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Abstract Background Efficiency, equity and financial risk protection are key health systems objectives. Equitable distribution of health care is among the priority strategic initiative of the government of Ethiopia. However, data on the distribution of interventions benefits or on disease burden disaggregated by subpopulations to guide health care priority setting is not available in Ethiopia. Methods Aligned with policy documents, we identified the following groups to be the worse off in the Ethiopian context: under-five children, women of reproductive age, the poor, and rural residents. We used the Delphi technique by a panel of 28 experts to assign a score for 253 diseases/conditions over a period of two days, in phases. The expert panel represented different institutes and professional mix. Experts assigned a score 1 to 4; where 4 indicates disease/condition predominantly affecting the poor and rural residents and 1 indicates a condition more prevalent among the wealthy and urban residents. Subsequently, the average equity score was computed for each disease/condition. Results The average scores ranged from 1.11 (for vitiligo) to 3.79 (for obstetric fistula). We standardized the scores to be bounded between 1 and 2; 1 the lowest equity score and 2 the highest equity score. The scores for each disease/condition were then assigned to their corresponding interventions. We used these equity scores to adjust the CEA values for each of the interventions. To adjust the CEA values for equity, we multiplied the health benefits (the denominator of the cost-effectiveness value) of each intervention by the corresponding equity scores, resulting in equity adjusted CEA values. The equity adjusted CEA was then used to rank the interventions using a league table. Conclusions The Delphi method can be useful in generating equity scores for prioritizing health interventions where disaggregated data on the distribution of diseases or access to interventions by subpopulation groups are not available.

Ethiopia has made significant progress in the last two decades in improving the availability and coverage of essential maternal and child health services including childhood immunizations. As Ethiopia keeps momentum towards achieving national immunization goals, methods must be developed to analyze routinely collected health facility data and generate localized coverage estimates. This study leverages the District Health Information Software (DHIS2) platform to estimate immunization coverage for the first dose of measles vaccine (MCV1) and the third dose of diphtheria-pertussis-tetanus-Hib-HepB vaccine (Penta3) across Ethiopian districts ("woredas"). Monthly reported numbers of administered MCV1 and Penta3 immunizations were extracted from public facilities from DHIS2 for 2017/2018-2021/2022 and corrected for quality based on completeness and consistency across time and districts. We then utilized three sources for the target population (infants) to compute administrative coverage estimates: Central Statistical Agency, DHIS2, and WorldPop. The Ethiopian Demographic and Health Surveys were used as benchmarks to which administrative estimates were adjusted at the regional level. Administrative vaccine coverage was estimated for all woredas, and, after adjustments, was bounded within 0-100%. In regions with the highest immunization coverage, MCV1 coverage would range from 83 to 100% and Penta3 coverage from 88 to 100% (Addis Ababa, 2021/2022); MCV1 from 8 to 100% and Penta3 from 4 to 100% (Tigray, 2019/2020). Nationally, the Gini index for MCV1 was 0.37, from 0.13 (Harari) to 0.37 (Somali); for Penta3, it was 0.36, from 0.16 (Harari) to 0.36 (Somali). The use of routine health information systems, such as DHIS2, combined with household surveys permits the generation of local health services coverage estimates. This enables the design of tailored health policies with the capacity to measure progress towards achieving national targets, especially in terms of inequality reductions.

Objective This analysis is to present the burden and trends of morbidity and mortality due to lower respiratory infections (LRIs), their contributing risk factors, and the disparity across administrative regions and cities from 1990 to 2019.Design This analysis used Global Burden of Disease 2019 framework to estimate morbidity and mortality outcomes of LRI and its contributing risk factors. The Global Burden of Disease study uses all available data sources and Cause of Death Ensemble model to estimate deaths from LRI and a meta-regression disease modelling technique to estimate LRI non-fatal outcomes with 95% uncertainty intervals (UI).Study setting The study includes nine region states and two chartered cities of Ethiopia.Outcome measures We calculated incidence, death and years of life lost (YLLs) due to LRIs and contributing risk factors using all accessible data sources. We calculated 95% UIs for the point estimates.Results In 2019, LRIs incidence, death and YLLs among all age groups were 8313.7 (95% UI 7757.6–8918), 59.4 (95% UI 49.8–71.4) and 2404.5 (95% UI 2059.4–2833.3) per 100 000 people, respectively. From 1990, the corresponding decline rates were 39%, 61% and 76%, respectively. Children under the age of 5 years account for 20% of episodes, 42% of mortalities and 70% of the YLL of the total burden of LRIs in 2019. The mortality rate was significantly higher in predominantly pastoralist regions—Benishangul-Gumuz 101.8 (95% UI 84.0–121.7) and Afar 103.7 (95% UI 86.6–122.6). The Somali region showed the least decline in mortality rates. More than three-fourths of under-5 child deaths due to LRIs were attributed to malnutrition. Household air pollution from solid fuel attributed to nearly half of the risk factors for all age mortalities due to LRIs in the country.Conclusion In Ethiopia, LRIs have reduced significantly across the regions over the years (except in elders), however, are still the third-leading cause of mortality, disproportionately affecting children younger than 5 years old and predominantly pastoralist regions. Interventions need to consider leading risk factors, targeted age groups and pastoralist and cross-border communities.

