Development aid and health equity in Ethiopia

ABSTRACT

In recent decades, Ethiopia has been a major recipient of development aid and made considerable progress towards achieving development outcomes, particularly in the health sector. Central to this has been reforms prioritizing community-based health interventions and a commitment to attaining universal health coverage (UHC). Yet while encouraging, access to health services has tended to disproportionately benefit those with greater economic means, higher levels of education, or those residing in urban areas. In light of this, the current article examines the progress towards UHC and donor organizations’ perceptions of how development aid intersects with issues of health equity in Ethiopia. Using primary qualitative interviews with bilateral and multilateral donor organizations and a review of relevant policy documents, we consider how issues of equity in health coverage are understood and reflected in the positions of donors. In doing so, we shed light on the processes underlying and shaping donor actions in supporting progress towards achieving equitable and universal health coverage in Ethiopia and identify challenges that remain.

KEYWORDS:

• Development aid
• health
• universal health coverage
• Ethiopia
• equity
• health equity

1. Introduction

Inequitable access to healthcare is a fundamental development and human rights issue (Braveman and Gruskin 2003b; WHO 2008) and global policy agendas such as the Sustainable Development Goals (SDGs) have converged around the need to address health equity (Marmot and Bell 2018). While the earlier Millennium Development Goals (MDGs) lifted millions out of poverty, they also prioritized economic growth and poverty reduction over issues of inequality (Saith 2006; Fischer 2010, 2012). Tackling issues of equity and inequalities was seen to have been considerably under-represented and that ‘a new, ninth (MDG) Goal need(ed) to be added – to reduce inequality’ (Fukuda-Parr 2010, 34). In response, the inclusion of SDG Goal 10 focused on reducing inequality within and among countries, reflecting a shift that is beginning to change ‘well-established understandings of development’ and may result in ‘changes to the way “development” is conceptualized’ (Freistein and Mahlert 2016, 2040).

The increased attention to equity concerns as constituent aspects of development agendas is central to health-related global development goals. The 2005 Assembly meeting of the World Health Organization introduced the landmark resolution on Sustainable Health Financing, Universal Coverage and Social Health Insurance (WHO 2005), which urged states to work towards providing Universal Health Coverage (UHC) to its citizens. The central premise of UHC is that healthcare and medical services are available to all citizens who require them, without recipients suffering financial hardship and now forms a central focus of global health and development policy.¹ In Ethiopia, health service extension has been a priority (Assefa et al. 2017) and considerable strides have been made towards attaining UHC despite numerous challenges remaining (Assefa et al. 2019). While the country’s Health Sector Transformation Plan (HSTP) has committed to ‘equal access to essential health services, equal utilization [by] equal need, and equal quality of care for all’ (FMOH 2015, 14), unequal and inequitable health access and coverage persist (Woldemichael et al. 2019a, 2019b).

In examining health equity in Ethiopia, it is first necessary to distinguish between health equity and health equality. While similar concepts, health inequalities refer to measurable differences in health outcomes between different groups – such as life expectancy. These inequalities need not necessarily however be inequitable – as certain populations may be more or less prone to different health conditions. Rather, our focus is on health equity which includes social justice dimensions where the right or access to healthcare should be equitable such that there is an ‘absence of avoidable, unfair, or remediable differences in health among subgroups of a population’ (Bergen et al. 2019, 1). As others, we consider health equity to therefore relate to the processes that govern the distribution of resources which can either reduce or exacerbate unjust differences or inequalities in health access or health outcomes between different groups (Whitehead 1991; Braveman and Gruskin 2003a).

How then has Ethiopia’s trajectory towards Universal Health Coverage intersected with equitable extension of health services? This article examines how the evolution of equity concerns in development agendas is translating into donor priorities, actions and activities in the Ethiopian health sector. Drawing on semi-structured interviews from key informants at bilateral and multilateral donors and supported by document analysis, we examine donor perceptions on Ethiopia’s health sector progress and how issues of health equity are being operationalized by donor organizations. Our results suggest that donor views on issues of health equity vary considerably, and while there is recognition of progress in the sector, financial and bureaucratic constraints are seen to limit more equitable extension of health services in the country.

