Distributional impact of infectious disease interventions in the Ethiopian Essential Health Service Package: a modelling study

Abstract

Objectives: Reducing inequalities in health and financial risk are key goals on the path toward universal health coverage, particularly in low-income and middle-income countries. The design of the health benefit package creates an opportunity to select interventions through established criteria. The aim of this study is to examine the health equity and financial protection impact of selected interventions, along with their costs, at the national level in Ethiopia.

Design: Distributional cost-effectiveness analysis.

Population: The eligible population for all selected interventions is assumed to be 10 million.

Data sources: Data on disease prevalence and population size were gathered from the Global Burden of Disease database, and average health benefits and program costs are sourced from the Ethiopian Essential Health Service Package (EHSP) database, national surveys and other publicly available sources.

Intervention: A total of 30 interventions were selected from the latest EHSP revision and analysed over a 1-year period.

Outcome measures: Health benefits, social welfare indices and financial protection metrics across income quintiles were reported.

Results: We found 23 interventions that improve population health and reduce health inequality and four interventions reduce both population health and health inequality. Additionally, three interventions improve population health while increasing health inequality. Overall, the EHSP interventions provide a 0.021 improvement in health-adjusted life expectancy (HALE) per person, with a positive distributional equity impact: 0.029 (26.9%) HALE gained in the poorest and 0.015 (14.0%) in the richest quintile. Similarly, a total of 1 79 475 cases of catastrophic health expenditure were averted, including 82 100 (46.0%) cases in the poorest and 17 900 (10.0%) in the richest quintile.

Conclusion: Increasing access to the EHSP improves health equity and financial protection. Improved access to selected EHSP interventions also has the potential to provide greater benefits to the poorest and thereby improve social welfare.

Keywords: Ethiopia; distributional analysis; economic evaluation; financial risk protection; health inequality.

Figure 1

Baseline distribution of lifetime health in HALE in 2019 by income quintile in Ethiopia (Q1–Q5: poorest to richest; horizontal dotted line: average baseline HALE). HALE, health-adjusted life expectancy.

Figure 2

Health equity impact plane. HIV1: first-line antiretroviral therapy (ART) men; HIV2: first-line ART women; HIV3: paediatric ART; HIV4: cotrimoxazole for children; HIV5: prevention of mother-to-child transmission; HIV6: syphilis detection and treatment (pregnant women); Inf1: pneumonia treatment (children); Inf2: ORS for diarrhoea treatment; Inf3: zinc (diarrhoea treatment); Inf4: treatment for dysentery (antibiotics); M1: long-lasting insecticide-treated net; M2: indoor residual spraying; M3: malaria treatment for pregnant women; M4: uncomplicated malaria treatment in children (rapid diagnostic test (RDT)); M5: uncomplicated malaria treatment in children (microscopy); M6: severe malaria treatment in children (RDT); M7: severe malaria treatment in children (microscopy); M8: intermittent preventive treatment for pregnant women; M8: uncomplicated malaria treatment in adults (RDT); TB1: drug susceptible tuberculosis (DS-TB) treatment; TB2: DS-TB treatment and ART for TB; TB3: DS-TB treatment, ART for TB, and preventive therapy; TB4: DS-TB treatment and preventive therapy; TB5: DS-TB treatment and preventive therapy for children; TB6: multidrug-resistant tuberculosis (MDR-TB) treatment; TB7: MDR-TB treatment and ART for TB; TB8: MDR-TB treatment, ART for TB, and preventive therapy; TB9: MDR-TB treatment and preventive therapy; TB10: MDR-TB treatment and preventive therapy for children. EDE, equally distributed equivalent; HALY, healthy life year; NHB, net health benefit.

Figure 3

(A) Impact of selected interventions in the distribution of lifetime health (benefits are scaled at 100); (B) comparison of gross, net health benefits and opportunity costs; (C) distribution of financial protection across income quintiles in Ethiopia (2019). HALE, health-adjusted life expectancy.