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

Prevalence and associated factors of anemia among postpartum mothers in public health facilities in Ethiopia, 2024: a systematic review and meta-analysis

BACKGROUND

Postpartum anemia, characterized by hematocrit or hemoglobin levels below the defined cutoff point (< 11gm/dl or hematocrit < 33%), is a prevalent global issue. It serves as an indirect contributor to maternal mortality and morbidity. Mothers in the postpartum period experience diminished quality of life, impaired cognitive function, emotional instability, and an increased risk of postpartum depression due to anemia. Additionally, infants of affected mothers may face challenges such as insufficient breast milk supply and a lack of proper care. Examining the combined prevalence and factors associated with postpartum anemia is crucial for addressing maternal health risks and complications during the postnatal phase attributed to anemia.

OBJECTIVE

The study aimed to synthesize the existing literature on the prevalence and associated factors of postpartum anemia in public health facilities of Ethiopia, in 2024.

METHODS

The study was conducted by searching through the Google Scholar, PubMed, and Cochrane Library search engines. The search utilized keywords and MeSH terms such as anemia, low hemoglobin, postpartum, postnatal women, and Ethiopia. The collected data underwent analysis and comparison with the WHO criteria to determine if it met the threshold for declaring a public health concern. Heterogeneity was evaluated through the Cochran Q test and I2 statistics. Prevalence and odds ratio estimations were performed using a random-effects model with a 95% confidence interval.

RESULT

Four studies were included in this systematic review and meta-analysis. The overall pooled prevalence of anemia among postpartum women in Ethiopia was 69% (95% CI: 60- 77%).Lack of formal education(OR = 3.5;CI:2.639,4.408),Low Pre-delivery hemoglobin (OR = 4.2;CI: 1.768-6.668), Postpartum women < 4 ANC visit (OR = 2.72; 95% CI:2.14,3.3 ),history of post partum hemorrhage (OR = 2.49; CI: 1.075-3.978),history of Forceps/vacuum delivery(OR = 3.96; CI:2.986-4.947), Poor iron and folic acid adherence (OR = 2.8;95% CI:2.311,3.297), C/S (OR = 4.04; 95% CI: 3.426,4.671),lower dietary diversity (OR = 4.295% CI:1.768,6.668) were significantly associated postpartum anemia.

CONCLUSION

Postpartum women in Ethiopia continue to face a considerable public health challenge in the form of anemia. Consequently, there is a pressing need for the government to formulate comprehensive, multi-sectorial policies and strategies. These initiatives should be designed to address the substantial regional disparities influenced by interconnected factors, with the aim of reducing the prevalence of anemia among postpartum women in Ethiopia.

The impact of community-based health insurance on universal health coverage in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Ideally health insurance aims to provide financial security, promote social inclusion, and ensure equitable access to quality healthcare services for all households. Community-based health insurance has been operating in Ethiopia since 2011. However, its nationwide impact on universal health coverage has not yet been evaluated despite several studies being conducted.

OBJECTIVE

We evaluated the impact of Ethiopia's community-based health insurance (2012-2021) on universal health coverage.

METHODS

On 27 August 2022, searches were conducted in Scopus, Hinari, PubMed, Google Scholar, and Semantic Scholar. Twenty-three studies were included. We used the Joana Briggs Institute checklists to assess the risk of bias. We included cross-sectional and mixed studies with low and medium risk. The data were processed in Microsoft Excel and analyzed using RevMan-5. The impact was measured first on insured households and then on insured versus uninsured households. We used a random model to measure the effect estimates (odds ratios) with a p value < 0.05 and a 95% CI.

RESULTS

The universal health coverage provided by the scheme was 45.6% (OR = 1.92, 95% CI: 1.44-2.58). Being a member of the scheme increased universal health coverage by 24.8%. The healthcare service utilization of the beneficiaries was 64.5% (OR = 1.95, 95% CI: 1.29-2.93). The scheme reduced catastrophic health expenditure by 79.4% (OR = 4.99, 95% CI: 1.27-19.67). It yielded a 92% (OR = 11.58, 95% CI: 8.12-16.51) perception of health service quality. The health-related quality of life provided by it was 63% (OR = 1.71, 95% CI: 1.50-1.94). Its population coverage was 40.1% (OR = 0.64, 95% CI: 0.41-1.02).

CONCLUSION

Although the scheme had positive impacts on health service issues by reducing catastrophic costs, the low universal health coverage on a limited population indicates that Ethiopia should move to a broader national scheme that covers the entire population.

Equity trends for the UHC service coverage sub-index for reproductive, maternal, newborn and child health in Pakistan: evidence from demographic health surveys

BACKGROUND

Pakistan, the world's sixth most populous country and the second largest in South Asia, is facing challenges related to reproductive, maternal, newborn and child health (RMNCH) that are exacerbated by various inequities. RMNCH coverage indicators such as antenatal care (ANC) and deliveries at health facilities have been improving over time, and the maternal mortality ratio (MMR) is gradually declining but not at the desired rates. Analysing and documenting inequities with reference to key characteristics are useful to unmask the disparities and to amicably implement targeted equity-oriented interventions.

METHODS

Pakistan Demographic Health Survey (PDHS) based UHC service coverage tracer indicators were derived for the RMNCH domain at the national and subnational levels for the two rounds of the PDHS in 2012 and 2017. These derivations were subgrouped into wealth quintiles, place of residence, education and mothers' age. Dumbbell charts were created to show the trends and quintile-specific coverage. The UHC service coverage sub-index for RMNCH was constructed to measure the absolute and relative parity indices, such as high to low absolute difference and high to low ratios, to quantify health inequities. The population attributable risk was computed to determine the overall population health improvement that is possible if all regions have the same level of health services as the reference point (national level) across the equity domains.