The article proceeds as follows: In Section 2 we outline briefly the Ethiopian health sector context and progress towards UHC as well as important donor and Government of Ethiopia (GoE) health sector initiatives. In Section 3 we outline our methodology and Section 4 presents our analysis and lays out some of the key emerging findings and narratives. Section 5 presents a discussion of key issues and concludes.

2. Healthcare and equity in Ethiopia

2.1. Healthcare progress and policy

Ethiopia is the second most populous African country with a population of approximately 115 million inhabitants. While one of the fastest growing economies in Sub Saharan Africa, Ethiopia still has a largely rural population and persistently low levels of development as measured by GDP per capita. Yet Ethiopia has made major commitments to improving the health sector, with considerable reforms in the past two decades. In 2003, the GoE introduced the Health Extension Program (HEP) designed to improve health access and quality through targeted interventions at the household and community level (FMOH 2005). This has focused on women’s health – particularly maternal and child healthcare, HIV/AIDS, Malaria, and Tuberculosis prevention and recorded considerable successes (e.g. IHP+ Results 2016).

The results have been notable. Indicators including life expectancy, immunization rates, breastfeeding rates, contraception use, and skilled birth delivery have markedly improved in the aggregate in the past two decades (FMOH 2010; Wang and Ramana 2014; CSA and ICF International 2012; Ethiopian Health and Nutrition Research Institute and Partners 2012). Other indicators have shown similar improvements. The total fertility rate declined from 7.7 in 1990 to 4.6 in 2015; the maternal mortality ratio fell 71% between 1990 and 2016; access to piped water increased from 18% in 2000 to 88% in 2015; immunization rates increased from 21% in 2000 to 54% in 2015; skilled birth attendance rates increased from 6% in 2000 to 28% in 2015; births at health facilities (excluding health posts) increased from 5% in 2000 to 26% in 2016; unmet needs for family planning (of married women) declined from 37% in 2000 to 22% in 2016; and the number of health posts, health centers, hospitals, physicians and health financing increased significantly (CSA and ICF 2016; Tadesse et al. 2013; CSA and ICF International 2012).

These results have emerged from a comprehensive approach to healthcare extension. This has centered around the GoE’s flagship HEP designed to deliver health services through community-based interventions on basic health care delivery and behavioral change and supported by community Health Extension Workers (HEWs).² As a core component of the broader health system, the HEP is a defined package of basic and essential promotive, preventive and selected high impact health services designed to improve the health status of households at the community level. This relies on a guiding philosophy that households are able to take responsibility in producing and maintaining their own health where they are provided with appropriate knowledge, skills and capacities regarding healthy practices and appropriate care-seeking behaviors (Wang and Ramana 2014).

The HEP was rolled out in all areas of the country through the training and deployment of 30,000 HEWs responsible for providing outreach services. Focusing on the kebele, the smallest administrative unit that on average has about 5000 people, HEPs are located in a Health Post which is the operational center for two HEWs. Health departments at Federal, Regional, and woreda (district) levels are responsible for supervising HEWs, with the latter linked to Voluntary Community Health Workers (VCHW) that further support health knowledge and skill sharing at the household level. While interventions focus on households and communities, the program requires coordinated action across levels of governance, with larger administrative units providing referral care, technical and practical support to HEPs at the kebele level (Damtew 2013). This decentralized approach to health care delivery sees the GOE covering the curriculum development, training and salaries of HEWs through block grants to regions and woredas, making HEWs civil servants with defined career paths (Wang and Ramana 2014; Wang et al. 2016). External support from donors has also been central to the HEP, earmarked for building health posts, procuring equipment commodities and supplies, and training and capacity building.

2.2. Health equity in Ethiopia

The GoE has guided the overall direction and implementation of health sector reforms in the past two decades (Teshome and Hoebink 2018). The HEP has been a broadly successful core health initiative providing primary health care services in both in rural and urban areas by strengthening community ownership, participation and capacity building. Moreover, it plays important roles in promoting gender equality in accessing health services and helps bridge the gap between communities and health facilities by improving the utilization of health services in the periphery (Jackson and Hailemariam 2016).