Abstract Background Treatment abandonment is one of major reasons for childhood cancer treatment failure and low survival rate in low- and middle-income countries. Ethiopia plans to reduce abandonment rate by 60% (2019–2023), but baseline data and information about the contextual risk factors that influence treatment abandonment are scarce. Methods This cross-sectional study was conducted from September 5 to 22, 2021, on the three major pediatric oncology centers in Ethiopia. Data on the incidence and reasons for treatment abandonment were obtained from healthcare professionals. We were unable to obtain data about the patients’ or guardians’ perspective because the information available in the cancer registry was incomplete to contact adequate number of respondents. We used a validated, semi-structured questionnaire developed by the International Society of Pediatric Oncology Abandonment Technical Working Group. We included all (N = 38) health care professionals (physicians, nurses, and social workers) working at these centers who had more than one year of experience in childhood cancer service provision (a universal sampling and 100% response rate). Results The perceived mean abandonment rate in Ethiopia is 34% (SE 2.5%). The risk of treatment abandonment is dependent on the type of cancer (high for bone sarcoma and brain tumor), the phase of treatment and treatment outcome. The highest risk is during maintenance and treatment failure or relapse for acute lymphoblastic leukemia, and during pre- or post-surgical phase for Wilms tumor and bone sarcoma. The major influencing risk factors in Ethiopia includes high cost of care, low economic status, long travel time to treatment centers, long waiting time, belief in the incurability of cancer and poor public awareness about childhood cancer. Conclusions The perceived abandonment rate in Ethiopia is high, and the risk of abandonment varies according to the type of cancer, phase of treatment or treatment outcome. Therefore, mitigation strategies to reduce the abandonment rate should include identifying specific risk factors and prioritizing strategies based on their level of influence, effectiveness, feasibility, and affordability.

BackgroundThe 2030 agenda for sustainable development goals has given injury prevention new attention, including halving road traffic injuries. This study compiled the best available evidence on injury from the global burden of diseases study for Ethiopia from 1990 to 2019.MethodsInjury data on incidence, prevalence, mortality, disability-adjusted life years lost, years lived with disability, and years of life lost were extracted from the 2019 global burden of diseases study for regions and chartered cities in Ethiopia from 1990 to 2019. Rates were estimated per 100,000 population.ResultsIn 2019, the age-standardized rate of incidence was 7,118 (95% UI: 6,621–7,678), prevalence was 21,735 (95% UI: 19,251–26,302), death was 72 (95% UI: 61–83), disability-adjusted life years lost was 3,265 (95% UI: 2,826–3,783), years of live lost was 2,417 (95% UI: 2,043–2,860), and years lived with disability was 848 [95% UI: (620–1,153)]. Since 1990, there has been a reduction in the age-standardized rate of incidence by 76% (95% UI: 74–78), death by 70% (95% UI: 65–75), and prevalence by 13% (95% UI: 3–18), with noticeable inter-regional variations. Transport injuries, conflict and terrorism, interpersonal violence, self-harm, falls, poisoning, and exposure to mechanical forces were the leading causes of injury-related deaths and long-term disabilities. Since 1990, there has been a decline in the prevalence of transport injuries by 32% (95% UI: 31–33), exposure to mechanical forces by 12% (95% UI: 10–14), and interpersonal violence by 7.4% (95% UI: 5–10). However, there was an increment in falls by 8.4% (95% UI: 7–11) and conflict and terrorism by 1.5% (95% UI: 38–27).ConclusionEven though the burden of injuries has steadily decreased at national and sub-national levels in Ethiopia over the past 30 years, it still remains to be an area of public health priority. Therefore, injury prevention and control strategies should consider regional disparities in the burden of injuries, promoting transportation safety, developing democratic culture and negotiation skills to solve disputes, using early security-interventions when conflict arises, ensuring workplace safety and improving psychological wellbeing of citizens.