RESULTS

The results indicate an overall improvement in coverage across all indicators over time, but with a higher concentration of data points towards higher coverage among the wealthiest groups, although the poorest quintile continues to have low coverage in all regions. The UHC service coverage sub-index on RMNCH shows that Pakistan has improved from 45 to 63 overall, while Punjab improved from 50 to 59 and Sindh from 43 to 55. The highest improvement is evident in Khyber Pakhtunkhwa (KP) province, which has increased from 31 in 2012 to 51 in 2017. All regions made slow progress in narrowing the gap between the poorest and wealthiest groups, with particularly noteworthy improvements in KP and Sindh, as indicated by the parity ratio. The RMNCH service coverage sub-index gap was the greatest among women aged 15-19 years, those who belonged to the poorest wealth quintile, had no education, and resided in rural areas.

CONCLUSIONS

Analysing existing data sources from an equity lens supports evidence-based policies, programs and practices with a focus on disadvantaged subgroups.

Geographical disparities and determinants of infant mortality in Ethiopia: mapping and spatial analysis using EDHS data

BACKGROUND

Infant mortality remains a public health challenge in Ethiopia. Exploring infant mortality will aid in tracking the progress toward achieving sustainable development goals.

OBJECTIVE

The study aimed to explore the geographical variations and associated factors of infant mortality in Ethiopia.

METHOD

A total of 11,023 infants from the 2016 Ethiopian Demographic and Health Survey (EDHS) data were extracted and included in the analysis. EDHS used a two-stage cluster sampling design with a census enumeration area as the primary sampling unit and households as the secondary sampling unit. Arc GIS software was used for spatial analysis using clusters for exploring geographical variations in infant mortality. A binary logistic regression was employed using R software to identify the significant determinants of infant mortality.

RESULTS

The study revealed that the spatial distribution of infant mortality was non-random in the country. Infants whose mothers not receiving ANC (AOR = 1.45; 95%CI: 1.17, 1.79), not breastfed status (AOR = 3.94; 95%CI: 3.19, 4.81), poor wealth index (AOR = 1.36; 95%CI: 1.04, 1.77), male infants (AOR = 1.59; 95%CI: 1.29, 1.95), birth order of six or above (AOR = 3.11; 95%CI: 2.08, 4.62), small birth size (AOR = 1.27; 95%CI: 1.26, 1.60), birth spacing [(≤ 24 months (AOR = 2.29; 95%CI: 1.79, 2.92), 25-36 months (AOR = 1.16; 95%CI: 1.12, 1.49)], multiple births (AOR = 6.82; 95%CI: 4.76, 10.81), rural residence (AOR = 1.63; 95%CI: 1.05, 2.77) and regions [Afar (AOR = 1.54; 95%CI: 1.01, 2.36), Harari (AOR = 1.56; 95%CI: 1.04, 2.56), and Somali (AOR = 1.52; 95%CI: 1.03, 2.39)] were the determinants of infant death in Ethiopia.

CONCLUSIONS

There is a great geographical disparity in infant mortality rates across regions. Afar, Harari, and Somali regions were verified as hot spot areas. ANC usage, breastfed status, wealth index, sex of the infant, birth order, birth size, birth spacing, birth type, residence, and region were the determinants of infant death in Ethiopia. Therefore, appropriate interventions need to be implemented in the hot spots to alleviate the risk factors for infant mortality.

Mapping wasted children using data from the Ethiopia Demographic and Health Surveys between 2000 and 2019: A bayesian geospatial analysis

OBJECTIVES

Undernutrition, particularly wasting, is continuing to be a major challenge in developing countries like Ethiopia. However, data on the geographic variations over time are limited. We aimed to investigate the spatiotemporal variation of wasting in Ethiopia using two decades of Ethiopia Demographic and Health Surveys data, from 2000 to 2019.

METHODS

Trend and geospatial regression analysis using a bayesian framework were used to predict wasting in Ethiopia among children aged <5 y. The primary outcomes (wasting) were obtained from the Ethiopia Demographic and Health Surveys conducted between 2000 and 2019. Covariates were accessed from different publicly available credible sources at a high resolution. The spatial binomial regression model through the bayesian framework was fitted to identify drivers of wasting among children in Ethiopia.

RESULTS

The overall national prevalence of wasting among children aged <5 y in Ethiopia was 11.9% in 2000, 11.1% in 2005, 10.2% in 2011, 12.3% in 2016, and 9.4% in 2019, with substantial spatial variation across subnational and local levels over time. Spatial clustering of wasting was observed in eastern Ethiopia (Afar and Somali regions). Altitude (mean regression coefficient = -0.38; 95% credible interval, -0.69 to -0.07) and population density (mean regression coefficient = -0.02; 95% credible interval, -0.03 to -0.01) were negatively associated with wasting, whereas distance to health facilities (mean regression coefficient = 0.13; 95% credible interval, 0.03-0.23) was positively associated with wasting.

CONCLUSIONS

The reduction in the national prevalence of wasting among children was not as expected. Spatial clustering of wasting was observed in the northern, northeastern, eastern, and western parts of Ethiopia. Spatial clustering of wasting was associated with altitude, precipitation, population density, distance to health facilities, travel time to the nearest cities, and distance to a water body. Early screening and treatment of wasted children should be strengthened. Furthermore, outreach community awareness, especially in rural parts of the country, should be recommended through community health extension workers.

Spatial and Multilevel Analysis of Unscheduled Contraceptive Discontinuation in Ethiopia: Further analysis of 2005 and 2016 Ethiopia Demography and Health Surveys

Background

Unscheduled discontinuation of contraceptives is a public health problem among women of reproductive age. Particularly, it is associated with unwanted pregnancies that lead to maternal and child mortality, but little is known about the spatial distribution of the problem. Therefore, this study aims to assess the spatial distribution and associated factors of unscheduled contraceptive discontinuation in Ethiopia.

