Transforming Ethiopia’s health care system from the ground up

Ethiopia's State Minister of Health Keseteberhan Admassu and a colleague

August 29, 2012 — There are currently more Ethiopian doctors working in Chicago than in Ethiopia, according to Keseteberhan Admassu, the country’s state minister of health. Speaking to an international group of experts assembled by Harvard School of Public Health’s (HSPH) Department of Global Health and Population and Yale Global Health Leadership Institute (GHLI), Admassu described the challenges Ethiopia faces as it works to improve access to care for its neediest citizens.

The meeting, which took place July 30-31, 2012, brought together representatives from Brazil, Estonia, South Africa, Sri Lanka, and Thailand in addition to Ethiopia, to discuss their countries’ varied approaches to delivering and financing basic health services. The objective was to provide the Ethiopian delegation with the opportunity to learn from health leaders from other low and middle-income countries that have successfully managed primary care system reform efforts of their own.

Ethiopia has made significant health gains in recent years, such as lowering infant mortality, but more work needs to be done—particularly in rural areas. Now, as the country embarks on a 20-year plan to improve primary care delivery, the country’s Federal Ministry of Health has enlisted the help of HSPH and GHLI, with funding from the Bill & Melinda Gates Foundation, to develop a strategy.

GHLI’s Elizabeth Bradley, professor of public health and faculty director, told attendees that even countries at similar stages of economic development tackle health care delivery differently and there is no clear evidence for a one-size-fits-all strategy. The “right” solution is shaped by a country’s economic, political, and cultural context, she said.

HSPH’s Peter Berman, professor of the practice of global health systems and economics, observed that the United States faces its own struggles, which are likely to become more pronounced as the system strains to accommodate those newly insured under the Affordable Care Act. “Developing primary care is an ongoing process for all countries,” he said. “Health care delivery is not just a problem in low and middle-income countries. It is a problem around the world.”

In Brazil, where health is a constitutional right for all citizens, the decentralized health care system using innovative family health teams has made gains in improving access but suffers from stagnant government funding. Estonia tackled simple health reforms with high impact following the country’s independence from the Soviet Union in 1991. Later, it developed a nationally institutionalized primary care system centered on family medicine. In Sri Lanka, health care is a well-established government priority, which has resulted in a highly cost-effective system with strong outreach programs for prevention and curative services. Thailand’s “universal coverage” public health insurance program provides defined benefits to registered members for a fixed copayment, linking lower level hospitals to primary care providers.

In Ethiopia, the government has worked to fill gaps in access to care throughout its extensive and often hard to reach rural communities by recruiting and training women as paid frontline health workers. They train families in hygiene and other public health practices, deliver a defined package of basic services, and serve as role models for girls—a vital service in a country where under-age marriage is still common. Nurses in the program provide additional and complementary services at local clinics. The government hopes to eventually offer advanced training to the health workers so that they can more fully fill the gap left by the “brain drain” of doctors seeking higher paid employment in other countries. The project is helping Ethiopia develop affordable and sustainable innovative health care delivery solutions that can grow in scale and scope as the nation advances.

Wim van Lerberghe, director of health systems policies and workforce at the World Health Organization (WHO), was among the representatives from international organizations who also attended the event. He discussed the meaning of “primary health care,” which the WHO differentiates from “primary care.” While the latter deals with delivery of basic services, primary health care represents a broader movement toward health equity. The goal of primary health care is to view “people as people, not diseases.” This is particularly a concern in the developing world, where there may be programs to provide HIV medication but inadequate surgical facilities for car crash victims, he said.

The two-day conference left the Ethiopian delegation with many new ideas to consider. Speaking metaphorically about primary care in his country, Admassu observed, “We have constructed the hardware. Now we will work on the software to get the system to work.”

Berman was optimistic that the country will continue making progress in improving the health of its citizens. “We are in a historic time when change is really possible,” he said.

— Amy Roeder