BackgroundVaccine-preventable diseases (VPDs) remain major causes of morbidity and mortality in low- and middle-income countries (LMICs). Universal access to vaccination, besides improved health outcomes, would substantially reduce VPD-related out-of-pocket (OOP) expenditures and associated financial risks. This paper aims to estimate the extent of OOP expenditures and the magnitude of the associated catastrophic health expenditures (CHEs) for selected VPDs in Ethiopia.Methods and findingsWe conducted a cross-sectional costing analysis, from the household (patient) perspective, of care-seeking for VPDs in children aged under 5 years for pneumonia, diarrhea, measles, and pertussis, and in children aged under 15 years for meningitis. Data on OOP direct medical and nonmedical expenditures (2021 USD) and household consumption expenditures were collected from 995 households (1 child per household) in 54 health facilities nationwide between May 1 and July 31, 2021. We used descriptive statistics to measure the main outcomes: magnitude of OOP expenditures, along with the associated CHE within households. Drivers of CHE were assessed using a logistic regression model. The mean OOP expenditures per disease episode for outpatient care for diarrhea, pneumonia, pertussis, and measles were $5·6 (95% confidence interval (CI): $4·3, 6·8), $7·8 ($5·3, 10·3), $9·0 ($6·4, 11·6), and $7·4 ($3·0, 11·9), respectively. The mean OOP expenditures were higher for inpatient care, ranging from $40·6 (95% CI: $12·9, 68·3) for severe measles to $101·7 ($88·5, 114·8) for meningitis. Direct medical expenditures, particularly drug and supply expenses, were the major cost drivers. Among those who sought inpatient care (345 households), about 13·3% suffered CHE, at a 10% threshold of annual consumption expenditures. The type of facility visited, receiving inpatient care, and wealth were significant predictors of CHE (p-value < 0·001) while adjusting for area of residence (urban/rural), diagnosis, age of respondent, and household family size. Limitations include inadequate number of measles and pertussis cases.ConclusionsThe OOP expenditures induced by VPDs are substantial in Ethiopia and disproportionately impact those with low income and those requiring inpatient care. Expanding equitable access to vaccines cannot be overemphasized, for both health and economic reasons. Such realization requires the government's commitment toward increasing and sustaining vaccine financing in Ethiopia.

Objective To estimate the cost-effectiveness of running a paediatric oncology unit in Ethiopia to inform the revision of the Ethiopia Essential Health Service Package (EEHSP), which ranks the treatment of childhood cancers at a low and medium priority.Methods We built a decision analytical model—a decision tree—to estimate the cost-effectiveness of running a paediatric oncology unit compared with a do-nothing scenario (no paediatric oncology care) from a healthcare provider perspective. We used the recently (2018–2019) conducted costing estimate for running the paediatric oncology unit at Tikur Anbessa Specialized Hospital (TASH) and employed a mixed costing approach (top-down and bottom-up). We used data on health outcomes from other studies in similar settings to estimate the disability-adjusted life years (DALYs) averted of running a paediatric oncology unit compared with a do-nothing scenario over a lifetime horizon. Both costs and effects were discounted (3%) to the present value. The primary outcome was incremental cost in US dollars (USDs) per DALY averted, and we used a willingness-to-pay (WTP) threshold of 50% of the Ethiopian gross domestic product per capita (USD 477 in 2019). Uncertainty was tested using one-way and probabilistic sensitivity analyses.Results The incremental cost and DALYs averted per child treated in the paediatric oncology unit at TASH were USD 876 and 2.4, respectively, compared with no paediatric oncology care. The incremental cost-effectiveness ratio of running a paediatric oncology unit was USD 361 per DALY averted, and it was cost-effective in 90% of 100 000 Monte Carlo iterations at a USD 477 WTP threshold.Conclusions The provision of paediatric cancer services using a specialised oncology unit is most likely cost-effective in Ethiopia, at least for easily treatable cancer types in centres with minimal to moderate capability. We recommend reassessing the priority-level decision of childhood cancer treatment in the current EEHSP.

