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Ethiopia

Ethiopia’s tuberculosis (TB) burden (over 314 thousand cases in 2007) ranks the country seventh in world, and this burden is exacerbated by the spread of HIV infection (980,000 cases in 2008). Health Systems 20/20 work in Ethiopia therefore focuses on issues related to these diseases, and their implications for the broader health system:

• How performance-based incentives might be used to expand and improve services in the private sector
• If financing for testing, treating, and caring for persons with TB and/or HIV can be sustained
• Who spends how much, and on which health care services
• How the Global Fund to Fight AIDS, Tuberculosis and Malaria affects the broader health system

Pay for Performance

TB is a major cause of death among people living with HIV/AIDS, and its prevalence among HIV-infected people is the main reason for Ethiopia’s failure to meet TB control targets. Despite this, HIV counseling and testing (HCT) rates are low among TB patients; in a 2005 study, only 58 percent of TB patients were willing to be tested. Even with expansion of TB DOTS and HCT service delivery into selected private for-profit facilities since 2006, the HCT rate of TB patients remains low, at 63 percent in these facilities.

Health Systems 20/20 has therefore begun a research activity to compare the effectiveness of performance-linked health worker incentives to increase HCT among TB patients at private facilities; it will look at the effectiveness of both financial and non-financial incentives. The study is being carried out in collaboration with the Miz Hasab Research Center (MHRC) and USAID’s Private Heath Sector Program and Health Sector Financing Reform/TASC3 Project. A final report on the findings will be available in late 2011.

Also regarding pay for performance (P4P), the Health Systems 20/20 maternal and child health (MCH) P4P case study series includes a report on the design of and challenges to the Federal Ministry of Health’s P4P strategy to improve MCH, HIV, TB, and other health outcome indicators and thereby achieve Millennium Development Goals and Health Sector Development Plan targets. Read the case study.

Financial Sustainability of Health Expenditure

Health Systems 20/20 is carrying out a financial sustainability analysis of Ethiopia’s national HIV/AIDS program, using the project’s HIV/AIDS Sustainability Analysis Tool (HAPSAT). Staff from PEPFAR and USAID/Ethiopia and other donors, HIV/AIDS programs, NGOs, and government agencies contributed to the policy questions and alternative policy scenarios that the HAPSAT analysis studied. The Ethiopia Federal HIV/AIDS Prevention and Control Office is reviewing the HAPSAT report.

As a result of its HAPSAT work, Health Systems 20/20 costed Ethiopia’s HIV/AIDS Strategic Plan (SPM-II). The project team worked with groups to identify specific activities under the SPM; for example, with the Adult ART (antiretroviral treatment) Technical Working Group, it determined ART drug regimens based on the adult patient’s CD-4 count.

Health Systems 20/20 experts contributed to Ethiopia’s National Health Accounts estimation, which included subaccounts on HIV/AIDS, TB, reproductive health, child health, malaria, and health information systems; a report of the findings was produced by the Private Heath Sector Program.

System-wide Effects of the Fund

Health Systems 20/20 is looking at the health system-wide effects of the Global Fund (SWEF). The study is a follow-up to the SWEF studies done in 2004 and 2006 by the USAID Partners for Health Reformplus project. Initial findings suggest that the Global Fund has played a significant role in Ethiopia’s health system by addressing policy and program constraints, human resource issues, management systems, and logistics and supply systems, as well as fostered a positive relationship between the public and private sectors. A final report on the findings is expected in late 2010.