Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis

Ethiopia’s health service is structured into a three-tier system: primary, secondary and tertiary levels of care. A primary health care unit (PHCU) comprises four health centers (HCs), five health posts within each health center, and a primary hospital. Each health post is responsible for a population of 3,000–5,000 people. A health center provides both preventive and curative services. In addition to what an HC can provide, a primary hospital provides emergency surgical services, including caesarean section and gives access to blood transfusion services. Secondary level of care consists of general hospitals. In addition, it serves as a referral center for primary hospitals. Finally, the tertiary level of care comprises federally-run, specialised hospitals and university hospitals [11, 16] (Fig. 1).

A structured narrative review was conducted by reviewing studies published between January 1998 and August 2021 using the three inter-linked HCF framework components.

Electronic databases such as PubMed, Scopus and Web of Science were used to search all published articles. In addition, hand search engines, such as Google search engine and Google Scholar, were also used to search for additional literature on 08 August 2021. The search terms were identified under three themes: healthcare financing, universal health coverage, and Ethiopia. The search strategies were built based on using the “Medical Subject Headings (MeSH)” and “All field” by linking “AND” and “OR” Boolean operator terms as appropriate (Supplementary file 1). In addition, we used the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) checklist for reporting the findings [24].

All retrieved studies were initially imported into the Endnote library to remove the duplicates. After removing the duplicates, we screened the articles by title and abstract based on the eligibility criteria. A quality assessment was done for all eligible retrieved articles by the three independent reviewers using the Joanna Briggs Institute’s (JBI) critical appraisal checklist for qualitative research. Later we discussed in the team, and the last author verified the list of studies. We retained the full texts of all relevant studies found to meet the inclusion criteria for the final synthesis (Table 1).

We used Microsoft excel spreadsheet format for data extraction. The excel sheet contained the first author's name, year of publication, title, type of article, and its primary outcomes. In addition, we conducted a double check-up and verification of the extracted information. In this review, we assessed the application of HCF to attain UHC, which includes the provision of equitable and quality health services without financial risk. We used framework analysis to synthesise our extracted data using the three inter-linked HCF framework components: revenue generation, risk pooling/ sharing, and strategic purchasing of services [8, 25]. Explanations of the three inter-linked HCF functions were also presented (Table 2).

Total of 52 articles (32 quantitative, five qualitative, seven mixed, seven project briefs reports, and 1 policy brief) were eligible for final review (Fig. 2). In addition, we included seven articles in Oromia, 13 in Amhara, six in SNNP, seven in Addis Ababa and the remaining in other regions of Ethiopia.

We extracted data from all eligible articles related to the contributions and challenges of HCF towards UHC in Ethiopia. We mapped the key successes, contributions and challenges of the eight HCF reforms/initiatives under the three inter-linked HCF framework components. The successes, contributions and challenges of each HCF function towards UHC are indicated (Table 3).

Of the reviewed articles, 16 described their findings on revenue generations. Various successes were reported in revenue generation/ resource mobilisation. Health facility retained revenue is an additive to the public health facility budgets with major sources including: sale of drugs, medical supplies, consultation fees, non-medical services [26]. Private wing at hospitals also offers additional income for health facilities [27]. Health insurance is another option to mobilise financial resources, increasing the revenue generation of the health institutions [33‐35].

Health financing strategies in Ethiopia also contribute to revenue generation. Private wings at hospitals generate additional income for health facilities [28‐30] to provide healthcare services. Health insurance is also another option to generate sustainable resources for health sectors [11, 36]. Health facility governance boards facilitate the linkage of the community to increase resource mobilisation for facilities to solve problems locally [39].

Limited capacity in knowledge and skills of health facility governance related to lack of training and monitoring at federal, regional and woreda levels for planning, difficulty in interpreting the guideline, implementing, and monitoring the HCF [11, 26] were the challenges for revenue generation and utilisation. Low client satisfaction associated with their expectations and high payments were also challenges during private wing implementation [31, 32]. Poor community awareness and costs of premium collection for CBHI concerning the scattered settlement of agricultural households and mobility of the pastoralists were the challenges in revenue collection [11, 13, 37]. Low enrolment rates, high dropouts and weak premium collection for the scheme were additional barriers for CBHI at the community level [11, 38].