BackgroundDespite the recent interest in expanding pediatric oncology units in Ethiopia, reflected in the National Childhood and Adolescent Cancer Control Plan (NCACCP), little is known about the cost of running a pediatric oncology unit and treating childhood cancers.MethodsWe collected historical cost data and quantity of services provided for the pediatric oncology unit and all other departments in Tikur Anbessa Specialized Hospital (TASH) from 8 July 2018 to 7 July 2019, using a provider perspective and mixed (top-down and bottom-up) costing approaches. Direct costs (human resources, drugs, supplies, medical equipment) of the pediatric oncology unit, costs at other relevant clinical departments, and overhead cost share are summed up to estimate the total annual cost of running the unit. Further, unit costs were estimated at specific childhood cancer levels.ResultsThe estimated annual total cost of running a pediatric oncology unit was USD 776,060 (equivalent to USD 577 per treated child). The cost of running a pediatric oncology unit per treated child ranged from USD 469 to USD 1,085, on the scenario-based sensitivity analysis. Drugs and supplies, and human resources accounted for 33% and 27% of the total cost, respectively. Outpatient department and inpatient department shared 37% and 63% of the cost, respectively. For the pediatric oncology unit, the cost per OPD visit, cost per bed day, and cost per episode of hospital admission were USD 36.9, 39.9, and 373.3, respectively. The annual cost per treated child ranged from USD 322 to USD 1,313 for the specific childhood cancers.ConclusionRunning a pediatric oncology unit in Ethiopia is likely to be affordable. Further analysis of cost effectiveness, equity, and financial risk protection impacts of investing in childhood cancer programs could better inform the prioritization of childhood cancer control interventions in the Ethiopia Essential Health Service Package.

IntroductionThe aging population is rapidly increasing globally, with 80% of the older population living in low- and middle-income countries. In Eastern African countries, there exists an incongruence between readiness–economically, structurally, politically, and culturally–to create a conducive environment for healthy aging, which implies public health as well as ethical concerns. The aim of this scoping review was to explore existing evidence addressing the various ethical issues in connection with elder care in the region of Eastern Africa.MethodsWe searched six databases (Africa-Wide Information, AgeLine, CINHAL, MEDLINE, APA PsycInfo, and SocINDEX) to identify peer-reviewed journal articles that could meet some eligibility criteria such as being a peer-reviewed journal article written in English, having been published in any year until July 2020, and focusing on ethical issues in the care of older people aged 60 years and older from Eastern Africa. We also searched for additional evidence in the references of included papers and web-based platforms. We included 24 journal articles and analyzed them using the inductive content analysis approach.ResultsThe included articles represent seven (38.9%) of the 18 countries in the Eastern African region. The articles covered six ethical concerns: lack of government attention to older persons (n = 14, 58.3%), inaccessibility of health care services (n = 13, 54.2%), loneliness and isolation (n = 11, 45.8%), gender inequalities in old age (n = 9, 37.5%), mistreatment and victimization (n = 8, 33.3%), and medical errors (n = 2, 8.3%).ConclusionThis scoping review summarized ethical issues arising in relation to providing care for older persons in the Eastern African context. In light of the rapid increase in the number of older persons in this region, it is critical for governments and responsible bodies to implement and accelerate efforts promptly to generate more evidence to inform programs and policies that improve the health and wellbeing of older persons. Further research is needed to inform global health efforts that aim at improving the lives of older persons, particularly in low- and middle-income countries.Clinical Trial Registrationhttps://osf.io/sb8gw, identifier: 10.17605/OSF.IO/SB8GW.

Abstract Background Increasing the coverage of community-based treatment of childhood pneumonia (CCM) is part of the strategy to improve child survival, increase life-expectancy at birth and promote equity in Ethiopia. However, full coverage of CCM has not been reached in any regions of the country. There are no sub-national cost-effectiveness analyses available to inform decision makers on the most equitable scale up strategy. Objectives Our first objective is to estimate the sub-national cost-effectiveness and the interindividual inequality impacts of scaling up CCM coverages to 90% in each region. Our second objective is to explore the costs, health effects, and geographical inequality impacts associated with three scale-up scenarios promoting different policy-aims: maximizing health, reducing geographical inequalities, and achieving 90% universal coverage. Methods We used Markov modelling to estimate the sub-national cost-effectiveness of CCM in each region. All data were collected through literature review and adjusted to the region-specific proportions of the rural population. Health effects were modeled as life years gained and under-five deaths averted. Interindividual and geographical inequality impacts were measured by the GINI index applied to health. In scenario analysis we explored three different scale-up strategies: 1) maximizing health by prioritizing the regions where the intervention was the most cost-effective, 2) reducing geographical inequalities by prioritizing the regions with high baseline under-five mortality rate (U5MR), and 3) universal upscaling to 90% coverage in all the regions. Results The regional incremental-cost effectiveness ratio (ICER) of scaling up the intervention coverage varied from 26 USD per life year gained in Addis to 199 USD per life year gained in the Southern Nations, Nationalities, and Peoples’ region. Universal upscaling of CCM in all regions would cost about 1.3 billion USD and prevent about 90,000 under-five deaths. This is less than 15,000 USD per life saved and translates to an increase in life expectancy at birth of 1.6 years across Ethiopia. In scenario analysis, we found that prioritizing regions with high U5MR is effective in reducing geographical inequalities, although at the cost of fewer lives saved as compared to the health maximizing strategy. Conclusions Our model results illustrate a trade-off between maximizing health and reducing health inequalities, two common policy-aims in low-income settings.