Method

This study used secondary data from the Ethiopia Demography and Health Survey (EDHS) data of 2005 and 2016. The study population was women who used contraceptives in the preceding 5 years before the survey. A total of 2,327 and 3,858 eligible women were included in the final analysis of the 2005 and 2016 EDHS, respectively. For the spatial analysis, both the 2005 and the 2016 EDHS data were analyzed using ArcGIS version 10.7, while for multilevel regression analysis, the 2016 EDHS data were used. The final model reported an adjusted odds ratio (AOR) with a 95% confidence interval (CI), and a p-value of 0.05 was used to declare statistical significance.

Result

This study revealed that unscheduled discontinuation of contraceptives varied geographically, and hotspots were detected in the central, north, and eastern parts of Ethiopia. Moreover, diploma and higher education (AOR = 1.40; 95% CI: 1.01-1.95), urban residence (AOR = 1.37; 95% CI: 1.08-1.72), history of termination of pregnancy (AOR = 1.47; 95% CI: 1.14-1.94), married women (AOR = 10.79; 95% CI: 6.98-16.69), separated/divorced women (AOR = 1.54: 95% CI: 1.07-2.30), -two to four number of children (AOR = 1.46; 95% CI: 1.15-1.84), and involvement in the decision-making process of contraceptive use (AOR = 39.26; 95% CI: 28.84-53.45) were all factors associated with unscheduled discontinuation of contraceptives.

Conclusion

This study revealed that unscheduled discontinuation of contraceptive distribution was significantly clustered in the central, north, and eastern parts of Ethiopia, as found in two surveys. The magnitude of this discontinuation increased from 2005 to 2016. The finding underscores that further interventions such as the availability of multiple mixed methods and improvement in women's decision-making ability in the choice of contraceptive methods and utilization are needed in hotspot areas of Ethiopia.

Visual impairment in Ethiopia: Systematic review and meta-analysis

WHO Prevention of Blindness Program launched ‘‘VISION 2020” in 1999 to reduce visual impairment and eradicate avoidable blindness by the year 2020. Ethiopia launched the “VISION 2020” initiative in 2002. This systematic review and meta-analysis aimed to present the national prevalence of visual impairment at the end of “VISION 2020”. Electronic search was conducted on the PubMed, SCOPUS, EMBASE, Web of Science, CINAHL, Google scholar databases for including articles. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Endnote reference manager was used for downloading, organizing, and citing articles. Methodological quality was assessed using the Joanna Briggs Institute (JBI) quality appraisal tool for prevalence studies. Statistical analysis was done using the STATA™ software version 14. In this systematic review and meta-analysis, 18 studies involving 14,953 participants were included. The pooled prevalence of visual impairment in Ethiopia after correction for publication bias by Duval and Tweedie’s trim and fill analysis was estimated to be 6.24% (95% confidence interval [CI] = [2.66, 9.82]). The pooled prevalence of visual impairment among school children and adults in Ethiopia was 6.13% (95% CI = [4.27, 7.98]) and 19.89% (95% CI = [10.85, 28.93]), respectively. The most common causes of visual impairment in decreasing order of prevalence were refractive error, cataract, trachoma, glaucoma, and corneal opacity. Amblyopia was the cause of visual impairment among school-age child. The prevalence of visual impairment in Ethiopia was still significant at the end of “VISION 2020” program. Therefore, the program of “VISION 2020” should be extended and other large-scale programs were needed to reduce the prevalence of vision impairment in Ethiopia.

Bioethical Implications of Vulnerability and Politics for Healthcare in Ethiopia and The Ways Forward

Vulnerability and politics are among the relevant and key topics of discussion in the Ethiopian healthcare context. Attempts by the formal bioethics structure in Ethiopia to deliberate on ethical issues relating to vulnerability and politics in healthcare have been limited, even though the informal analysis of bioethical issues has been present in traditional Ethiopian communities. This is reflected in religion, social values, and local moral underpinnings. Thus, the aim of this paper is to discuss the bioethical implications of vulnerability and politics for healthcare in Ethiopia and to suggest possible ways forward. First, we will briefly introduce what has been done to develop bioethics as a field in Ethiopia and what gaps remain concerning its implementation in healthcare practice. This will give a context for our second and main task - analyzing the healthcare challenges in relation to vulnerability and politics and discussing their bioethical implications. In doing so, and since these two concepts are intrinsically broad, we demarcate their scope by focusing on specific issues such as poverty, gender, health governance, and armed conflicts. Lastly, we provide suggestions for the ways forward.

Change in stunting and its associated factors among children aged less than 5 years in Ethiopia using Ethiopia Demographic and Health Survey data from 2005 to 2019: a multivariate decomposition analysis

OBJECTIVE

The aim of this study is to assess change in stunting and its associated factors among children aged less than 5 years in Ethiopia using Ethiopia Demographic and Health Survey data from 2005 to 2019.

DESIGN

A community-based cross-sectional study was conducted.

SETTING

The study was conducted in Ethiopia.

PARTICIPANTS

In 2005, 4586 individuals were examined, followed by 10 282 in 2011, 9462 in 2016 and 4937 in 2019.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome of the study was stunting, and the secondary outcome was factors associated with stunting and its change. A multilevel logistic regression model was fitted to identify individual and community-level factors associated with stunting among children aged less than 5 years. Multivariate decomposition analysis was also carried out to assess the role of compositional characteristics and behavioural change for decline in stunting among children aged less than 5 years in Ethiopia.

RESULTS

Over the study period, the prevalence rate of stunting in children aged less than 5 years decreased from 47% to 37% in 2019. Differences in behavioural change among children under the age of 5 years account for 76.69% of the overall decline in stunting prevalence rate in the years 2005-2011, 86.53% in the years 2005-2016, 98.9% in the years 2005-2019, 70.34% in the years 2011-2016 and 73.77% in the years 2011-2019. Behavioural adjustments among breastfed children, diet diversity, place of delivery, ANC follow-up and region have all had a major effect on stunting prevalence rate. The wealth index, parenteral education, child's age in months, length of breast feeding and area were among the compositional change factors.

