Background
Ethiopia, a low-income country in Eastern Africa, ranks 173rd on the United Nations Development Program (UNDP) Human Development Index [
1]. With a projected population of 109 million in 2020 and growth rate of 2.6%, half of the population is under 15 years old and the average life expectancy at birth has increased to 66.2 years [
1].
Ethiopia has decentralized health care governance and delivery structured into a three-tier system. This enables the government to examine the effectiveness, efficiency, equity and sustainability of health services as well as foster engagement of local stakeholders through policy dialogue [
2]. Ethiopia’s health sector has been guided by a national health policy, translated into action through a 20-year long series of five-year plans known as the Health Sector Development Plan (HSDP) (1995–2015) and the Health Sector Transformation Plan (HSTP) post 2015. Ethiopia aspires to achieve universal health coverage by 2035 [
2].
Ethiopia’s health strategies primarily focus on creating access to primary health care services, improving equity and quality of health care through utilization of essential health services, and building community ownership. These strategies have resulted in improving health outcomes of the population, as evidenced by achieving most of the health-related Millennium Development Goals (MDGs), and remarkable progress in the other non-health MDG indicators [
2]. Building on these successes and on a global focus on sustainable development, Ethiopia aligned its HSTP impact targets with the Sustainable Development Goals (SDG) to meet the SDG targets by 2030 [
2].
Over the past two decades, the government has implemented comprehensive social and economic reforms. A key feature of this reform has been the government’s strong commitment to shifting its spending to sectors such as health, education, road infrastructure, agriculture, and rural development that, if strengthened, will reduce poverty [
3]. The presence of a strong health system is critical to ensuring universal access to quality and affordable health care, protect people from health emergencies, and encourage them live healthier lives [
4,
5]. However, efforts addressing these three areas are fragmented. Fragmentation across health system structures, healthcare funding, and global health actors’ engagement has been widely reported in global health literature [
6‐
9]. This fragmentation has resulted in suboptimal care, higher cost due to duplication of efforts and resources, reduced efficiency, and poor quality of care, and it has negatively affected efforts to strengthen health systems. Multiple reasons were provided for this fragmentation, including a tendency among global actors towards vertical programs [
6,
9,
10]. Such fragmentation is particularly common in low- and middle-income countries, and Ethiopia is no exception.
In contrast, there is evidence supporting the existence of synergies among universal health coverage, health security and health promotion [
4,
11] and these three priorities are mutually reinforcing, not mutually exclusive [
12]. Health system strengthening comprises the means (the policy instruments), while universal health coverage is a way of framing the objectives of policy. This policy identifies that individual health security provides the intrinsic value of protection against risk, including disease prevention and health promotion [
4,
5]. Collective health security, reducing the vulnerability of societies to health threats that spread across national borders, is a goal that extends beyond the definition of universal health coverage. Health security traditionally emphasizes the role of health system capacities and technical areas in the prevention, detection, and response to emerging and re-emerging infections. Health system strengthening, on the other hand, is often conceptualized in the six building blocks of the WHO health system framework [
5].
To date, no study has comprehensively documented Ethiopia’s efforts at utilizing a synergistic approach toward the three main global health agendas. It is believed that documenting this experience may help other low- and middle-income countries learn from Ethiopia. Our questions and outcomes were driven by assumptions of the Lancet Commission on synergies between universal health coverage, health security and health promotion to improve health and equity for all people worldwide [
13]. Therefore, this study specifically aimed to document Ethiopia’s efforts to align universal health coverage (UHC), health security (HS) & health promotion (HP) and their implementation within its health system. Furthermore, we aimed to understand Ethiopia’s efforts to create synergies through health systems analysis, and to identify social, political, and economic conditions that may have facilitated synergy in Ethiopia.