Ethiopia raised taxes on tobacco products in early 2020, increasing the overall price of the typical pack of cigarettes by about 67%. We quantify the potential impacts of Ethiopia's tobacco tax hike on various outcomes—life years, tax revenues, cigarette expenditures and catastrophic health expenditures (CHE). Using parameters like price elasticity of demand for cigarettes and smoking prevalence in Ethiopia from the existing literature and secondary data sources, we model the potential implications of the reform at the population level and for different wealth quintiles. We focus only on men since a small proportion of Ethiopian women smoke. Results indicate that Ethiopia's tax hike could induce a significant proportion of current smokers to quit smoking and thereby save almost eight million years of life in the current population. The reform is also likely to increase tax revenues by USD26 million in the first year after its introduction. The richest quintile will bear the greatest share of this higher tax burden and the poorest will bear the least. Additionally, deaths due to the main diseases associated with smoking will fall. This is expected to avert up to 173,000 CHE cases due to the out-of-pocket costs that would have been incurred in obtaining medical treatment. This analysis highlights that cigarette tax hikes in countries that have low smoking prevalence can reduce smoking even further, and thereby protect against the future health and financial costs of smoking. Importantly, the effects of these policies can be progressive across the income spectrum.

Abstract Background Hepatitis B virus (HBV) infection is an important cause of morbidity and mortality with a very high burden in Africa. The risk of developing chronic infection is marked if the infection is acquired perinatally, which is largely preventable through a birth dose of HBV vaccine. We examined the cost-effectiveness of a birth dose of HBV vaccine in a medical setting in Ethiopia. Methods We constructed a decision analytic model with a Markov process to estimate the costs and effects of a birth dose of HBV vaccine (the intervention), compared with current practices in Ethiopia. Current practice is pentavalent vaccination (DPT-HiB-HepB) administered at 6, 10 and 14 weeks after birth. We used disability-adjusted life years (DALYs) averted to quantify the health benefits while the costs of the intervention were expressed in 2018 USD. Analyses were based on Ethiopian epidemiological, demographic and cost data when available; otherwise we used a thorough literature review, in particular for assigning transition probabilities. Results In Ethiopia, where the prevalence of HBV among pregnant women is 5%, adding a birth dose of HBV vaccine would present an incremental cost-effectiveness ratio (ICER) of USD 110 per DALY averted. The estimated ICER compares very favorably with a willingness-to-pay level of 0.31 times gross domestic product per capita (about USD 240 in 2018) in Ethiopia. Our ICER estimates were robust over a wide range of epidemiologic, vaccine effectiveness, vaccine coverage and cost parameter inputs. Conclusions Based on our cost-effectiveness findings, introducing a birth dose of HBV vaccine in Ethiopia would likely be highly cost-effective. Such evidence could help guide policymakers in considering including HBV vaccine into Ethiopia’s essential health services package.

Immunization is one of the most effective public health interventions, saving millions of lives every year. Ethiopia has seen gradual improvements in immunization coverage and access to child health care services; however, inequalities in child mortality across wealth quintiles and regions remain persistent. We model the relative distributional incidence and mortality of four vaccine-preventable diseases (VPDs) (rotavirus diarrhea, human papillomavirus, measles, and pneumonia) by wealth quintile and geographic region in Ethiopia. Our approach significantly extends an earlier methodology, which utilizes the population attributable fraction and differences in the prevalence of risk and prognostic factors by population subgroup to estimate the relative distribution of VPD incidence and mortality. We use a linear system of equations to estimate the joint distribution of risk and prognostic factors in population subgroups, treating each possible combination of risk or prognostic factors as computationally distinct, thereby allowing us to account for individuals with multiple risk factors. Across all modeling scenarios, our analysis found that the poor and those living in rural and primarily pastoralist or agrarian regions have a greater risk than the rich and those living in urban regions of becoming infected with or dying from a VPD. While in absolute terms all population subgroups benefit from health interventions (e.g., vaccination and treatment), current unequal levels and pro-rich gradients of vaccination and treatment-seeking patterns should be redressed so to significantly improve health equity across wealth quintiles and geographic regions in Ethiopia.