The HEP has also made considerable progress towards UHC by narrowing gaps in health care provision between urban and rural areas, between geographic regions in the country and between socioeconomic groups by implementing comprehensive, multi-sectoral and targeted interventions aimed at benefitting the marginalized populations. As a result, the HEP has been at least somewhat successful at beginning to address issues of equity in the health sector. Tranvåg, Ali, and Norheim (2013), for instance, note that the distribution of health service delivery in Ethiopia is more equal in 2011 than it was in 2000. Yet while the coverage and quality of health services have risen in the past two decades – and have sought to address equity concerns by targeting interventions at marginalized populations – considerable health inequalities still exist (Wagstaff et al. 2016). State-level and regional differences in health service delivery and the progress on sectoral reforms are notable; rural-urban differences are striking (Woldemichael et al. 2019a; Oh 2019); and health extension workers and managers themselves recognize persistent health inequities related to the geography of health service delivery (Bergen et al. 2019). Further, household wealth-status, maternal and paternal education, and religion have also been found to be associated with the systematic differences in the use of child health services (Ayalneh, Fetene, and Jin 2017).

Thus, while health extensions have reduced health inequality gaps where mass outreach or targeting campaigns have achieved significant scale effects and rapid positive changes for poorer populations, coverage gaps may persist or worsen where access to skilled healthcare workers or health facilities may be unequally accessible or resources inequitably distributed (Wagstaff et al. 2016; Victora et al. 2012). This issue of inequitable access to skilled health care services is reflected in a recent 24 country study by McKinnon et al. (2014) who find that inequalities (based on differences in income and education level) in neonatal mortality rates actually increased in Ethiopia. Similarly, even within the well-served capital of Addis Ababa, Mirkuzie finds that despite ‘fairly equitable access to antenatal care, infant immunization, universal health coverage and free access to maternal and newborn care’, inequalities persist among resident and migrant women in accessing skilled birth attendant and postpartum care (2014, 110). Yesuf and Calderon-Margalit (2013) also show considerable disparities in the use of antenatal care between urban-rural locations, income levels and educational levels. Likewise, Wilunda et al. (2013) demonstrate that access to emergency obstetric care is overwhelmingly skewed towards urban dwellers and higher income groups with the richest quintile comprising 70% of users while the bottom 40% representing less than 1%. They find similar results for Ethiopia in a multi-country study of Tanzania, Ethiopia and Uganda where ‘stark inequities in utilization of institutional delivery care were present in all districts and across all health facilities’, and that there were ‘serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts’ (Wilunda et al. 2015, 2).

Broadly then, while the HEP and other activities have proved to be highly successful at improving quality of health care, a persistent issue in Ethiopia is that of inequitable access to healthcare services for different groups or individuals (Workie and Ramana 2013; Berhane 2015). Considerable disparities exist between geographic regions, urban and rural areas and socioeconomic groups, and health financing mechanisms such as household out-of-pocket expenditures further sharpens inequitable access to health services. While health expenditure (as a percentage of total government expenditure) increased from 3% in 1995 to 4.9% in 2014, this remains far below the African Union’s 2001 Abuja Declaration to allocate at least 15% of their annuals budget to the health sector (Assefa et al. 2017). And even despite the precipitous rise in Ethiopia’s per capita health expenditure from US$ 4.50 in 1995 to US$ 26.70 in 2014, it remains far below the US$ 35 (2001) and US$ 60 (2014) recommended by the WHO that is required to deliver essential healthcare services in low-income countries (Assefa et al. 2017).

2.3. The role of donors

Development aid and donor organizations play important roles in supporting the HEP under the management of the GoE; and the goals of equity and a universally inclusive agenda for health. Donors appear acutely aware of the challenges related to both health coverage and health equity, including the high degree of reliance of the GoE on donor support for health financing and relatively high levels of aid fragmentation (Teshome and Hoebink 2018). The WHO has observed geographical disparities in health coverage, noting how predominantly urban regions tend to have greater health budget allocations per capita than their predominantly rural counterparts (WHO 2002). These disparities between urban and rural areas are reflected by the limited number of (rural) health institutions, poor distribution of medical supplies and relative inaccessibility of health care services for rural populations. The UNDP notes the presence of both within and between group health inequalities in the country, and while these have declined over time, reiterate the need to address these. According to the UNDP, this requires ‘a concerted effort to identify factors beyond wealth that might be behind health inequality in the country’ – including the inequitable distribution of health facility provision across the country (UNDP 2015, 11).