Methods
Case study is a comprehensive method that incorporates multiple sources of data to provide detailed accounts of complex research phenomena in real-life contexts [
14]. This study employed a case study design as it was found to be of significant advantage to explore the answers to “what”, “why” and “how” questions. In addition, the study described a real-life context where the process has already happened, thus, the researchers have no control over the events.. This study described how decisions were made in the health sector. Multiple data sources, including strategy and policy documents, and key informant interviews, were used to support data triangulation [
15] and ensure the rigour of the study. Only reports and information written in English language were considered. The Government of Ethiopia’s policy and strategy documents and reports were included in the review. In addition to documentary evidence, purposive and snowballing techniques were employed to select key informants for interviews, including previous and current policymakers, and academics in the Ethiopian health system. We initially planned to include nine key informants to participate in the study, however, saturation was reached after six respondents. Respondents were women (
n = 2) and men, and held senior managerial, technical, and academic research positions. All study respondents had extensive experience on the topic we examined and a profound knowledge on the issues of fragmentation at the national and global level, which allowed us to efficiently capture key areas relating to our study aims. The authors collaboratively analysed the document reviews and interviews. Following initial familiarization with the data, the WHO building block framework was identified as most appropriate to analyze the data by including relevant respondents’ quotations. A framework analysis containing both the “hardware” and the “software” of the health systems, which has been previously used in health policy and systems research [
15,
16], were employed to analyse the Ethiopian health system for synergistic approaches to UHC, HS and HP.. The WHO Health Systems Framework was developed to provide a model to capture the interlinked and complex nature of health systems [
4]. This framework was used to guide the development of data collection tools and data analysis. The “hardware” of the health system includes the six core components or WHO’s building blocks of the health system: (i) service delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) financing, and (vi) leadership/governance. The “software” of the health system includes “the ideas and interests, values and norms, and affinities and power that guide actions and underpin the relationships among system actors and elements” [
16‐
18].
The study protocol was approved by the Addis Continental Institutional Review Board (Ref. No. ACIPH/IRB/005/2019).
Discussion
Summary of main findings
The major forms of fragmentations in Ethiopian health system had been identified as planning, budgeting, human resource, service delivery, sectoral collaboration, and reporting. Later, the Ministry of Health adopted the “one-plan, one-budget and one-report” approach and led efforts that resulted in improved synergy of the main global health agendas. This approach followed restructuring the budgeting and reporting scheme to one-plan, one-budget, and one-report at all levels of the health system to increase effectiveness, and played an important role in improving harmonization and alignment in the Ethiopian health sector.
Comparison with other studies
Previous studies in low- and middle-income countries documented that weak leadership and health system have led donors to establish their own planning, implementation, monitoring, accounting, and reporting mechanisms [
6‐
8]. This has resulted in fragmentation of service delivery and availability of medical supplies for non-commodity programs which, in turn, led the community to high out-of-pocket (OOP) spending [
8,
9,
41]. The consequence of financial fragmentation was that the allocated budget was not used for the priority agendas, leading to duplications and gaps. This resulted in unmet needs in terms of geographic coverage and programs. As reported by other global health initiatives, key barriers to improving service delivery include weak drug and medical supply systems. In Sierra Leone, donors’ responses to this challenge included establishing parallel supply chains to quickly meet the needs of their specific program [
9,
42]. However, unavailability of standardized and systematic indicators put tremendous burden on the available limited human resource due to duplication of effort in reporting and resulted in significant dissatisfaction [
6‐
8].
Furthermore, pursuing equity and efficiency requires allocating resources according to health care need. However, resources were allocated based on historical precedent and political negotiation. This patchy approach to health care financing compromises equity and efficiency by hindering the effective application of the budget [
43]. Thus, fragmentation is not only of concern from an equity perspective, but also in relation to health system efficiency and affordability [
44].
Ethiopia’s health system has long recognized primary health care since the Alma Ata declaration and formulation of the health policy in 1993. The Ethiopian Ministry of Health took the lead in defragmenting the health sector by introducing one plan/budget/report as a useful tool for health sector planning, alignment of activities with strategic priorities and plans.
These priorities include an essential health service package to address universal health coverage proximate to the community, community-based health insurance and hospital revenue as means of health care financing, developing strategy for the health workforce, reforming the health information system and improving/assuring medical supply. A study conducted in the Ethiopian health system and health facility governance indicated that all reform efforts, including health care financing, were dependent on a well-functioning board structure [
3]. Boards and governing bodies are instrumental in improving health facility performance and quality of health services [
3]. Many countries in Africa are undertaking health care reforms and developing policies to improve health care systems. However, the success of health care reforms, policies and practices is dependent on the ability of the designers of health care delivery systems to replace fragmentation and waste with coordination and cost-effectiveness across disciplines [
45].