Background The COVID-19 pandemic has caused profound health, economic, and social disruptions globally. We assessed the full costs of hospitalization for COVID-19 disease at Ekka Kotebe COVID-19 treatment center in Addis Ababa, the largest hospital dedicated to COVID-19 patient care in Ethiopia. Methods and findings We retrospectively collected and analysed clinical and cost data on patients admitted to Ekka Kotebe with laboratory-confirmed COVID-19 infections. Cost data included personnel time and salaries, drugs, medical supplies and equipment, facility utilities, and capital costs. Facility medical records were reviewed to assess the average duration of stay by disease severity (either moderate, severe, or critical). The data collected covered the time-period March-November 2020. We then estimated the cost per treated COVID-19 episode, stratified by disease severity, from the perspective of the provider. Over the study period there were 2,543 COVID-19 cases treated at Ekka Kotebe, of which, 235 were critical, 515 were severe, and 1,841 were moderate. The mean patient duration of stay varied from 9.2 days (95% CI: 7.6–10.9; for moderate cases) to 19.2 days (17.9–20.6; for critical cases). The mean cost per treated episode was USD 1,473 (95% CI: 1,197–1,750), but cost varied by disease severity: the mean cost for moderate, severe, and critical cases were USD 1,266 (998–1,534), USD 1,545 (1,413–1,677), and USD 2,637 (1,788–3,486), respectively. Conclusions Clinical management and treatment of COVID-19 patients poses an enormous economic burden to the Ethiopian health system. Such estimates of COVID-19 treatment costs inform financial implications for resource-constrained health systems and reinforce the urgency of implementing effective infection prevention and control policies, including the rapid rollout of COVID-19 vaccines, in low-income countries like Ethiopia.

BackgroundEthiopia has been responding to the COVID-19 pandemic through a combination of interventions, including non-pharmaceutical interventions, quarantine, testing, isolation, contact tracing, and clinical management. Estimating the resources consumed for COVID-19 prevention and control could inform efficient decision-making for epidemic/pandemic-prone diseases in the future. This study aims to estimate the unit cost of COVID-19 sample collection, laboratory diagnosis, and contact tracing in Addis Ababa, Ethiopia.MethodsPrimary and secondary data were collected to estimate the costs of COVID-19 sample collection, diagnosis, and contact tracing. A healthcare system perspective was used. We used a combination of micro-costing (bottom-up) and top-down approaches to estimate resources consumed and the unit costs of the interventions. We used available cost and outcome data between May and December 2020. The costs were classified into capital and recurrent inputs to estimate unit and total costs. We identified the cost drivers of the interventions. We reported the cost for the following outcome measures: (1) cost per sample collected, (2) cost per laboratory diagnosis, (3) cost per sample collected and laboratory diagnosis, (4) cost per contact traced, and (5) cost per COVID-19 positive test identified. We conducted one-way sensitivity analysis by varying the input parameters. All costs were reported in US dollars (USD).ResultsThe unit cost per sample collected was USD 1.33. The unit cost of tracing a contact of an index case was USD 0.66. The unit cost of COVID-19 diagnosis, excluding the cost for sample collection was USD 3.91. The unit cost of sample collection per COVID-19 positive individual was USD 11.63. The unit cost for COVID-19 positive test through contact tracing was USD 54.00. The unit cost COVID-19 DNA PCR diagnosis for identifying COVID-19 positive individuals, excluding the sample collection and transport cost, was USD 37.70. The cost per COVID-19 positive case identified was USD 49.33 including both sample collection and laboratory diagnosis costs. Among the cost drivers, personnel cost (salary and food cost) takes the highest share for all interventions, ranging from 51-76% of the total cost.ConclusionThe costs of sample collection, diagnosis, and contact tracing for COVID-19 were high given the low per capita health expenditure in Ethiopia and other low-income settings. Since the personnel cost accounts for the highest cost, decision-makers should focus on minimizing this cost when faced with pandemic-prone diseases by strengthening the health system and using digital platforms. The findings of this study can help decision-makers prioritize and allocate resources for effective public health emergency response.