Given both the broader focus on the health sector and concerns about health equity, donors have contributed substantial financial and technical support to the GoE. Growing out of the World Bank’s Protection/Promotion of Basic Services (PBS) program in 2005/2006, support to the health sector has since developed into a multi-donor program that is a key source of financing for basic health service provisioning and support for local government capacity to manage and deliver health services (Wang and Ramana 2014). The United States Agency for International Development (USAID), for instance, has supported community-based health insurance (CBHI) programs, which provides participants with hospital and clinical care and other health services coverage and covers expenses ‘which otherwise could create financial ruin or leave someone between life and death’ (USAID 2018: online). Furthermore, CBHI registration fees see revenues invested to renovate health facilities, procure medical equipment and improve the quality of care provided (USAID 2018).

3. Methodology

This article aims to understand how donors perceive the progress and challenges in the Ethiopian health sector and how donors operate to support the equitable healthcare delivery. Our focus is on donor perspectives surrounding three key themes relevant to the current Ethiopian context. First, how issues of equity are understood and internalized by donors. Second, how issues of health equity shape donor policy and programming. And third, the successes of these approaches and the challenges that remain.

To examine this, we use a qualitative research design that relies on primary data gathered from semi-structured key informant interviews. These were supported by a review of selected donors’ strategic documents and reports on activities in the health sector in Ethiopia. Our primary data was collected from interviews among senior health sector staff at 10 bilateral and multilateral agencies, each of who have a significant presence operating in the Ethiopian health sector. We accessed the majority of the key bilateral and multilateral organizations operating in the sector, and individuals we interviewed were in senior positions with considerable experience and knowledge of both their own policy priorities and the terrain of the Ethiopian health sector more broadly. While we cannot ensure this captures the full range of viewpoints of all donors in this sector, donor perspectives converged in several key areas across our interviews, suggesting that they are at the least broadly illustrative of how donors perceive their engagement in supporting the health sector.

Interviews were conducted between November 2018 and February 2019 and used a systematic semi-structured interview guide across all interviews. These were carried out in person, via telephone and via written correspondence as required, with repeat or follow up interviews carried out where necessary. Our questions addressed several key dimensions of inquiry, including donor perceptions of Ethiopia’s progress in health reform and extension; progress towards universal health coverage; key health sector challenges; donors’ strategic approaches to promoting health equity; and issues of donor coordination and alignment.

Interviews and notes were transcribed and coded manually using a qualitative coding matrix.³ We initially developed a set of thematic dimensions and provisional codes that derived from our interview questions, and mapped interviewee responses onto relevant dimensions (see e.g. Miles and Huberman 1994). In addition, while we developed initial codes from our key questions and dimensions, we also allowed new codes to emerge from the interview data where relevant. In this way, our approach is both structured and partly grounded, in the sense that we do not seek to support or reject a priori hypotheses, but rather allow our findings to be guided from both our key dimensions of interest and the responses of interviewees.

In reviewing and coding transcripts, key phrases from interviews were linked to relevant codes, and aggregated into categories using a qualitative coding matrix that allowed higher level themes to emerge. This approach enabled data to be triangulated across interviews and permitted a structured qualitative comparison and synthesis of key dimensions of our inquiry across donor organizations. In reporting our findings in the analysis section below, we include select quoted passages that were representative of perspectives of multiple donors.⁴ This allows us to present nuanced and indicative donor viewpoints on how health equity is being conceptualized and enacted in development policy and how it intersects with the challenges and opportunities in the Ethiopian health sector.

