Healthcare Inequalities Impede National Progress

There is little doubt within the local and international policy circles about the great strides Ethiopia has taken in making basic healthcare services accessible to the millions of citizens living in hard to reach areas. The nation’s efforts have often been used as a success story in international forums.

National health policy gurus, including the health minister, Kesetebirhan Admasu (MD), are seen touring the world to speak about the silver bullets they employ to make healthcare accessible to more and more Ethiopians. For Kesetebirhan, who served as director for disease prevention and state minister under Tedros Adhanom (PhD) – a reputed health minister who now presides over the foreign ministry – selling the positive progress of the nation remains the major preoccupation. He is often seen making remarks about the possibility of bringing transformational change to the healthcare systems of developing countries, via effective and targeted public investment.

To his favour, Kesetebirhan has many concrete achievements he can carry with him anywhere in the world. After all, Ethiopia is a nation with a highly recognised health extension program (HEP), which is considered as an innovative approach to taking basic healthcare and disease prevention closer to the community. By way of deploying thousands of extension workers, therefore, the health ministry has created a decentralised and harmonious system to ensure the health of society.

A latest recognition of the efforts has been the one that came from the United Nations. This relates to Ethiopia’s achievement in reducing infant mortality by half well before the end of the Millennium Development Goals (MDGs). It surely is a great achievement that health policymakers need to be very proud of.

But this is not the only area of accomplishment. Other areas, such as under-five mortality, neonatal death, skilled birth attendance, vaccinations and deaths from curable diseases, such as pneumonia, have also witnessed considerable progress. Of course, the progress in these areas are not as significant as the case with infant mortality.

In economic terms, the improvements of the past 15 years have involved huge investment. Public investment has been the key driver of these changes. Thanks to the generosity of the state under the leadership of the Revolutionary Democrats, almost every corner of the nation has come to see facilities providing healthcare services.

If one is to be honest about the analysis of the progress made in the health sector, though, the leadership provided by the late Meles Zenawi and the former health minister, Tedros, comes to the fore. A combination of the two had stirred the rather long overdue passive waters of the sector, like no other time in history, and managed to persuade international donors to channel their resources to the health sector.

Under the leadership of the two figures, the state has also managed to allocate considerable resources to the construction of health posts, health centres, hospitals, referral hospitals and specialised healthcare centres. Budgetary support to the sector has witnessed rapid growth – well over 25pc annually – to reach close to 16pc of the annual budget of the federal government. Of course, this is without accounting for the share of healthcare from the 15 billion Br annual MDG budget, which was created with the recommendation of the late Meles Zenawi.

As much as Kesetebirhan et al could have a lot to take from the era of Tedros, however, they are now faced with their own challenge. It is not that the challenge is new to the health policy arena, but it has been given less attention by policymakers. The challenge – inequality of healthcare services – has reached an all new level now, which, if it is not attended to with tailored policies, could reverse the gains made over the past 15 years of implementing the health sector development programs (HSDPs).

Latest research conducted on the state of inequalities in healthcare provision in Ethiopia shows that the sector remains pro-rich. Unequal distribution of access to health services is a characteristic trait to the current state of the sector.

Concentration indexes – measures to the level of distribution of healthcare services – of basic indicators, including under-five mortality, neonatal death, vaccinations, ORS and antibiotics, show that there is huge disparity between income levels and amongst regions. Index calculations show that the concentration varies between 0.001 to 0.11, which would be high when aggregated across income levels, and hence depict significant differences that need policy attention.

It is not only in such research that inequality is shown, though. In the many reports that the health ministry churns out, inequality is identified as a major problem within the health sector. It is, therefore,  the limited attention it receives that is the problem.

Inequality, be it in income levels or spatially, is an input to systemic instability. It also relates to the right of people to benefit from the economic system in which they are participants of. This, in a way, also means that the public investment portfolio in the health sector is not as balanced as it needs to be.

Unattended, service provision inequality, be it in healthcare or other sectors, could aggravate public disappointment. A disappointed public could pose its own challenge to the stability of the political system.

Zooming in the case onto healthcare, the inequality also entails inequality of opportunities and productivity. By virtue of biasing the productivity pattern, which is a direct result of the difference in time spent on productive engagements and life expectancy, the inequality could also affect the equilibrium of the economic system.

In every sense, therefore, attending to the inequality in healthcare service provision across the country is the question of the time. Policymakers need to bring the issue of inequality to the fore before it reverses the gains of the past two decades. They need to subtly evaluate the fundamentals of their investment and reorient it towards a more balanced equilibrium.

To the policy gurus at the health ministry, including Kesetebirhan, this is all about maintaining the legacy of their predecessors and adding value to it. As it goes naturally, legacies could not be maintained unless they are complemented with new results that the times demand.

As it stands, the time demands for basic healthcare services in the country, from neonatal care to skilled birth attendance, from vaccination to antibiotic provision, and from the treatment of curable disease to the provision of vitamin supplements, to be equally provided for all people of every income level and region. As much as such an action is about resources, it is primarily about policy intention. It is, therefore, this policy will that the nation’s health policymakers need to bring to create a healthy and productive citizenship that could sustain the economic growth of the day.


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