Costs and resource needs for primary health care in Ethiopia: evidence to inform planning and budgeting for universal health coverage

Abstract

IntroductionThe Government of Ethiopia (GoE) has made significant progress in expanding access to primary health care (PHC) over the past 15 years. However, achieving national PHC targets for universal health coverage will require a significant increase in PHC financing. The purpose of this study was to generate cost evidence and provide recommendations to improve PHC efficiency.MethodsWe used the open access Primary Health Care Costing, Analysis, and Planning (PHC-CAP) Tool to estimate actual and normative recurrent PHC costs in nine Ethiopian regions. The findings on actual costs were based on primary data collected in 2018/19 from a sample of 20 health posts, 25 health centers, and eight primary hospitals. Three different extrapolation methods were used to estimate actual costs in the nine sampled regions. Normative costs were calculated based on standard treatment protocols (STPs), the population in need of the PHC services included in the Essential Health Services Package (EHSP) as per the targets outlined in the Health Sector Transformation Plan II (HSTP II), and the associated costs. PHC resource gaps were estimated by comparing actual cost estimates to normative costs.ResultsOn average, the total cost of PHC in the sampled facilities was US$ 11,532 (range: US$ 934–40,746) in health posts, US$ 254,340 (range: US$ 68,860–832,647) in health centers, and US$ 634,354 (range: US$ 505,208–970,720) in primary hospitals. The average actual PHC cost per capita in the nine sampled regions was US$ 4.7, US$ 15.0, or US$ 20.2 depending on the estimation method used. When compared to the normative cost of US$ 38.5 per capita, all these estimates of actual PHC expenditures were significantly lower, indicating a shortfall in the funding required to deliver an expanded package of high-quality services to a larger population in line with GoE targets.DiscussionThe study findings underscore the need for increased mobilization of PHC resources and identify opportunities to improve the efficiency of PHC services to meet the GoE’s PHC targets. The data from this study can be a critical input for ongoing PHC financing reforms undertaken by the GoE including transitioning woreda-level planning from input-based to program-based budgeting, revising community-based health insurance (CBHI) packages, reviewing exempted services, and implementing strategic purchasing approaches such as capitation and performance-based financing.

An assessment of primary health care costs and resource requirements in Kaduna and Kano, Nigeria

“…Recent studies conducted in Afghanistan ( 38 ), Ethiopia ( 31 ), and Kenya ( 32 ) have similarly examined the actual and normative costs of PHC service packages. Consistent with our research, they revealed substantial resource gaps between existing PHC resources and the financial requirements to provide quality PHC services to all those who need them.…”

“…In accordance with the World Health Organization’s PHC Measurement Framework and Indicators ( 30 ), key metrics that can be analyzed in the PHC-CAP Tool include inpatient and outpatient services per clinical staff, daily service output per clinical staff, cost per input, cost per service, total cost, and cost per capita—contingent on data availability. Aside from Nigeria, the PHC-CAP Tool has also been used in five additional countries, including Ethiopia ( 31 ) and Kenya ( 32 ).…”

“…Per capita actual costs for Kaduna and Kano were determined by dividing the total cost of each estimate for each state by the respective populations. This approach of approximating total actual PHC costs in a geographic area by extrapolating from a sample of health facilities has been employed in several previous studies ( 31 , 32 , 37 , 38 ).…”

“…The financial resource gaps for PHC services in Kaduna and Kano were calculated as the difference between actual and normative costs ( 31 , 32 , 37 , 38 ). We calculated resource gaps using actual estimates 1 and 2 described above.…”