4. Analysis

4.1. Health sector progress and perceptions of health equity

Across our interviews, donors broadly acknowledged that there had been positive progress made in health sector over the past 15 years. Yet they also shared differing perceptions of how much progress had been made, and the work left to do. Generally, the HEP was seen to have had a positive effect in extending access to healthcare in a more equitable way. One donor stated that:

The HEP has been instrumental for the success achieved to meet the goals stipulated under the Millennium Development Goals (MDGs) … Moreover, the health services provided by the HEWs are free of charge and directly available to the community ensuring equity for all.⁵

Another was highly supportive, stating that their overall perceptions were ‘positive, (that) indicators are looking good, and things are going well in (both) rural and urban areas due to contributions made by the donors related to the SDG pooled fund to the Ministry of Health’,⁶ From this perspective, the overall impression was that ‘the work on the ground is fine except for a few things that need to be corrected’.⁷

This perspective was contrary to several other donors who had a more balanced or cautious view of the extent of progress achieved. One suggested that ‘achievements have been made and (yet) there are also gaps that call for further actions’.⁸ Another donor cited challenges surrounding the uptake in healthcare use among beneficiary populations. They stated that ‘in general, the use of HEP key services is limited’, but also reiterated that ‘its fee free service and focus on preventive care are useful in bringing about some level of equity’.⁹ While there was a general agreement that HEP and broader health initiatives had made positive inroads into delivering more equitable health coverage, several donors acknowledged that serious inequities remained related to wealth, poverty, geography (such as urban/rural and regional differences), gender and disability, and among pastoral and agrarian communities. The most prevalent concerns were perceived to exist between rural and urban areas; and pastoralist and agrarian communities were unanimously seen to be underserved whereby ‘cultural or religious factors seem to be significant determinants of inequalities’.¹⁰

A further narrative emerging from donors was that the commitment of the GoE and the Ministry of Health to extend healthcare services in an equitable fashion was not a primary concern. Instead, the relatively weak implementation and oversight of planning was identified as a key impediment to more equitable coverage in the health sector. Despite the focus of the HEP in extending services to more excluded rural communities, one donor expressed that: ‘implementation tends to be weakest in areas of greatest need’.¹¹

4.2. Challenges to equitable health care

Many of the issues related to implementation of government health policy were noted in relation to the challenges to achieving equitable health coverage. Several donors suggested the policies of the GoE and commitments to reduced inequities were ‘adequate’, ‘fine’ or ‘well situated’ to move equitable health provision forward.¹² One donor noted that:

Ethiopia’s health sector on the whole is quite efficient in using its limited resources to deliver health services and improve health outcomes, however overall consistency in quality across the regions is still a challenge.¹³

Despite this, aggregate level financing was seen as a particular challenge, and many donors viewed the GoE as not devoting sufficient financial resources to the sector or allocating them in a transparent way. As indicated by one interviewee, the ‘GoE needs to allocate a higher percentage of its own resources to health and manage all resources in ways that are transparent and accountable’.¹⁴ This resonates with several donor comments about more serious impediments related to capacity (‘uneven distribution of capacity, including administrative and managerial staff as well as health workers’), financing (‘the Ethiopian health sector as a whole is under-funded’) and bureaucratic issues (‘there is a serious problem of underutilization of financial resources due mainly to bureaucratic processes that take long time and consume a lot of paper’).¹⁵ Such constraints were considered to have undermined the implementation of what were seen to be reasonably well designed and well-intentioned health policies and goals that had a focus on mitigating inequalities and extending equitable healthcare delivery.

As a sort of synthesis of the above concerns, one donor offered an overarching critique of financing, capacity and managerial shortcomings that encapsulate many of the perceptions that donors had of the current state of the sector. The donor noted that:

our perception, by experience, (is) that in many parts of Ethiopia (there are) regional disparities in infrastructure, medical equipment and drugs supplies – either shortages or inadequate provision – a lack of amenities such as power and water, lack and unequal distribution of qualified health personnel, with a weak capacity for managing, and supervising human resources. In addition, a lack of evidence based annual planning and weak financial management are common.¹⁶

