Table 3 Successes, contributions and challenges of healthcare financing towards UHC in Ethiopia, 2021
HCF functions | Reforms | Successes | Contributions | Challenges |
|---|---|---|---|---|
Revenue generation | Revenue retention and utilisation | •Retain revenue is an additive to the government health budgets with major sources of revenue including: sale of drugs and other medical supplies, fees for consultation, non-medical services [26] | •Lack of training for governing bodies, slow decision-making, inadequate financial skills by health facility staff, and difficulty interpreting the guidelines [26] •Weak monitoring and evaluation system to conduct regular auditing and make corrective measures [11] | |
Private wing in public hospitals | •Offer additional income for health facilities [27] | •Generate additional income for health facilities [28,29,30] | •Low client satisfaction is associated with their expectations and high payments [31, 32] | |
Health insurance | •Mobilise financial resources, increasing revenue generation [33,34,35] | •Options to generate sustainable resources for health sectors [11, 36] | •Low awareness and costs of premium collection in relation with scattered settlement of agricultural households and mobility of the pastoralists [11, 13, 37] •Low enrolment rates, high dropouts and weak premium collection for the scheme were additional barriers to CBHI resource mobilisation at the community level [11, 38] | |
Health facility governance autonomy | •Boards facilitate linkage with the community and advocate increasing resource mobilisation for facilities and solving local problems [39] | •Limited capacities in knowledge and skills for planning, implementing and monitoring health financing [11] | ||
Risk pooling /sharing | User fee settings and revisions | •Promotes cost-sharing between the Government and users considering the community’s willingness, ability to pay and cost of services [27] | •Affordable fees and some sort of subsidy by the Government enhance access to health care [11] | •Variations in regional laws in terms of mandating the user fee revisions and settings. For instance, the mandate of user fee revisions and settings in Amhara and Oromia gave to the regional council by the regional Government. At the same time, SNNP allowed health facilities to introduce user fee revisions [11, 26, 27] •Discrepancy in adherence to regional legislation was another challenge. For example, the regional law gave the mandate of user fee revision to the regional council in the Amhara region, but some health facilities revised user fees on their own [27] |
Health insurance | •Health insurance helps the population with special assistance mechanisms for those who cannot afford to pay [11] •Helps risk pooling and social solidarity for the non-predicted illness [40, 41] | •Contribute to financial risk protection to the users [11, 36] •Contribute to protecting rural dwellers from facing financial hardship to achieve UHC [42] •Contributed to increasing financial risk protection and ensuring UHC for all [43, 44] •Reduce out-of-pocket expenditure (OOP), which increases protection from catastrophic health expenditure [33,34,35] •Establish financial protection equitably and sustainably for all citizens [29] •Enhance healthcare access and reduce the burden of OOP expenditure as a means of achieving UHC [14, 45] | •Low quality health service; long bureaucracy in reimbursement for institutions and high burden of payroll contributions for SHI [13] •Under coverage of the poor [11] •Unable to pay the premium; inadequate benefit packages; and preference for OOP payment [46] •Voluntary participation in the CBHI scheme results in adverse selection. For instance, households with chronic diseases within their family members purposely enrolled on the CBHI scheme associated with their disease status [47] •Premium load for CBHI is only decided based on family size without considering their income level [48] •High premium contribution, unclear benefit packages, high cost of living and burden of other deductions from salary for SHI [49, 50] •High SHI contribution might lead us to further crisis and illness associated with being unable to wear clean clothes and eat right [49] •Low contract renewal rate related to the inability to afford the premiums and expected returns from the insurance [51, 52] •Free health care services for healthcare providers from their employer health care institution [53] | |
Strategic purchasing of services | Revenue retention and utilisation | •Increase resource availability for service provision [11] •Use of retained revenue for procurement of drugs and medical supplies, and oversight implementation [27] | •Improve infrastructures, utilities, procure medical equipment, supplies, medical supplies, drugs, information systems, management procedures, and training to enhance services quality [26, 29, 54] •Avail of essential medicines; reduce stock-outs of essential drugs; improve the diagnostic capacity of health facilities; maintain continual quality of care; improve water supply, electricity to health facilities; and health infrastructures [27, 54] | •Lack of understanding of the working procedures and fear of accountability led health facilities to be reluctant to use the retained revenues. This led to health facilities being reluctant to use the retained revenues and demonstrated the loss of efficiency in health service delivery [11] |