CONCLUSION

A large percentage of children aged less than 5 years remains stunted in Ethiopia. Stunting was associated with alterations in the compositional and behavioural characteristics of children. Stimulating existing nutritional measures and improving the wealth index will make a significant difference in reducing stunting among Ethiopian children aged less than 5 years.

Magnitude of cesarean-section and associated factors among diabetic mothers in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: A cross-sectional study

Background

Gestational diabetes is associated with multiple adverse pregnancy outcome as a result of unfavorable labor and delivery process with a consequent increase in obstetric interventions including cesarean-section. Even though diabetes mellitus increases the cesarean-section rate; there is no study conducted in Ethiopia. therefore, this study aimed to assess the magnitude of cesarean-section and associated factors among diabetic mothers in Tikur Ambessa Specialize Hospital, Addis Ababa, Ethiopia.

Methods

A facility-based retrospective cross-sectional study was conducted in Tikur Anbessa Specialized Hospital from 1 February to 30 April 2018 among 346 diabetic mothers. All required data were extracted from patients' charts using checklists, and incomplete records were excluded. The collected data were entered into Epi data version 4.2 and exported to SPSS version 20 for analysis. Multiple logistic regression models were fitted to identify factors associated with cesarean section. Adjusted odds ratios along with 95% CI were estimated to measure the strength of the association and declared statistical significance at a p-value <0.05.

Results

The magnitude of cesarean-section was 57.8% (95% CI: 51.7, 63.3). Pregnancy-induced hypertension [AOR: 3.35, (95% CI: (1.22, 9.20)], previous C/S [AOR: 1.62, (95% CI: (2.54, 4.83)], and fetal distress [AOR: 4.36, (95% CI: 1.30, 14.62)] were factors significantly associated with cesarean-section.

Conclusion

A considerable number of diabetic mothers gave birth by cesarean-section. Pregnancy-induced hypertension, previous cesarean-section, and fetal distress were factors more likely to increase the rate of cesarean-section. Most of the factors were modifiable by following the WHO recommendation for cesarean-section.

Self-injected contraceptives: does the investment reflect women's preferences?

Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is an innovative contraceptive method aimed at meeting women's unique circumstances and needs, largely due to its ability to be self-injected. Substantial research and advocacy investments have been made to promote roll-out of DMPA-SC across sub-Saharan Africa. To date, research on the demand for DMPA-SC as a self-injectable method has been conducted largely with healthcare providers, via qualitative research, or with highly specific subsamples that are not population based. Using three recent rounds of data from Performance Monitoring for Action, we examined population-representative trends in demand, use, and preference for self-injection among current non-users in Burkina Faso, the Democratic Republic of Congo (Kinshasa and Kongo Central regions), Kenya, and Nigeria (Lagos and Kano States). We found that while over 80.0% of women had heard of injectables across settings, few women had heard of self-injection (ranging from 13.0% in Kenya to 24.8% in Burkina Faso). Despite initial increases in DMPA-SC prevalence, DMPA-SC usage began to stagnate or even decrease in all settings in the recent three years (except in Nigeria-Kano). Few (0.0%-16.7%) current DMPA-SC users were self-injecting, and the majority instead were relying on a healthcare provider for administration of DMPA-SC. Among current contraceptive non-users wishing to use an injectable in the future, only 1.5%-11.4% preferred to self-inject. Our results show that self-injection is uncommon, and demand for self-injection is very limited across six settings, calling for further qualitative and quantitative research on women's views on DMPA-SC and self-injection and, ultimately, their contraceptive preferences and needs.

Prevalence of COVID-19 in West Gondar Zone, Northwest Ethiopia: A Population-Based Retrospective Study

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has spread rapidly around the world, affecting every community directly or indirectly. Therefore, this study aims to investigate the prevalence of COVID-19 infection in the population of the West Gondar zone.

METHOD

A retrospective cross-sectional study was conducted from November 2020 to January 2021, in the West Gondar zone, Northwest Ethiopia. Records of study participants with required information like age, gender, travel history, type of specimen taken, and site of specimen taken were included. For analysis, the statistical package for social sciences (SPSS) version 20 software was used. Descriptive statistics were summarized as percentages and means ± standard deviation. The chi-squared test is used to compare categorical data.

RESULTS

A total of 1,166 participants were enrolled in this study. Of them, 16 individuals had positive results, giving a prevalence of 1.37% (95% CI: 0.66-2.08). Living in an urban area (P-value = 0.035) and being female (P-value = 0.045) was statistically associated with the positive rate for COVID-19.

CONCLUSIONS

This study revealed a low prevalence of COVID-19 infection in the study area despite the increasing and rapid dissemination of the disease. State-wide population prevalence study should be done to estimate the general prevalence of COVID-19 in Ethiopia.

Willingness to join community based health insurance among households in South Wollo, Northeast Ethiopia: A community-based cross-sectional study

BACKGROUND

Poor health care financing remains a major challenge to health service utilization among the lower socioeconomic society. Consequently, countries have designed different health insurance programs to overcome financial barriers against health services utilization. Similarly, Ethiopia has been implementing community-based health insurance programs since 2011 to improve health care financing system. However, only a small number of people are enrolled which might be attributed to lack of willingness towards the program and the reasons for this remained under reported. This study was intended to examine willingness to join the community-based health insurance program and its associated factors in South Wollo, Northeast Ethiopia.

METHOD

A community-based cross-sectional study was conducted among 421 households. A multistage systematic random sampling technique was employed to recruit the study households. Data were entered into EpiData version 3.1 and was exported into SPSS version 24.0 for analysis. Bivariable and multivariable logistic regression analysis with a backward elimination method was performed to identify the determinants of willingness to join community-based health insurance. Finally, a statistically significant level was declared at a p-value of less than 0.05.

