Addressing the challenge of equitable access to quality health care in Ethiopia

With funding from the Fund for Innovations in Development (FID), PEP is supporting a team of local researchers to assess the effectiveness of a new "contribution system", tailored to the economic capacity of households, to increase access to equitable access to health care services in Ethiopia.

The research team, based at Jimma University, is working in collaboration with the Ethiopian Health Insurance Service (EHIS), the government institution in charge of implementing this new "policy initiative".

The issue

In 2010, in order to promote equitable access to health care services and thereby improve the health sector for the entire population, the Ethiopian government introduced Community-Based Health Insurance (CBHI), which was designed to end excessive out-of-pocket health care expenses for more than 80% of Ethiopians working in the informal sector.

    However, the premium, which is the same for everyone regardless of their financial capacity, has resulted in the distorsion of the distributional effect and has affected people’s take-up of the CBHI. Indeed, low-income households cannot always afford to join the scheme, and the low quality of health services does not attract high-wealth households. This reality contributes to inequity in the system and disinterest in CBHI.

    The introduction of a new flexible contribution system, based on the socioeconomic status of households, has the potential to encourage vulnerable populations to seek health care. It can also influence health financing in Ethiopia to achieve equitable, quality, efficient, and sustainable services for the entire population.

    The research

    With support from the PEP experimental research group, the research team is conducting an impact evaluation via a randomized controlled trial to analyze the cost-effectiveness of the new "sliding scale system", adjusted depending on individual’s income, in terms of health gains and financial risk sharing, compared to paying the same amount of contributions to all households regardless of their resources.

    Specifically, the study is intended to assess the impact of the program on the following outcomes:

    1. Equitable health service utilization and reductions in the disparity between households’ economic status
    2. Financial protections (Out-of-pocket health expenditure per capita; catastrophic health expenditure and Impoverishment)
    3. Women's empowerment and gender equity in healthcare utilization
    4. Acceptance and beneficiaries’ satisfaction with the new policy initiative
    5. Measures of healthcare quality

    At the same time, the study aims at educating and sensitizing communities to use health services.

    The evaluation is being conducted in three major regions of Ethiopia (Oromia, Amhara, and Southern Nation) from January 2023 to December 2026. It collects data at the household and health facility levels and conducts qualitative and statistical analyses to inform policy decisions.

    Expected results

    The project aims at improving the distributive impact and sustainability of community-based health insurance (CBHI) through:

    • Reduced inequities in health financing and access between very poor and rich households
    • Increased utilisation of health services (increased health revenues)
    • Strengthened capacity of health facilities to provide better care (thanks to revenues from increased enrollment of households)
    • Improved overall health status of communities

    Funded by

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