To make progress toward universal health coverage, countries should define the type and mix of health services that respond to their populations’ needs. Ethiopia revised its essential health services package (EHSP) in 2019. This paper describes the process, methodology and key features of the new EHSP. A total of 35 consultative workshops were convened with experts and the public to define the scope of the revision, develop a list of health interventions, agree on the prioritization criteria, gather evidence and compare health interventions. Seven prioritization criteria were employed: disease burden, cost effectiveness, equity, financial risk protection, budget impact, public acceptability and political acceptability. In the first phase, 1,749 interventions were identified, including existing and new interventions, which were regrouped and reorganized to identify 1,442 interventions as relevant. The second phase removed interventions that did not match the burden of disease or were not relevant in the Ethiopian setting, reducing the number of interventions to 1,018. These were evaluated further and ranked by the other criteria. Finally, 594 interventions were classified as high priority (58%), 213 as medium priorities (21%) and 211 as low priority interventions (21%). The current policy is to provide 570 interventions (56%) free of charge while guaranteeing the availability of the remaining services with cost-sharing (38%) and cost-recovery (6%) mechanisms in place. In conclusion, the revision of Ethiopia’s EHSP followed a participatory, inclusive and evidence-based prioritization process. The interventions included in the EHSP were comprehensive and were assigned to health care delivery platforms and linked to financing mechanisms.

In health outcomes terms, the poorest countries stand to lose the most from these disruptions. In this paper, we make the case for a rational approach to public sector health spending and decision making during and in the early recovery phase of the COVID-19 pandemic. Based on ethics and equity principles, it is crucial to ensure that patients not infected by COVID-19 continue to get access to healthcare and that the services they need continue to be resourced. We present a list of 120 essential non-COVID-19 health interventions that were adapted from the model health benefit packages developed by the Disease Control Priorities project.

Purpose: Noncommunicable diseases, prominently cancer, have become the second leading cause of death in the adult population of Ethiopia. A population-based cancer registry has been used in Addis Ababa (the capital city) since 2011. Availability of up-to-date estimates on cancer incidence is important in guiding the national cancer control program in Ethiopia. Methods: We obtained primary data on 8,539 patients from the Addis Ababa population-based cancer registry and supplemented by data on 1,648 cancer cases collected from six Ethiopian regions. We estimated the number of the commonest forms of cancer diagnosed among males and females in Ethiopia and computed crude and age-standardized incidence rates. Results: For 2015 in Ethiopia, we estimated that 21,563 (95% CI, 17,416 to 25,660) and 42,722 (95% CI, 37,412 to 48,040) incident cancer cases were diagnosed in males and females, respectively. The most common adult cancers were: cancers of the breast and cervix, colorectal cancer, non-Hodgkin lymphoma, leukemia, and cancers of the prostate, thyroid, lung, stomach, and liver. Leukemia was the leading cancer diagnosis in the pediatric age group (age 0 to 14 years). Breast cancer was by far the commonest cancer, constituting 33% of the cancers in women and 23% of all cancers identified from the Addis Ababa cancer registry. It was also the commonest cancer in four of the six Ethiopian regions included in the analysis. Colorectal cancer and non-Hodgkin lymphoma were the commonest malignancies in men. Conclusion: Cancer, and more prominently breast cancer, poses a substantial public health threat in Ethiopia. The fight against cancer calls for expansion of population-based registry sites to improve quantifying the cancer burden in Ethiopia and requires both increased investment and application of existing cancer control knowledge across all segments of the Ethiopian population.

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

Emerging demographic, epidemiological and health system changes in low-income countries require revisions of national essential health services packages in accordance with standard healthcare priority setting methods. Policy makers are in need of explicit and user-friendly methods to compare impact of multiple interventions. We provide experiences of country contextualisation of WHO-CHOICE methods and models to a country level. Results from three contextualised cost-effectiveness analyses (CEAs) are presented, and we discuss how this evidence can inform priority setting in Ethiopia. Existing models for a range of interventions in obstetric and neonatal care, psychiatric and neurological treatment and prevention and treatment of cardiovascular diseases are contextualised to the Ethiopian setting. CEAs are defined as contextualised if they include national analysts and use country-specific input for either costs, epidemiology, demography, baseline coverage or effects. Interventions (n=61) are ranked according to incremental cost-effectiveness rates (ICERs), and expected health outcomes (Disability Adjusted Life Years (DALYs) averted) and budget impacts are presented for each intervention. Dominated interventions (n=30) were excluded. A US$2.8 increase per capita in the annual health budget is needed in Ethiopia (currently at US$28 per capita) for increasing coverage by 20%–75% for all the 22 interventions with positive net health benefits. This investment is expected to give a net benefit at around 0.5 million DALYs averted in return in total, with a willingness to pay threshold at US$2000 per DALY averted. In particular, three interventions, neonatal resuscitation, kangaroo mother care and antibiotics for newborn sepsis, stand out as best buys in an Ethiopian setting. Our method of contextualised CEAs provides important information for policy makers. Rank ordering of interventions by ICERs, together with presentations of expected budget impact and net health benefits, is a clear and policy friendly illustration of possible efficient stepwise pathways towards universal health coverage.