RESULTS

Two hundred and ninety-three [73.6% (95%CI:68.8%-77.9%)] households were willing to join community-based health insurance programs. Being male headed household (AOR:0.2, 95%CI: 0.07-0.58), being a member of Idir (AOR:0.46, 95%CI: 0.25-.84), absence of chronic illness in the household (AOR: 0.31, 95%CI: 0.13-0.77), and family size < 4 (AOR: 0.18, 95% CI:0.08-0.41) were barriers to join community-based health insurance program whereas rural residency (AOR:1.9, 95% CI: 1.09-3.32), perceived quality health services (AOR:2.96, 95%CI:1.4-6.24), and having positive attitude (AOR:4.1, 95%CI:2.32-7.22) and good knowledge to programs (AOR:2.62, 95%CI:1.43-4.8) were enabling factors.

CONCLUSION

Nearly three-fourths of the households were willing to join community-based health insurance programs. However, different household and health service-related factors affected their willingness. The ministry of health with the regional and woreda health offices should work towards improving the quality of health services, conduct program advocacy and community sensitization towards the program, and build trust with the community.

Socioeconomic Determinants of Universal Health Coverage in the Asian Region

The World Health Organization (WHO) states that examining medical financial systems is the most important process in evaluating universal health coverage (UHC). This study used the service coverage index (SCI) as a proxy of the progress toward UHC in eleven Asian countries. We employed a fixed-effects regression model to analyze panel data from 2015 to 2017, to explain the interrelationship between the SCI and major socioeconomic indicators. We also conducted a performance analysis (ratio of achieved SCI level to gross domestic product (GDP) or health expenditure displacement) to examine the balance between the degree of achievements related to UHC and a country’s economic level. The results showed that GDP and health expenditure were significantly positively correlated with the SCI (p < 0.01). The panel data analysis results showed that GDP per capita was a factor that greatly influenced the SCI as well as poverty (partial regression coefficient: 0.0017, 95% CI: 0.0013–0.0021). The results of the performance analysis showed that the Philippines had the highest scores (GDP: 1.84 SCI score/USD per capita, health expenditure: 1.04 SCI score/USD per capita) and South Korea the lowest. We conclude that socioeconomic factors, such as GDP, health expenditure, unemployment, poverty, and population influence the progress of UHC, regardless of system maturity or geographic characteristics.

Universal Health Coverage Policy and Progress towards the Attainment of Universal Sexual and Reproductive Health and Rights Services in Ethiopia

Critical interpretive analysis of literature review was applied to shed light on the status of universal access to Sexual and Reproductive Health and Rights (SRHR) and the progress towards Universal Health Coverage (UHC) in Ethiopia. Special emphasis was given to the determinations of the Ethiopian health policy frameworks to include comprehensive SRHR services in the UHC benefit package. Clinical services for pregnant women and newborn, abortion care, family planning, Female Genital Mutilation (FGM) complication treatment, Comprehensive Sexuality Education (CSE), and sexual health services are included in the national cost exempted services, but the latter three are not yet included in the health programs with defined objective and work plan. Capital intensive Sexual and Reproductive Health (SRH) services (such as infertility and reproductive cancers diagnosis and treatment) are not included in the UHC benefit package. Over the last two decades, a substantive progress is made in family planning service and maternal and child health, probably because they were taken as Millennium Development Goals (MDGs) indicators and have got better financial protection and political commitment. In order to include other SRHR services in the benefit package in due course and attain universal SRHR services without financial hardship in the Primary Health Care (PHC) setting, the domestic financing should be endorsed as a driving force. To make the multi-sectoral efforts towards achieving UHC and sustainable development goals (SDGs) complete, building resilient health systems through the humanitarian-development nexus for health systems strengthening in fragile setting should be equally prioritized, thereby leaving no one behind underserved.

Association of anthropometric indices of obesity with hypertension among public employees in northern Ethiopia: findings from a cross-sectional survey

OBJECTIVES

The burden of hypertension is increasing in low-income countries, including Ethiopia. Obesity is widely known to be associated with hypertension, but different anthropometric indices of obesity might differ in association with hypertension, which is largely unknown in northern Ethiopia.

DESIGN

Data from our previous cross-sectional epidemiological survey were statistically analysed.

SETTING

Public employees in the regional capital city in northern Ethiopia.

PARTICIPANTS

The data of 1380 participants (823 men and 557 non-pregnant women) aged 25 and 64 years were analysed.

OUTCOME MEASURES

The presence of hypertension was the outcome measure and multivariable-adjusted logistic regression analyses were used to investigate the association of body mass index (BMI), waist circumference, and waist-hip ratio in men and women separately. The area under the curve (AUC) for three anthropometric indices for discriminating hypertension was also obtained. Separate analyses were conducted for waist circumference and waist-hip ratio analyses further adjusted for BMI.

RESULTS

BMI was linearly associated with hypertension in men (OR for 1 SD increase in BMI 1.45, p=0.001) and women (OR for 1 SD increase in BMI 1.41, p=0.01). The association of waist circumference was independent of BMI both in men (OR for 1 SD increase in waist circumference: 1.74, p=0.002) and women (OR for 1 SD increase in waist circumference: 1.57, p=0.029). The association of waist-hip ratio with hypertension adjusted for BMI was significant in men (OR for 1 SD increase in the waist-hip ratio: 1.46, p<0.001), but was weak and non-significant in women. The AUC for BMI was 0.64 in men and 0.67 in women, while AUC for waist circumference was 0.69 both in men and women.

CONCLUSIONS

Waist circumference was associated with hypertension independent of BMI among public employees in northern Ethiopia.

Linking poverty-targeted social protection and Community Based Health Insurance in Ethiopia: Enrolment, linkages, and gaps

BACKGROUND

Community-Based Health Insurance (CBHI) has received increasing attention in low and middle-income countries as a pathway toward universal health coverage. In 2011, the government of Ethiopia piloted CBHI and subsequently integrated CBHI with its flagship social protection programme, the Productive Safety Net Program (PSNP) which was established in 2005. We examined enrolment decisions by PSNP households, including, understanding of the programme, reasons for non-coverage, and factors associated with enrolment decisions.

