health care financing reform in Ethiopia

1. Introduction1.1 Country profileEthiopia is located in the northeastern segment of Africa continent, with a land mass area 1.104 million square kilometers. With a total population of 104.96 million in 2017, Ethiopia is the second most populous country in Africa, next to Nigeria (1, 3). Like many other Africa countries, Ethiopia is a country of various cultures, ethnicity, and histories. In spite of its earliest civilizations and being the only other country in the continent that was not colonized as well as one of the oldest territorially essential nation in the world (2). Source: Health status Ethiopia is characterized by a mainly rural and bankrupt population with inadequate access to clean drinking water, dwelling, basic sanitation, food and, health care service. Estimated life expectancy is 64 years for males and 65 years for females in 2017(3). Table 1: key health indicators of Ethiopia Health indicators Data Maternal mortality ratio (2015) 353 death per 100,000 live birthsNeonatal mortality rate (2017) 28.9 death per 1000 live birthsInfant mortality rate (2017) 41 death per 1000 live birthsChild mortality rate (2017) 58.5 death per 1000 live birthsHealth expenditure on share of GDP (2015) 4.09%Health expenditure per capita (2015) $24HIV prevalence (2017) 0.9%Incidence of tuberculosis (2017) 164 cases per 100,000Source: World Bank accessed online, 20171.3 Overview of health care system and financing in Ethiopia1.3.1 Public Health Care SystemEthiopians health care service is structured three-tier system with a defined catchment of populations: primary, secondary, tertiary levels (figure 1) (4). Primary health care level consists of a health center with five satellite health posts catchment population of 25,000 and followed by a primary hospital, catchment population of 60,000 to 100,000 for rural communities. For urban communities, a health center serving for 40,000 peoples (5). Health post provides preventive and promoting services staffed by two health care extension workers. Health centers are staffed by around 20 persons and provide preventive, curative and inpatients services. A primary hospital provides preventive, curative, inpatient and outpatient, blood transfusion services and emergency surgical services such as cesarean section, appendectomy and etc. staffed by around 52 persons. They also serve as a referral center for the health center and practical training for nurses, midwifery and other paramedical health care professionals(4). Secondary health care level consists of a general hospital with population coverage 1 to 1.5 million people. The general hospital provides inpatient and outpatient services and is staffed by around 235 persons (5). They also serve as a referral center for primary hospitals and educational center for health officers, emergency surgeons, nurses, midwives, and other paramedical health care professionals. Tertiary health care system consists of a specialized hospital provides inpatient services and referral center for general hospital and staffed 440 persons. They were also known as teaching hospital governed by the federal government (4). Figure 1: Ethiopia health care tier system Source: Accessed from Ethiopian Health Sector Transformation Plan, 20151.3.2 Private Health SectorThe private health sector in Ethiopia can be categorized typically into private for-profit and private for-not-profit. The private for-profit can further be subdivided into formal health service and the informal health service. The category of formal private health service includes health care providers working in hospitals, and clinics, diagnostic facilities either laboratory or imaging like CT scan, MRI and etc., drug stores at rural and urban, manufacturers of pharmaceutical health commodities and technologies and health care professional training institutions.The category of informal private health service includes: traditional healers and birth attendants, and alternative medicine or vendors of herbal drugs (5).

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