Background: The way in which a government chooses to finance a health intervention can affect the uptake of health interventions and consequently the extent of health gains. In addition to health gains, some policies such as public finance can insure against catastrophic health expenditures. We aimed to evaluate the health and financial risk protection benefits of selected interventions that could be publicly financed by the government of Ethiopia. Methods: We used extended cost-effectiveness analysis to assess the health gains (deaths averted) and financial risk protection afforded (cases of poverty averted) by a bundle of nine (among many other) interventions that the Government of Ethiopia aims to make universally available. These nine interventions were measles vaccination, rotavirus vaccination, pneumococcal conjugate vaccination, diarrhoea treatment, malaria treatment, pneumonia treatment, caesarean section surgery, hypertension treatment, and tuberculosis treatment. Findings: Our analysis shows that, per dollar spent by the Ethiopian Government, the interventions that avert the most deaths are measles vaccination (367 deaths averted per $100 000 spent), pneumococcal conjugate vaccination (170 deaths averted per $100 000 spent), and caesarean section surgery (141 deaths averted per $100 000 spent). The interventions that avert the most cases of poverty are caesarean section surgery (98 cases averted per $100 000 spent), tuberculosis treatment (96 cases averted per $100 000 spent), and hypertension treatment (84 cases averted per $100 000 spent). Interpretation: Our approach incorporates financial risk protection into the economic evaluation of health interventions and therefore provides information about the efficiency of attainment of both major objectives of a health system: improved health and financial risk protection. One intervention might rank higher on one or both metrics than another, which shows how intervention choice—the selection of a pathway to universal health coverage—might involve weighing up of sometimes competing objectives. This understanding can help policy makers to select interventions to target specific policy goals (ie, improved health or financial risk protection). It is especially relevant for the design and sequencing of universal health coverage to meet the needs of poor populations. Funding: Bill & Melinda Gates Foundation.

BACKGROUND:Pneumonia and pneumococcal disease cause a large disease burden in resource-constrained settings. We pursue an extended cost-effectiveness analysis (ECEA) of two fully publicly financed interventions in Ethiopia: pneumococcal vaccination for newborns and pneumonia treatment for under-five children in Ethiopia. METHODS:We apply ECEA methods and estimate the program impact on: (1) government program costs; (2) pneumonia and pneumococcal deaths averted; (3) household expenses related to pneumonia/pneumococcal disease treatment averted; (4) prevention of household medical impoverishment measured by an imputed money-metric value of financial risk protection; and (5) distributional consequences across the wealth strata of the country population. Available epidemiological and cost data from Ethiopia are applied and the two interventions are assessed separately at various incremental coverage levels. RESULTS:Scaling-up pneumococcal vaccines at around 40% coverage would cost about $11.5 million and avert about 2090 child deaths annually, while a 10% increase of pneumonia treatment to all children under 5 years of age would cost about $13.9 million and avert 2610 deaths annually. Health benefits of the two interventions publicly financed would be concentrated among the bottom income quintile, where 30-40% of all deaths averted would be expected to occur in the poorest quintile. In sum, the two interventions would eliminate a total of $2.4 million of private household expenditures annually, where the richest quintile benefits from around 30% of the total private expenditures averted. The financial risk protection benefits would be largely concentrated among the bottom income quintile. The results are most sensitive to variations in vaccine price, population size, number of deaths due to pneumonia, efficacy of interventions and out-of-pocket copayment share. CONCLUSIONS:Vaccine and treatment interventions for children, as shown with the illustrative examples of pneumococcal vaccine and pneumonia treatment, can bring large health and financial benefits to households in Ethiopia, most particularly among the poorest socio-economic groups.