METHODS

Cross-sectional data for this study come from an Integrated Safety Net Program (ISNP) baseline survey implemented in four rural woredas in Amhara region, Ethiopia between December 2018 and February 2019. We collected data from 5398 PSNP beneficiary households, categorized as either Public Work (PW) or Permanent Direct Support (PDS) types. We used descriptive methods to characterize sample households and fitted binary logistic regression to identify factors associated with households' CBHI enrolment decisions.

RESULTS

Current CBHI enrolment is higher among PW households (70.1 %) than PDS clients (50.3 %). The most common reason for not enrolling in both PW and PDS households is cost. Results further show that the following characteristics are positively associated with CBHI enrolment: the number of children and working-age adults in the household, older household head, female household head, married household head, having been food insecure in the previous 12 months, heads having experienced illness in the past month, and increasing household wealth status.

CONCLUSION

While demographic factors are important in households' decisions to enrol in CBHI, various mechanisms could be used to increase enrolment among vulnerable households such as PDS clients. In this regard, while better communication about CBHI could increase enrolment for some households, other poor and vulnerable households will need fee waivers to induce enrolment.

Low and unequal use of outpatient health services in public primary health care facilities in southern Ethiopia: a facility-based cross-sectional study

BACKGROUND

Outpatient department visits per individual for each year are one of the core indicators of healthcare delivery to assess accessibility or quality of services. In addition, this study aimed to assess health service utilisation and disease patterns in southern Ethiopia, by including the health authorities' suggestions to improve the services. No study has assessed this in Ethiopia previously.

METHODS

An institution-based cross-sectional design study was done in 65 primary health care units in Dale and Wonsho districts, in Sidama region, for all patients visiting health facilities from 1 July 2017 to 30 June 2018. We estimated the utilisation rate as visits per person per year, the odds ratio for health use and proportions of diseases' diagnoses. The results of our study were presented to local health authorities, and their suggestions for improvements were incorporated into the analysis.

RESULT

A total of 81,129 patients visited the health facilities. The annual outpatient health service utilisation was 0.18 (95% CI: 0.18-0.19) new visits per person per year. The health service utilisation rate per year for the rural population was lower than the urban utilisation by 91% (OR = 0.09; 95% CI: 0.08-0.09). Children in the age group of 5-14 years had lower odds of health service utilisation by 78% (OR = 0.22; 95% CI: 0.21-0.23), compared to children under 5 years of age. Females were four times (OR = 4.17; 95% CI: 4.09-4.25) more likely to utilise health services than males. Febrile illness constituted 17.9% (14,847 of 83,148) of the diagnoses in all age groups. Almost half of the febrile cases, 46.5% (3827 of 8233), were among children under 5 years of age. There were very few cases of non-communicable diseases diagnosed in the health facilities. The health authorities suggested improving diagnostic capacities at health centres, enhancing health professionals' skill and attitudes, and improving affordability and physical accessibility of the services.

CONCLUSION

The health service utilisation rate was low in Sidama. The use of health services was lower among rural residents, men, children and elderly, and health post users. Improving the quality, affordability and accessibility of the health services, by involving responsible stakeholders could increase service usage.

Assessment of medicine use among outpatients at healthcare facilities in Ethiopia using the WHO's prescribing indicators with a focus on antibiotics: a systematic review and meta-analysis

OBJECTIVES

To summarize studies on prescribing medicine to general outpatients through the WHO/International Network for Rational Use of Drugs (INRUD) prescribing indicators with a focus on antibiotic prescription.

METHODS

A systematic review and random-effects meta-analysis of studies on the WHO prescribing indicators with a focus on the percentage of encounters with antibiotics prescribed (PEAP) was performed. The databases PubMed, Web of Science, EMBASE and Global Index Medicus were searched.

RESULTS

Twenty-six studies with a total of over 34 000 prescription encounters were included in the systematic review, showing a mean of two medicines per encounter. In each meta-analysis, a range of 19 to 25 studies was included. The percentages of medicines prescribed with an international non-proprietary name (INN) and from the essential medicines list (EML) were 91% and 96% of the total number of medicines, respectively, while 19% of encounters contained injections. Studies with over 25 000 prescription encounters reported an average PEAP of 58% and PEAP showed an increasing trend over the years included in this review. Multivariable meta-regression showed that PEAP increased with the average number of medicines per encounter (estimate = 0.83, P value = 0.0005). The number of medicines, study design and year of prescription explained over 40% of the variation in PEAP across studies.

CONCLUSIONS

Patterns of medicine use within and close to the WHO reference values were reported for the number of medicines, INN prescribing, prescription of injections and compliance with the EML, on average. Prescription of antibiotics requires attention as amounts much higher than the reference values were prescribed, which were even higher with polypharmacy and increasing over the years included in this review.

Aiming for Universal Health Coverage through insurance in Ethiopia: State infrastructural power and the challenge of enrolment

Many developing countries are considering insurance as a means of pursuing Universal Health Coverage. A key challenge to confront is how to achieve high levels of health insurance enrolment. For voluntary schemes this entails mass awareness raising and promotional activity, though as schemes move to compulsory enrolment, monitoring and enforcement are required. This paper focuses on Ethiopia, which has made state health insurance for the informal sector a central pillar of its Universal Health Coverage strategy. The paper shows that high enrolment requires particular forms of state capacity, captured by Michael Mann's concept of state 'infrastructural power'. The paper draws on detailed case studies of insurance implementation in the Tigray and Oromiya regions of Ethiopia to illustrate variation in state infrastructural power and the implications for health insurance. Findings suggest that the potential of state health insurance as a means of promoting health access for a broad section of the population may be limited to the minority of countries or regions within countries exhibiting high levels of infrastructural power.

Adequacy of prenatal care services and associated factors in Southern Ethiopia

BACKGROUND

Prenatal care is an important component for the continuum of care in maternal and child health services. Despite increased attention on prenatal care service coverage, the adequacy of service provision has not been well addressed in Ethiopia. Therefore, this study aimed to describe the status of the adequacy of prenatal care and its associated factors in Southern Ethiopia.