Systematising fee-waivers | •Provide free of charge to the poorest segments of the population to access the full range of health services [29] | •Access free health care for poor households [27] •Contribute to increasing financial protection and ensuring UHC for all in Ethiopia [43] •Reduce inequities in access to health care services [29] •Increase healthcare service utilisation for the poor [55] | •Shortage of drugs and procedures in a public health facility; and fee waiver certificate restricted or valid only in a single health facility precludes the use of services for the users [56] •Under-coverage of the poorest; inclusion of those able to pay; and delay or non-reimbursement of costs to health facilities [11] •High non-medical costs, referral to a higher-level facilities, and health care costs including transportation, lodging, food, and opportunity costs [56] •Provision of identification cards during emergency cases may create a loophole for abuse as it is out of schedule [57] •Lack of adequate training on procedures of fee waivers [58] •Lack of consistency and common understanding of selection criteria [57, 58] •Guideline did not verify the income in proportion to the family size [57, 58] •Renewing the waiver card without revising their current economic status resulted in the non-poor receiving benefit intended for the poor [58] •Guideline only considered the income of the family, not their expense for basic needs. For instance, the guideline excluded households with seven members and got ETB 400 per month because of the income. On the other hand, households with four members and earned ETB 300 per month were eligible regardless of the income generated by the family members [57] •Healthcare inequality between fee waivers and cash payers did not protect the poor from financial hardship [58] •Unfair criteria since the criteria could not consider households who had chronic disease family member/s [58] •Absence of a clear income level cut-off for granting fee waivers [59] | |
Standardised exemption services | •Provide a package of services free of charge to all citizens through exemptions from fees for certain critical public health services to enhance equity [29] •Provide exempted services include: TB and leprosy diagnosis and treatment; antenatal care; delivery, postnatal care, family planning, leprosy, HIV care, treatment for malaria, immunisation services; HIV/AIDS diagnosis, care and support; and epidemics [11, 60] | •Private health facilities charged for such exempted services to cover the health worker’s time [11] •Shortage of drugs and medical supplies, absence of clear guidance, incurred additional costs, and inadequate support from the Government and NGOs to provide exempted health services [27] •Some health facilities charged for delivery-related services and supplies, such as laboratory services, gloves, glucose, and some drugs, were the challenges in implementing exempted healthcare services [27] | ||
Private wing in public hospitals | •Offer more choices of services to the users [27] | •Raise motivation of medical professionals; staffs’ sense of hospitals ownership; decline the turnover rate, provide alternative services and improve quality of health services through avail infrastructures and additional investment in staff training [28,29,30] | •There is no reward for staff based on performance, equity-related complaints on payment, and low knowledge about private wings medical service seekers as alternative options [28] •Poor health care services, access, physical facility, provider behaviors, high expectation and long travel time [61] •Affect work performance of professionals associated with their participation [62] | |
Outsourcing of non-clinical services | •Encourages public hospitals to outsource non-clinical services such as laundry, security, and catering by contracting with local vendors that have a comparative advantage in providing these services assisted the hospital in improving its efficiency and reducing the burden on hospital management teams [29] | •Helps to improve efficiency, reduce costs, and enable health facilities to focus on their core clinical services [27] •Controlled cost, reduced the internal administrative burden, increased the effectiveness and quality of the outsourced services [63] | •Conflicts between the hospitals and service providers regarding the quality of non-clinical services, poor specification in the contract, managing the price variations over the life of the contract agreement; and increases in input prices for the cost of the outsourced services were the challenges in implementing outsourcing of non-clinical services [63] •Absence of competitive vendors, limited internal capacity to prepare technically feasible contracts, weak record-keeping and data management systems by hospitals prevented hospitals from documenting the overall achievements, cost–benefit gains and losses from outsourcing [63] | |
Health insurance | •Health insurance improves healthcare delivery [11] •Improve access to health care for all citizens [29] •Reduce inequalities in access to basic health care services [11, 36] •Contribute to essential drugs and good perception of quality of care and treatment choice [64, 65] •Increase utilisation of health-care services [40, 41] and improve quality of life [66] •Enhance healthcare access to achieve UHC [14, 45] •Guarantee dwellers of rural areas access to quality health services and achieve UHC [42] •Enhance access to health care and improve health care quality, increasing healthcare utilisation and patient satisfaction [33,34,35] | •Service disparity between cash payers and insurance users; low-quality health services; inadequate equipment and staff; lack of trained personnel; adverse selection; moral hazard; fraud and corruption [13] •Health facilities are unable to fulfil the criteria to provide healthcare services for insurance beneficiaries [67] •Demands extraordinary drugs; tend to collect more drugs; giving their card to non-insured, and frequent health facility visits were the clients' side moral hazard practices [68] •Overestimating the cost of services to CBHI members, occasional charges of undelivered insurance services, and health providers insulting service users were also the moral hazard of service providers [68] •Exclusion of family members above 18 years did not consider the society’s real situation [49] •Low awareness, low benefits packages, poor perception of quality of services and lack of trust of the management [69,70,71,72] | ||
Health facility governance autonomy | •Existence of clear action plans, national scope of implementation, and regulatory frameworks facilitated HCF [73] •Improve health service quality, introduce accountability and transparency mechanisms [26] | •Ensure facilities' HCF implementation is efficient and effective [29] •Instrumental to improve health facility performance [39] •Allocate resources, bridge performance and improve quality to achieve better health outcomes [74] | •Absenteeism, inappropriate delegation, and lack of adequate priority, capacity, and confusion on the governing body's role [26] |