Regarding government actions to improve health equity, several issues were commonly suggested by donors. These included: (i) greater budgetary allocation of GoE resources to the health sector; (ii) health policy formulation that focused more attention on the development of strategic plans and greater harmonization and alignment within the sector; and (iii) greater financial accountability and good management practices such that resources are managed in ways that are transparent and accountable. Beyond these issues, donors also raised cautions against relying entirely on quantitative indicators when carrying out needs assessments and selecting priority areas for investment. One donor presented a nuanced response that suggested an approach attentive to a more multidimensional understanding of exclusion and inequity:

In general, one can argue that equity may not work on blanket criteria basis simply because there are locally based unique factors that require particular contextualization to avoid averages that mask local grassroots features. In this regard, equity becomes a sensitive issue that needs a ‘political decision’ by looking at qualitative facts which are beyond the figures produced through cost-benefit analysis or cost-effectiveness analysis.¹⁷

4.3. Progress towards universal health coverage

Recent discussions in the Ministry of Health have focused on the extension of the HEP with what is termed the HEP Optimization policy. This aims to significantly increase the number of HEWs working under the HEP, increase the geographical coverage of the program, and vastly improve the positive health impacts that result. As the HEP is a central health policy agenda of the GoE to achieve UHC, some donors considered this positively (while still readily noting the challenges involved), reiterating that ‘(they have) the impression that this is the right direction to move to attain government’s planned UHC by 2030 framed upon the Almata Declaration’.¹⁸ Yet issues of financing, capacity, and implementation of policy were seen as critical areas to address, and some donors expressed severe concerns as to whether UHC could even be seen as a realistic goal at all.

In this context two key issues emerged. First, the financing situation of the health sector was seen as problematic, in terms of both GoE and donor commitments. On one hand, concern was expressed that the GoE was not willing or able to finance the health sector adequately and was substantially missing on its funding targets. Moreover, donor contributions to the health sector were seen to be falling, both as a result of restrictions in overall donor budgets; and the broader reduction of support to Ethiopia due to the country’s strong economic growth (and by extension perceived relative reduction in need). One donor stated that:

Because of the observation of the country’s economic growth, multilateral organizations have begun fund reduction while still there are huge financial gaps. This is critical since the country is not in a comfortable position to provide full finance for the health system.¹⁹

These financial circumstances were seen as considerably problematic for the long-term prospects of the health sector. Another donor noted:

The global financial landscape is changing and hence the contribution of donors is dwindling. On the other hand, there are various health demands and a large population (in Ethiopia) that requires healthcare services in a varied geography. So, there is no question that available resources and financing are not adequate to make health services as good as possible despite the efforts made. The Abuja Declaration … couldn’t be met and innovative (domestic) financing (mechanisms) are not (being) attempted.²⁰

A second challenge related to furthering progress on UHC that was raised by donors was related to priority areas for intervention. In particular, it was emphasized how the goals of UHC may be undermined by the GoE’s shift towards allocating a greater proportion of healthcare budgets and investment toward secondary and tertiary healthcare at the expense of primary healthcare. This was seen as ‘compromising service availability on primary healthcare’ and ‘contradict(ing) the very ideals of HEP’, and thus required ‘strong monitoring to guide investment and budgeting, which is weak at present’.²¹

This perceived ‘misallocation’ of financing away from primary care (in combination with donors own funding reductions) was seen by donors to potentially exacerbate the already excessive out of pocket (OOP) healthcare expenditures that can lead to greater healthcare burdens on the poor and extreme poor (that HEP is actually designed to alleviate). This ultimately was seen to undermine the equitable extension of primary health care, reallocating funds in a way that reduces the ability for the country to achieve UHC. One donor noted that this could lead to more ‘catastrophic expenditure that pushes households into poverty’, and that ‘under such circumstances, UHC can hardly be achieved in Ethiopia’.²²

4.4. Health, inequities and donor action

In light of the progress and challenges related to Ethiopia’s HEP and goals of attaining equitable healthcare and ultimately achieving UHC how do donors see their own actions in this context? Emerging from our interviews, there were a range of approaches that donors took as relates to health equity, and which manifested quite differently in donor organizations’ health sector policy and activities. While some reiterated that addressing inequities and targeting the poorest or most excluded was a fundamental cornerstone of their development aid strategy, other agencies were less clear on how addressing equity concerns was a focus of their health sector interventions. One donor interviewee, for instance, suggested that their approach to supporting healthcare services was not related to specifically addressing inequalities or promoting health equity, but rather focused on providing general and technical support and capacity building in the health sector – primarily focusing on training skilled health personnel.²³