METHOD

A longitudinal study done by the Performance care Monitoring and Accountability (PMA2020) project was used. The study was conducted from August 2016 to January 2017 in Southern Ethiopia. A multistage stratified cluster design in which all enumeration areas were randomly selected using probability proportional to size and all households were screened to identify 324 pregnant women of six or more months. Questions regarding early attendance of prenatal care, enough visits, and sufficient services were asked to measure the adequacy of prenatal care. Finally, an ordered logistic regression analysis was employed to assess factors associated with the adequacy of prenatal care services.

RESULTS

Of the total pregnant women 44.21 % attended enough visits, 84.10 % had early visits, and 42.03 % received sufficient services. The women residing in urban areas had 2.35 odds of having adequate prenatal care in reference to rural areas (adjusted odds ratio (aOR) 2.35 [95 % CI 1.05-5.31]). Women who attended primary and secondary education had 2.42(aOR 2.42 [95 % C.I. 1.04, 5.65]), and 4.18 (aOR 4.18 [95 % CI 1.32, 13.29]) odds of adequate prenatal care in reference with those who never attended education respectively. The women participating in one to five networks have 2.18 odds of adequate prenatal care in reference to their counterparts (aOR 2.78 [95 % CI 1.01, 7.71]).

CONCLUSIONS

The adequacy of prenatal care services in Southern Ethiopia is very low. The Ethiopian health care system should strengthen one to five networks to discuss on family health issues. Further research, should validate the tools and measure the adequacy of the services in different contexts of Ethiopia using a mixed method study for an in-depth understanding of the problem.

Optimum maternal healthcare service utilization and infant mortality in Ethiopia

Background

Ethiopia has one of the highest rates of infant mortality in the world. Utilization of maternal healthcare during pregnancy, at delivery, and after delivery is critical to reducing the risk of infant mortality. Studies in Ethiopia have shown how infant survival is affected by utilization of maternal healthcare services, however, no studies to date have investigated the relationship between optimum utilization of maternal healthcare services utilization and infant mortality. Therefore, this study examined the effect of optimum utilization of maternal healthcare service on infant mortality in Ethiopia based on the World Health Organization (WHO, 2010) guidelines.

Methods

We used nationally representative cross-sectional data from the Ethiopian Demographic and Health Survey (EDHS). Sampling weights were applied to adjust for the non-proportional allocation of the sample to the nine regions and two city administrations as well as the sample difference across urban and rural areas. A total of 7193 most recent births from mothers who had provided complete information on infant mortality, ANC visits, tetanus injections, place of delivery and skilled birth attendance during pregnancy were included. The EDHS was conducted from January to June 2016. We applied a multivariate logistic regression analysis to estimate the relationship between optimum maternal healthcare service utilization and infant mortality in Ethiopia.

Results

The findings from this study showed that optimum maternal healthcare service utilization had a significant association with infant mortality after adjusting for other socioeconomic characteristics. This implies that increased maternal healthcare service utilization decreases the rate of infant mortality in Ethiopia. The main finding from this study indicated that infant mortality was reduced by approximately 66% among mothers who had high utilization of maternal healthcare services compared to mothers who had not utilized maternal healthcare services (AOR = 0.34; 95%CI: 0.16–0.75; p-value = 0.007). Furthermore, infant mortality was reduced by approximately 46% among mothers who had low utilization of maternal healthcare services compared to mothers who had not utilized any maternal healthcare services (AOR = 0.54; 95%CI: 0.31–0.97; p-value = 0.040).

Conclusions

From this study, we concluded that optimum utilization of maternal healthcare services during pregnancy, at delivery and after delivery might reduce the rate of infant mortality in Ethiopia.

Analyzing efforts to synergize the global health agenda of universal health coverage, health security and health promotion: a case-study from Ethiopia

BACKGROUND

Evidence exists about synergies among universal health coverage, health security and health promotion. Uniting these three global agendas has brought success to the country's health sector. This study aimed to document the efforts Ethiopia has made to apply nationally synergistic approaches uniting these three global health agendas. Our study is part of the Lancet Commission on synergies between these global agendas.

METHODS

We employed a case study design to describe the synergistic process in the Ethiopian health system based on a review of national strategies and policy documents, and key informant interviews with current and former policymakers, and academics. We analyzed the "hardware" (using the World Health Organization's building blocks) and the "software" (ideas, interests, and power relations) of the Ethiopian health system according to the aforementioned three global agendas.

RESULTS

Fragmentation of health system primarily manifested as inequities in access to health services, low health workforce and limited capacity to implementation guidelines. Donor driven vertical programs, multiple modalities of health financing, and inadequate multisectoral collaborations were also found to be key features of fragmentation. Several approaches were found to be instrumental in fostering synergies within the global health agenda. These included strong political and technical leadership within the government, transparent coordination, and engagement of stakeholders in the process of priority setting and annual resource mapping. Furthermore, harmonization and alignment of the national strategic plan with international commitments, joint financial arrangements with stakeholders and standing partnership platforms facilitated efforts for synergy.

CONCLUSIONS

Ethiopia has implemented multiple approaches to overcome fragmentation. Such synergistic efforts of the primary global health agendas have made significant contributions to the improvement of the country's health indicators and may promote sustained functionality of the health system.

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.

Individual-, household- and community-level determinants of infant mortality in Ethiopia

INTRODUCTION

People living in the same area share similar determinants of infant mortality, such as access to healthcare. The community's prevailing norms and attitudes about health behaviours could also influence the health care decisions made by individuals. In diversified communities like Ethiopia, differences in child health outcomes might not be due to variation in individual and family characteristics alone, but also due to differences in the socioeconomic characteristics of the community where the child lives. While individual level characteristics have been examined to some extent, almost all studies into infant mortality conducted in Ethiopia have failed to consider the impact of community-level characteristics. Therefore, this study aims to identify individual and community level determinants of infant mortality in Ethiopia.

