Universal health coverage of HIV, TB and malaria interventions in Ethiopia: economic burden, health benefits and financial risk protection
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Introduction: Human Immunodeficiency Virus (HIV), Tuberculosis (TB) and malaria remain a major threat to the Ethiopian population. In the past decades, substantial gains have been achieved in reducing morbidity and mortality caused by HIV, TB and malaria diseases. Despite this progress, the coverage of essential health services for these diseases is far below the global targets. The health financing model in Ethiopia heavily relies on out-of-pocket (OOP) spending, which predisposes households to financial hardship. Therefore, high disease burden along with economic barriers have prohibitive consequences on accessing quality health services in the country. In addition, the allocation of scarce healthcare resources needs to be rationed appropriately to improve the health of the population in fair and efficient ways. Furthermore, in Ethiopia, like most low-income countries, apart from the health benefit of interventions to control major communicable diseases, the interventions’ importance in greater household economic returns, financial risk protection (FRP) and distributional consequences has not been fully recognised. Hence, evaluation of patient costs and benefits of the scale-up of HIV, TB and malaria interventions through universal public financing on health, equity and FRP domains are essential for priority setting and resource allocation decisions in Ethiopia. Objectives: This thesis aims to provide evidence on the patient cost, health gains and financial risk protection of HIV, TB and malaria interventions across socio-economic groups in Ethiopia. Methods: This thesis comprises of three interrelated studies. In Paper-I, a nationwide household survey (for HIV) and a separate cross-sectional survey collected from health facilities selected from Oromia and Afar regions (for TB) was used to estimate the magnitude of patient costs, catastrophic health expenditure (CHE) and its determinants for households affected by these diseases. Patient costs and CHE were used as a primary outcome measure in Paper-I. In Paper-II, an Extended Cost-Effectiveness Analysis (ECEA) method was used to estimate the impact of the universal public finance of selected malaria interventions on health benefits and FRP domains across income groups. Paper-III is based on a national level modelling study to estimate the impact of the universal public finance of selected TB interventions on mortality and financial risk reduction across income groups over the period 2018-35. The main outcomes were death averted and CHE in Papers II and III, including private expenditure averted and net government costs for Paper-II. Results: The mean patient cost was USD 78 per year for HIV care and USD 115 per TB episode. Direct patient costs of HIV and TB account for 69% and 46% of the total costs, respectively. The overall incidence of CHE among HIV patients was 20% (43% for the poorest quintile and 4% for the richest quintile) and that of the TB household was 40% (ranging from 58% to 20%, between the poorest and richest income quintiles, respectively). The incidence of CHE is higher in patients with frequent healthcare visits, TB/HIV co-infection, drug-resistant TB and hospitalisation. Inequality in financial risk was present across the different income quintiles, where the lower quintile suffers most. Increasing coverage (by 10%) of artemisinin combination therapy (ACT), long-lasting insecticide-treated bed nets (LLIN), indoor residual spraying (IRS) and malaria vaccines among the population at risk would avert 358, 188, 107, and 38 malaria deaths per year in Ethiopia. The four malaria interventions would avert 440, 220, 125, and 18 cases of CHE, respectively. Similarly, among the four interventions, malaria treatment (ACT) averts approximately USD 4,277,000 in private expenditure. ACT and LLIN interventions were linked to the largest number of deaths and cases of CHE averted. Those people in the lowest income quintiles have the highest health and FRP benefits. For example, the poorest two quintiles accounted for almost half of the deaths averted, compared to one-third in the richest two quintiles. The government cost of the ACT, LLIN, IRS and malaria vaccine interventions is USD 5.7, 16.5, 32.6, and 5.1 million, respectively. Implementing active TB case finding from 2018 to 2035 would lead to reductions of 206,000 (27%) and 193,000 (32%) of the expected TB deaths and CHEs, respectively. Similarly, enhancing DOTS for drug-susceptible TB would avert 192,000 (25%) deaths and 93,000 (15%) CHEs; and improvements in MDR-TB care would avert up to 6,300 (1%) and 33,000 (6%) deaths and CHEs, respectively. Both the health and financial risk benefits would be greatest for the poorest two income quintiles. Conclusion: In Ethiopia, spending on HIV and TB care imposes a major economic burden on households. Healthcare payments for HIV and TB care have adverse impact on equitable access to health services and place the population, especially the poorest, at considerable financial risk. The universal public financing of TB and malaria control interventions saves patient lives and brings higher FRP benefits, particularly among the poorest. Therefore, the Ethiopian Government needs to focus on the universal public finance of health intervention to reduce CHE, foster equity and protect households from the financial risks posed by these diseases. Keywords: HIV, tuberculosis, malaria, economic burden, equity, catastrophic health expenditures, financial risk protection, universal health coverage, extended cost-effectiveness analysis, Ethiopia.
Består avPaper I: Financial burden of HIV and TB among patients in Ethiopia: a cross sectional survey. BMJ Open. 2020;10(6):e036892. The article is available at: https://hdl.handle.net/11250/2738349
Paper II: Assebe, L.F., Kwete, X.J., Wang, D. et al. Health gains and financial risk protection afforded by public financing of selected malaria interventions in Ethiopia: an extended cost-effectiveness analysis. Malar J 19, 41 (2020). The article is available at: https://hdl.handle.net/11250/2738360
Paper III: Mortality reduction and financial risk protection benefits of expanded TB control in Ethiopia: findings from a modelling study. (Under review in BMJ Open journal). Not available in BORA.