Yet several donors indicated that addressing equity concerns was in fact central to their strategic approaches. There was also some significant overlap in donors’ perceptions of inequality as a problem and the extent to which they addressed inequities concretely in their own activities. Noting the differences between health service extension in urban and rural areas, several donors focused on addressing geographic disparities. Responses included both supporting government programs to extend services such as health insurance schemes in rural areas; and designing specific regional actions according to local needs. Here, targeting programs to address inequities in health provision was singled out as a key motivating factor of how certain donors determined how and where they would operate.

One donor agency cited that addressing health inequities was a ‘highly relevant factor’ in their desire to support the GoE to work towards achieving UHC. Here the focus was on this being ‘a starting point to reach the most vulnerable, (including) the poor or the women or the people living in harsh environments – and to gain their confidence in health services’.²⁴ Other agencies referred more broadly to overarching commitments to addressing inequality as part of their organizations strategic priorities more so than their specific focus on health equity vis-à-vis their in-country programming activities.

Among donors we consulted, there was some pessimism that despite the progress that has been made, the persistent inequities in the Ethiopian health sector were hindering the achievement of goals related to equitable health service delivery and a fundamental impediment in the pursuit of UHC. Yet donors also appeared responsive to this, noting that in many cases their activities in the health sector were tailored to address inequitable access or quality of healthcare services. Such activities included: technical and managerial support to the Ministry of Health to strengthen health systems; capacity building and training of skilled healthcare personnel; and investing in and promoting cross-sectoral approaches that coordinated programming activities to address health inequalities as part of a wider constellation of multidimensional deprivation (such as addressing education, nutrition and related issues).

4.5. Future interventions

Regarding paths forward in the sector, donors highlighted several areas through which the persistence inequities in healthcare provision could be improved and identified numerous priority areas of intervention. First, the challenges of aid fragmentation were noted, with interviewees underscoring the need for consensus-based approaches between donors and GoE to both align priorities and responses and fill gaps in coverage. For instance, a greater and coordinated focus on remote areas was viewed as perhaps the critical area in the GoE being able to address geographic and income-based inequities related to health care provision.

Second, the need to address financial risk protection was also considered as another critical area in moving towards UHC, particularly as related to burden sharing of government administrative units. As one donor remarked:

Health insurance schemes (i.e. social and community-based health insurance – CBHI) need to be pooled at the regional level in order to safeguard poor Woredas (districts) from collapsing simply because the people are too poor to pay for insurance. Nevertheless, pooling these two insurance schemes requires strong government commitment.²⁵

To this end, the Ethiopian Health Insurance Agency is expected to pool the two insurance schemes (the social and CBHI) and establish a more effective common pool. As one donor alluded, the paper based insurance claims that are often currently practiced (which take a considerable amount of time to process and delay transfers) need to be replaced by the web based system at the Ethiopian Health Insurance Agency, which requires the completion of the Agency’s IT that is currently at its formative stage.²⁶

A third issue was the perception that the inefficiencies or mismanagement of certain resources and operations was hindering the ability to provide the health services needed, particularly in rural areas. Donors noted that in order to address these, the GoE would be required to streamline their bureaucracies in order to more effectively mobilize resources, both related to improving health worker training and capacity building, and the overall capacity and geographic distribution of skilled healthcare workers.