METHOD

Data from the Ethiopian Demographic and Health Survey in 2016 were used for this study. A total of 10641 live births were included in this analysis. A multi-level logistic regression analysis was used to examine both individual and community level determinants while accounting for the hierarchal structure of the data.

RESULTS

Individual-level characteristics such as infant sex have a statistically significant association with infant mortality. The odds of infant death before one year was 50% higher for males than females (AOR = 1.66; 95% CI: 1.25-2.20; p-value <0.001). At the community level, infants from pastoralist areas (Somali and Afar regions) were 1.4 more likely die compared with infants living in the Agrarian area such as Amhara, Tigray, and Oromia regions; AOR = 1.44; 95% CI; 1.02-2.06; p-value = 0.039).

CONCLUSION

Individual, household and community level characteristics have a statistically significant association with infant mortality. In addition to the individual based interventions already in place, household and community-based interventions such as focusing on socially and economically disadvantaged regions in Ethiopia could help to reduce infant mortality.

Newborns and Under-5 Mortality in Ethiopia: The Necessity to Revitalize Partnership in Post-COVID-19 Era to Meet the SDG Targets

The Sustainable Development Goals (SDGs) were adopted during the United Nations meeting in 2015 to succeed Millennium Development Goals. Among the health targets, SDG 3.2 is to end preventable deaths of newborns and children under 5 years of age by 2030. These 2 targets aim to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births. Ethiopia is demonstrating a great reduction in child mortality since 2000. In the 2019 child mortality estimation which is nearly 5 years after SDGs adoption, Ethiopia's progress toward reducing the newborns and under-5 mortality lie at 27 and 50.7 per 1000 live births, respectively. The generous financial and technical support from the global partners have helped to achieve such a significant reduction. Nevertheless, the SDG targets for newborns and under-5 mortality reduction are neither attained yet nor met the national plan to achieve by the end of 2019/2020. The partnership dynamics during COVID-19 crisis and the pandemic itself may also be taken as an opportunity to draw lessons and spur efforts to achieve SDG targets. This urges the need to reaffirm a comprehensive partnership and realignment with other interconnected development goals. Therefore, collective efforts with strong partnerships are required to improve the determinants of child health and achieving SDG target reduction until 2030.

Predictors of unmet need for family planning in Ethiopia 2019: a systematic review and meta analysis

Background

unmet need for family planning is a common cause of uninteded pregnancy which mostly end up with abortion. Many studies were conducted on predictors of unmet need of family planning in Ethiopia. But, up until now, single evidence has not been synthesized and various point prevalence estimates of unmet need for family planning have been reported. Therefore, this sytematic review and meta analysis was established to identify the predictors of unmet need for family planning in Ethiopia.

Methods

search engines including PubMed, Embase, CINAHL, Google Scholar, HINARI portal, and Cochrane Library were used to retrieve included articles and reported using the preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA) checklist guidelines. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was applied for critical appraisal. All observational studies done on reproductive age women and reported on unmet need for family planning were included. Unmet need for family planning is the percentage of women of reproductive age, either married or in a union, who have an unmet need for family planning to stop or delay childbearing. Random effect model was done to estimate the pooled prevalence of unmet need for family planning. Odds ratio with 95% confidence interval was considered to determine the association of identified variables with unmet need of family planning. Cochran’s Q statistic, Egger’s and Begg’s test were carried out to assess heterogeneity and publication bias.

Results

Fifteen articles and 17, 585 reproductive aged women were included to estimate the pooled prevalence of unmet need for family planning and its predictors in Ethiopia. The prevalence of unmet need for family planning in Ethiopia ranges from 26.52 to 36.39%. Age at first marriage < 18 yrs. with OR = 2.3 (95% CI: 1.08, 4.87), women with no formal education with OR = 1.9 (95%CI: 1.19, 3.04), partner with no formal education with OR = 1.78 (95%CI: 1.18, 2.68) and absence of discussion with their partner about family planning with OR = 3.52 (95%CI, 2.56, 4.87) were predictors of unmet need of family planning in Ethiopia.

Conclusion

This meta analysis revealed that, the prevalence of unmet need for family planning in Ethiopia was high as compared with the United Nations sphere standard of unmet need for planning, considered to be high if it is greater than 25%. Early marriage, no formal eduaction and lack of discussion with partner on family planning were predictors of unmet need for family planning. Therefore, efforts are needed to empower women through eduaction, avoiding early marriage and facilitating dicussion of partners about family planning in order to improve family planning usage.

Primary health care contributions to universal health coverage, Ethiopia

Many global health institutions, including the World Health Organization, consider primary health care as the path towards achieving universal health coverage (UHC). However, there remain concerns about the feasibility and effectiveness of this approach in low-resource countries. Ethiopia has been implementing the primary health-care approach since the mid-1970s, with primary health care at the core of the health system since 1993. Nevertheless, comprehensive and systemic evidence on the practice and role of primary health care towards UHC is lacking in Ethiopia. We made a document review of publicly available qualitative and quantitative data. Using the framework of the Primary Health Care Performance Initiative we describe and analyse the practice of primary health care and identify successes and challenges. Implementation of the primary health-care approach in Ethiopia has been possible through policies, strategies and programmes that are aligned with country priorities. There has been a diagonal approach to disease control programmes along with health-systems strengthening, community empowerment and multisectoral action. These strategies have enabled the country to increase health services coverage and improve the population’s health status. However, key challenges remain to be addressed, including inadequate coverage of services, inequity of access, slow health-systems transition to provide services for noncommunicable diseases, inadequate quality of care, and high out-of-pocket expenditure. To resolve gaps in the health system and beyond, the country needs to improve its domestic financing for health and target disadvantaged locations and populations through a precision public health approach. These challenges need to be addressed through the whole sustainable development agenda.