In this review, 24 articles reported their findings on risk pooling/ sharing in healthcare services. Health financing initiatives in Ethiopia have various successes in risk pooling. User-fee-setting and revision promote cost-sharing between the Government and users, considering the community’s willingness, ability to pay and cost of services [27]. Health insurance helps the population with special assistance mechanisms for those who can not afford to pay [11]. Health insurance can also help risk pooling/ sharing and social solidarity for the non-predicted illness [40, 41].

Health financing strategies in Ethiopia also contributes to risk pooling. Fee-setting and revision contribute to setting affordable fees and some subsidy by the Government to enhance healthcare access [11]. Health insurance can contribute to financial risk protection for the users [11, 36]. Community-based health-insurance particularly contributes to protecting rural dwellers from facing financial hardship to ensure UHC for all [42‐44]. It reduces out-of-pocket expenditure (OOP) for healthcare services, reducing catastrophic health expenditure [33‐35]. Health insurance can also establish financial protection equitably and sustainably for all citizens to enhance healthcare access and achieve UHC by reducing OOP expenditure for healthcare services [14, 29, 45].

Variations in regional laws and discrepancies in adherence to regional legislation in terms of mandating the user fee revisions and settings were the challenges to maintaining the consistency of HCF in Ethiopia. For instance, the mandate of user fee revisions and settings in Amhara and Oromia gave to the regional council, while SNNP allowed health facilities to introduce user fee revisions [11, 26, 27]. Moreover, the provincial law gave the mandate of user fee revision to the provincial (regional) council in the Amhara region, but some health facilities revised user fees on their own [27]. The adverse selection associated with voluntary based CBHI, inability to afford the premium, inadequate benefit packages; preference for OOP payment, and considering only family size without their level of income for premium load [46‐48] were the challenges during CBHI implementation. The constraints of implementing SHI are the high burden of payroll contributions to SHI, long bureaucracy in reimbursement, under-coverage of the poor, low contract renewal rate and expected returns [13, 51, 52]. Unclear benefit packages, high cost of living and the burden of other deductions from salary were the obstacles to initiating SHI [49, 50]. Free health care services for healthcare providers and frustration of illness associated with high SHI contribution [49, 53] could be the challenges to introducing SHI.

Forty articles from the reviewed articles described the strategic purchasing of healthcare services. Health financing initiatives in Ethiopia have various successes in purchasing healthcare services. Revenue retention can increase resource availability for service provision by using retained revenue to procure drugs and medical supplies and implement oversight [11, 27]. Fee waiver system provides free of charge to the poorest segments of the population to access the full range of health services [29]. Public hospitals' private wings offer more services to the service users [27]. Outsourcing non-clinical services at public hospitals encourages hospitals to outsource non-clinical services, such as laundry, security, and catering, by contracting with local vendors that improve the hospital’s efficiency and reduce the hospital management burden [29]. A clear action plan for healthcare delivery and the introduction of accountable and transparent regulatory frameworks facilitate HCF implementation [26, 73].

Health facility revenue retention could improve infrastructures, diagnostic capacity, procure medical equipment, supplies, medical supplies, drugs, information systems, management procedures, water supply, electricity, and training to enhance quality of healthcare services [11, 27, 54]. It assisted in availing essential medicines; reduce stock-outs of essential drugs; improve health facilities' diagnostic capacity, maintaining continual quality of care; improving water supply, electricity to health facilities; and health infrastructures [27, 54]. Exempted healthcare also helped to deliver the package of services free of charge to all citizens for certain critical public health services to enhance coverage and equity [29]. These services include TB and leprosy diagnosis and treatment; antenatal care; delivery, postnatal care, family planning, leprosy, HIV care, treatment for malaria, immunisation services; HIV/ AIDS diagnosis, care and support, and epidemics [11, 60]. In addition, outsourcing non-clinical services at public hospitals assisted to improve hospitals’ efficiency, reduce internal administrative burden, control costs, enable health facilities to focus on core clinical services, and increase effectiveness and quality of services [27, 29, 63].