A fourth need noted by several donors was the imperative to strengthen the role of communities. Beyond government health policy and its implementation, the role of communities as healthcare users was highlighted as critical in the pursuit of health equity. This was in reference to both the role of community health workers and organizations educating communities about healthcare availability and practice; and supporting the capacity of communities to understand health problems and demand for improved health extension. As one donor explained:

In general, and over the longer term, inequities and inequalities could be reduced if citizens were better able to demand accountability for equitable provision of high-quality health services that are responsive to their needs.²⁷

As commonly suggested by donors, since equity is an issue of development (for instance, education increases women’ knowledge to seek health services), factors beyond the health sector also need to be taken into consideration. In this regard, several donors saw the need for a tailored approach that aligned health aid with investments in other sectors through a multisectoral, holistic approach to achieving equitable development outcomes. Yet some important issues and gaps were noted in addressing equity in healthcare, including creating an enabling work environment (i.e. increasing the quality of governance); improving both supply and demand side delivery; and improving the quality of services.

Each of these issues and gaps affect the out-of-pocket expenditure of communities and related health situations. For instance, HEP is intended to address the primary health needs of the people, especially women and children – and in this it has had considerable success. But it does not yet adequately meet the needs of communities such as the pastoralists who remain markedly underserved. Moreover, for some health outcomes – especially maternal mortality – there is a need for considerable improvements in access to high quality secondary care in order to achieve greater equity in health care service delivery.

5. Conclusion

This brief article offers primary research-based insights into how donor organizations working in the health sector in Ethiopia understand and respond to issues of health extension and equity under the umbrella of the broader UHC agenda. While Ethiopia’s flagship HEP has recorded considerable successes, there remain several areas where further improvements in healthcare coverage and quality are required to continue moving forward on this positive trajectory.

Our findings suggest that donors are aware of the strides that have been made in the past decade in the Ethiopian health sector, despite inequities in quality, accessibility and coverage still being seen as a concern. Donors perceived that there are priority areas of need that include: the reduction of out-of-pocket expenditure for healthcare services; ensuring sustained and strong political will to develop the health sector; adequate financial and human resources; robust M&E to track progress and inform decision making; and improved government accountability to citizens. Likewise, challenges related to policy implementation, underutilization of financial resources, weak management of healthcare infrastructure and a lack of adequately trained health personnel, among others, were underlined by donors as areas requiring particular attention.

In light of both the progress and challenges in the sector, it is necessary to reiterate that health equity is fundamentally about achieving fairness in access and quality of services rather than attaining actual equality in health outcomes. However, as this article shows, there are clear disparities in health service delivery and coverage across dimensions related to geography, age, gender and disability and that are contributing to health inequities. And as noted by donors, addressing this requires attention be paid to how health disparities link with other equity issues as a broader development concern. The implication is that improving equity in healthcare requires that both donors and governments pay attention to factors beyond the health sector, and support this through tailored, strategic investments that further equitable human development. By doing so, there is a greater potential for development aid to contribute to a more just and inclusive path towards equitable and sustainable development.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Norwegian Research Council as part of the project “Development Aid, Effectiveness, and Inequalities in Conflict-Affected Societies” [grant number 250301].

Notes

1 SDG goal 3 aims to broadly ‘Ensure healthy lives and promote wellbeing for all at all ages’, and includes target 3.8 which seeks to ‘Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’ (UN 2015).

2 See for example Wang et al. 2016; FMOH 2010

3 See for example Basit (2003).

4 Quoted passages are lightly edited for clarity without changing the underlying meaning of interviewee statements.

5 Donor interview, Addis Ababa.

6 Donor interview, Addis Ababa.

7 Donor interview, Addis Ababa.

8 Donor interview, Addis Ababa.

9 Donor interview, Addis Ababa.

10 Donor interview, Addis Ababa.

11 Donor interview, Addis Ababa.

12 Donor interviews, Addis Ababa.

13 Donor interview, Addis Ababa.

14 Donor interview, Addis Ababa.

15 Donor interviews, Addis Ababa.

16 Donor interview, Addis Ababa.

17 Donor interview, Addis Ababa.

18 Donor interview, Addis Ababa. See also WHO (1978) on the Alma-Ata Declaration.

19 Donor interview, Addis Ababa.

20 Donor interview, Addis Ababa.

21 Donor interview, Addis Ababa.

22 Donor interview, Addis Ababa.

23 Donor interview, Addis Ababa.

24 Donor interview, Addis Ababa.

25 Donor interview, Addis Ababa.

26 Donor interview, Addis Ababa.

27 Donor interview, Addis Ababa.