Defining the Ethiopian Essential Health Service Package : Process, methods and cost-effectiveness evidence for the prioritisation of health interventions

Abstract

Background: All countries have signed up to the United Nations (UN) Sustainable Development Goals (SDGs), including Target 3.8 on achieving universal health coverage (UHC). UHC is realised when everyone has access to quality essential health services with financial risk protection. Countries should, therefore, measure and track their progress towards UHC over time and take appropriate action. Defining an essential health service package (EHSP) is the first and crucial step towards UHC progress. In defining an EHSP, counties identify the type and mix of health services that respond to their populations’ needs. However, there are gaps in evidence regarding Ethiopia’s current UHC status, and it had been more than 15 years since the EHSP was defined in Ethiopia. Furthermore, there is relatively little national cost-effectiveness evidence available to redefine the EHSP in Ethiopia. Therefore, this study aimed to estimate Ethiopia’s UHC service coverage status, generate relevant cost-effectiveness evidence and synthesise and describe the methods, process and key features of the revised Ethiopian EHSP.

Methods: This thesis consists of three studies. In Paper I, 16 individual tracer indicators that measure a health system’s performance in various domains were selected to measure UHC service coverage in Ethiopia. We grouped the tracer indicators into four major programme areas (i.e., reproductive maternal neonatal child health [RMNCH], infectious disease, noncommunicable disease [NCD] and capacity and access), and we constructed an overall UHC service coverage index using geometric means. We also estimated the subnational level of UHC service coverage. In this paper, various surveys and routinely collected administrative data were used. In Paper II, we employed a standardised WHO- CHOICE generalised cost-effectiveness analysis (GCEA) methodology. Average cost- effectiveness ratios (ACERs) for 159 health interventions were calculated. The health benefits of interventions were determined using healthy life years (HLYs) gained. The economic costs of interventions were estimated from the health system perspective. We used the OneHealth tool for data analysis. In the third paper (Paper III), we synthesised and described the methods, process and critical features of the 2019 EHSP. A total of 35consultative workshops were convened with experts and the public to define the revision’s scope, develop a list of health interventions, agree on the prioritisation criteria, gather evidence and compare health interventions. Seven prioritisation criteria were employed: disease burden, cost effectiveness, equity, financial risk protection, budget impact, public acceptability and political acceptability. Results: The overall UHC service coverage for Ethiopia in 2015 was 34.3%, ranging from the highest (52.2%) in Addis Ababa to the lowest (10%) in Afar. The programme area coverage varied from about 53% for infectious diseases to 20% for capacity and access (Paper I).

In Paper II, we found ACERs ranging from less than US$1 per HLY gained for family planning intervention to about USD 48,000 for colorectal cancer treatment at stage 4. About 75% of all interventions evaluated had ACERs of less than USD 1,000 per HLY gained. The majority (95%) of RMNCH and infectious disease interventions had an ACER of less than USD 1,000 per HLY while around half of interventions (44%) targeting NCDs had an ACER of less than USD 1,000 per HLY.

In Paper III (EHSP revision process), 1,749 interventions were identified in the first phase. These interventions were regrouped and reorganised, and 1,442 interventions were identified as possible candidates for the EHSP. In the second phase, we removed interventions that did not match the burden of disease or were not relevant in the Ethiopian setting, and, therefore, the number of EHSP intervention was reduced to 1,018. We then evaluated and ranked the interventions by the other six criteria. In the final EHSP, 594 (58%) interventions were classified as high priority, 213 (21%) as medium priority and 211 (21%) as low priority. The current policy is to provide 56% of interventions free of charge and to ensure 38% on cost-sharing and 6% on cost-recovery arrangements. Conclusions: In conclusion, the baseline (2015) UHC service coverage index for Ethiopia was low. Furthermore, several potential cost-effective interventions were available that could substantially reduce Ethiopia’s disease burden if scaled up. The revision of Ethiopia’s EHSP followed a comprehensive, participatory, inclusive and evidence-based process, and the EHSP interventions were linked to appropriate health care delivery platforms and financing mechanisms.