Access to healthcare services free health care for poor households through fee waiver systems increases financial protection and ensures UHC for all [27, 43]. Fee waiver systems increase healthcare service utilisation and reduce inequalities in accessing healthcare services for the poor [29, 55]. Private wing at hospitals can raise the motivation of medical professionals, staffs’ sense of hospitals ownership and a decline the turnover rate could help offer more choices and quality of care [27‐30]. Health insurance is reduced inequitable healthcare services for all citizens and improves healthcare delivery [11, 29, 36] and facilitates the path toward UHC [14, 45]. Community-based health insurance also contributes to avail essential drugs, good quality of care and treatment of choice to the users [64, 65]. Health facility governance autonomy is instrumental in increasing facility performance, fair resource allocation and quality of healthcare services to achieve better health outcomes [39, 74]. Community-based health insurance could enhance access to healthcare services and quality of life [40, 41, 66]. It also guaranteed access to equitable quality healthcare services among dwellers of the informal and rural areas [33‐35, 42].

High non-medical costs, including transportation, lodging, food, and opportunity costs, were the barriers for the poor to access healthcare [56]. Lack of consistency and common understanding of selection criteria, poor training on procedures, low coverage of the poor, inclusion of those able to pay, delay or non-reimbursement of the costs to health facilities, and corruption [11, 57, 58] were also the challenges during fee waiver implementation. Non-consideration of the household's income in proportion to the family size and their expenses for basic needs in the fee waiver guideline were the challenge to select the eligible households [57, 58]. For instance, the guideline excluded households with seven members and got ETB 400 per month. On the other hand, households with four members who earned ETB 300 per month were eligible regardless of the income generated by the family members [57]. The absence of a clear income level cut-off for granting fee waivers; renewal of the waiver card without revision of economic status; healthcare disparity between fee waivers and cash payers; and non-consideration of households with chronic disease within the family were the other barriers to protect the poor from financial hardship [58, 59]. In addition, restriction of fee waiver certification only in a single health facility precludes services for the poor [56]. Shortage of drugs and medical supplies, absence of clear guidance, incurred additional costs, inadequate support, charging for health delivery-related services and supplies by health facilities were also challenges in exempted health services [27].

Lack of understanding of the working procedures and fear of accountability led to health facilities being reluctant to use the retained revenues and demonstrated a loss of efficiency in the healthcare service delivery [11]. The absence of rewarding systems for staff based on performance, poor physical and healthcare infrastructures, provider behaviours, high expectations, and low awareness about alternative options of the private wing at the hospital were the challenges to its utilisation [28, 61, 62]. During its implementation, conflicts between hospitals and service providers regarding the quality of non-clinical services and poor contract specifications were common challenges [63]. Service disparity, low-quality health services, inadequate equipment and staff, lack of trained personnel, adverse selection, moral hazard, fraud, and corruption were the barriers affecting health insurance delivery [13]. Exclusion of family members above 18 years from insurance beneficiaries [49] and health facilities unable to fulfil the criteria to provide the insurance service [67] also challenged healthcare delivery. Demands extraordinary drugs; tend to collect more drugs, and give their card to non-insured patients from the client side while overestimating the cost of services. The charge of undelivered insurance services from service providers' perspective were frequently occurred moral hazards to deliver healthcare services by CBHI [68]. Low awareness and benefit packages, poor perception of quality of health services, and lack of trust of the management [69‐72] were the challenges to enrol CBHI membership. High turnover of board members, absenteeism, inappropriate delegation, lack of capacity, and confusion about the governing body's role hampered leadership and community ownership [11, 26, 27].

The policy implications for this review focused on the contribution and challenges of the HCF reforms for future improvement in the country. Appropriate health financing strategies that safeguard financial risk protection underpin sustainable health services and attain UHC. This review also has an implication to provide more equitable clinical healthcare services or ensure equal access to healthcare in general. This finding will also help to ensure the quality of care and address the clinical healthcare service disparities in Ethiopia. It advances awareness among health programmers and policymakers about the importance of HCF as a key building block of the health system. It also provides an insight on the critical HCF reforms in Ethiopia, include: revenue retention and utilisation, a fee-waiver system for the poor, exemption services, user fee setting and revision, private wing in public hospitals, outsourcing non-clinical services, health insurance, and promoting health facility governance autonomy to improve its implementation on the health system. The review could help the policymakers and government officials to revise and update its HCF strategies.

This review provides ample evidence on HCF towards UHC in Ethiopia. On the contrary, this review did not include a meta-analysis to estimate the pooled effect of HCF on the progress of healthcare service delivery towards UHC in Ethiopia since a meta-analysis to be valid requires all included studies to be sufficiently similar. However, a narrative review can cover a wide range of subject matter at various levels of completeness and comprehensiveness that may consist of research findings.