PROFIL DE FINANCEMENT DE LA SANTÉ: ÉTHIOPIE

The country's public sector accounts for the majority of resources in the healthcare sector, with the Ministry of Health (MoH) playing a crucial role in healthcare financing. The National Health Accounts (NHA) 2014 report indicates that private providers, both for-profit and non-profit, are concentrated in urban areas, where less than 20% of the population resides, and receive only 16% of total healthcare expenditures. The Ethiopian government has implemented various healthcare financing reforms since 1998, with the aim of improving and diversifying healthcare resource mobilization, ensuring equitable and efficient allocation of resources, and securing financial protection for citizens. The NHA 2010/11 report demonstrates that these reforms have led to impressive results, with a 300% increase in total healthcare expenditures and a 60% increase in per capita healthcare expenditures from $7.10 in 2004-5 to $20.77 in 2010-11. Key components of the healthcare financing reforms include the Collection and Utilization of Revenues (CUR) system, which involves collecting service fees from healthcare facilities to improve quality and combat medication shortages. The reforms also include governance of healthcare facilities, standardization of exempt services, and private wing and outsourcing of non-medical services. Despite these efforts, an estimated 9-13.5% increase in public healthcare expenditures is necessary to address resource constraints and provide effective healthcare services at all levels of the healthcare system. The Ethiopian government has introduced and financed two types of health insurance: the community-based health insurance (CBHI) for the informal and agricultural sectors, and the social health insurance (SHI) for formal sector employees. The Health Sector Transformation Plan (2015/16-2019/20) highlights the need for increased budget allocation to the healthcare sector, continued healthcare financing reforms, expansion of CBHI and SHI, and introduction of innovative domestic financing mechanisms to achieve the Universal Health Coverage (UHC) goals. The healthcare financing approach in Ethiopia is primarily based on needs (inputs) rather than outcomes (outputs). Harmonization of external donor funding and better planning and coordination between regional governments and the MoH could lead to more efficient use of resources. The government contributes through general subsidies to cover healthcare expenditures for hospitalized and non-hospitalized patients, surgeries, medications, and households enrolled in the programs. Currently, 6.5 million people are enrolled in the CBHI system, which accounts for 7% of the country's total population. The government must carefully calibrate the design of benefits, payment mechanisms for providers, and coordination of subsidies within and between programs. The MoH has established the Ethiopian Health Insurance Agency (EHIA) to manage the CBHI and SHI programs jointly. The EHIA is currently working with development partners to evaluate lessons and contribute to decision-making based on observations regarding payment mechanisms. A significant portion of healthcare services (61%) is reimbursed through government expenditures, while over 35% comes from household out-of-pocket expenditures. Performance-based contracts are used to improve service offerings, transferring funds from buyers (the MoH, regional health bureaus, and district health offices) to service providers (healthcare facilities) conditionally upon achieving predetermined performance targets. Under the CBHI program, providers are reimbursed on a fee-for-service basis. The reimbursement for services provided to CBHI members, combined with revenue collection by healthcare facilities, has increased the availability of healthcare resources within facilities.