Due to huge investments in health system strengthening by the Government of Ethiopia, Ethiopia was able to achieve most of millennium development goals and improved the life expectancy of its population compared to other African countries [
2]. Findings from a systematic review indicated that inter-organizational relationships and linked up service delivery can improve quality and efficiency [
46]. The needs of a population require collective action of organizations across the entire care continuum as they have a collective responsibility for the health and well-being of a population. This is mainly applicable to socially disadvantaged populations; those with large variations in wealth, education, culture and access to health care [
46].
Studies conducted in South Africa, Tanzania and Ghana showed that community-based health insurance had been the predominant form of health insurance, but had achieved very limited coverage. These schemes only cover outpatient care at primary health-care level [
44]. However, Ethiopia showed efforts to provide financial protection for the EPHS through implementing Community-based health insurance and user fee waivers at a national scale for specific care, such as TB, HIV/AIDS, leprosy, pregnancy care, family planning, fistula, and epidemics [
20]. These were mechanisms designed to ensure service reach to a larger population [
20].
Furthermore, the medical supply system has undergone reforms and been integrated within health system to manage all health sector supplies. This also included non-program commodities to reduce duplication and stockout and thus to strengthen efficiency of overall health systems. These findings are in line with the recommendations on systems strengthening in Sierra Leone [
9].
Strengths and limitations
Strengths of the study included the case study design which allowed triangulation between multiple data sources to map the process under study. Rich data were generated by reviewing national strategy and policy documents, and key informant interviews with the main actors in the Ethiopian health system. Findings of the key informant interviews were triangulated with strategy, policy documents and literature review. The composition of key informants was broad, to explore different insights. Due to the nature of a qualitative study, transferability is most relevant, and the findings may be useful for other countries moving towards synergy in their health system. The limitation of this study is unavailability of adequate data on the process of decision making. Further, establishing a causal link between synergistic approaches and improvement of health indicators was a challenge.
Implications for practice, policy, and further research
Implication for practice
Health system fragmentation may prevent governments from ensuring universal health coverage. As stated previously, fragmentation increases inequity, inefficiency, and can lead to poor health outcomes. Inequities in health, in turn, can translate into tensions in society and threaten social cohesion and inclusion. The potential for quality service delivery rests upon leading and coordinating the various abilities of different sectors across all regions. The governance structures need increased capacity so that they can provide adequate support to the system and facility management. Competency is highly related with quality and can be obtained from different trainings and from experience. Health service needs a right balance of health workforce with different skill mix. In addition, addressing health system inequities and inefficiencies through integrated approach is likely to provide mutual benefit to both the government and community.
Implication for policy
Strengthening health systems, harmonizing and aligning donor funding around national health plans and strategies, following the principles of the Paris Declaration on aid effectiveness, is crucial to sustained and improved health outcomes. In addition, government’s leadership and ownership will promote health systems synergy efforts.
Implication for further research
The process of decision making and the continued efforts to synergy of the global health agendas need to be properly documented.
Conclusions
In Ethiopia, fragmentation mainly manifested as inequality in accessing health services, multiple modalities of health financing, donors’ focus on funding vertical programs with poor integration to the health system, multiple actors and institutions with inadequate multi-sectoral collaboration, disparity in distribution of health workforce with high attrition rate, and variation in implementation capacity of policies and guidelines. Therefore, fostering synergies among the three global health agendas required strong stewardship and political commitment of the national government.
Ethiopia has implemented multiple approaches and instruments to overcome fragmentation. Some of the context-specific approaches used to create synergies among the three global health agendas in Ethiopia include: alignment and harmonization of donor efforts with national strategies and plans by following the principles of “One Plan, One Budget and One Report”; the Health Extension Program; a generalist approach toward health workforce development; prioritizing investment in health systems that included investment in a unified health information system and a unified pharmaceutical supply system; capital and human resource investment in creating access to primary health care; and active engagement and participation of stakeholders. Such synergy efforts may promote sustained functionality of the health system.
Finally, the negative effect of COVID-19 on essential healthcare services could challenge achieving the health-related Sustainable Development Goals. Hence, such global health issues call for a better coordinated effort between health actors to uphold approaches to synergy.
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