based VCT compared with facility-based VCT was USD 239 per HIV positive case

Generalised cost-effectiveness analysis of 159 health interventions for the Ethiopian essential health service package

Background: Cost effectiveness was a criterion used to revise Ethiopia’s essential health service package (EHSP) in 2019. However, there are few cost-effectiveness studies from Ethiopia or directly transferable evidence from other low-income countries to inform a comprehensive revision of the Ethiopian EHSP. Therefore, this paper reports average cost-effectiveness ratios (ACERs) of 159 health interventions used in the revision of Ethiopia’s EHSP. Methods: In this study, we estimate ACERs for 77 interventions on reproductive maternal neonatal and child health (RMNCH), infectious diseases and water sanitation and hygiene as well as for 82 interventions on non-communicable diseases. We used the standardised World Health Organization (WHO) CHOosing Interventions that are cost effective methodology (CHOICE) for generalised cost-effectiveness analysis. The health benefits of interventions were determined using a population state-transition model, which simulates the Ethiopian population, accounting for births, deaths and disease epidemiology. Healthy life years (HLYs) gained was employed as a measure of health benefits. We estimated the economic costs of interventions from the health system perspective, including programme overhead and training costs. We used the Spectrum generalised cost-effectiveness analysis tool for data analysis. We did not explicitly apply cost-effectiveness thresholds, but we used USD 100 and USD 1000 as references to summarise and present the ACER results. Results: We found ACERs ranging from less than USD 1 per HLY gained (for family planning) to about USD 48,000 per HLY gained (for treatment of stage 4 colorectal cancer). In general, 75% of the interventions evaluated had ACERs of less than USD 1000 per HLY gained. The vast majority (95%) of RMNCH and infectious disease interventions had an ACER of less than USD 1000 per HLY while almost half (44%) of non-communicable disease interventions had an ACER greater than USD 1000 per HLY. Conclusion: The present study shows that several potential cost-effective interventions are available that could substantially reduce Ethiopia’s disease burden if scaled up. The use of the World Health Organization’s generalised cost-effectiveness analysis tool allowed us to rapidly calculate country-specific cost-effectiveness analysis values for 159 health interventions under consideration for Ethiopia’s EHSP