Developing Systems of Care for Non-Communicable Diseases in Ethiopia

Zachary Hermes, M.D. 

Resident, Internal Medicine at the Brigham and Women’s Hospital, 

PGY3

02/08/2020

My time in Ethiopia has been a bit of a blur over the past 3 weeks traveling between busy cardiovascular clinics, crowded inpatient cardiology wards, and district hospital echocardiography clinics. Thankfully, I had a unique experience last Tuesday that allowed me to step back and take a birds’ eye view of the health care ecosystem in Ethiopia. I was invited to join a workshop hosted by the Federal Ministry of Health (FMOH) focused on Non-Communicable Diseases. The group had previously convened as the Ethiopian Non-Communicable Disease Interventions (NCDI) Commission, which was a cumulative effort by the FMOH, local academic institutions, individual experts, patient/professional associations with facilitation by the Global Lancet Commission on “Reframing Noncommunicable Diseases and Injuries (NCDIs) for the Poorest Billion.” This was an enlightening experience in that it provided macro-level, policy-focused view of health delivery in Ethiopia, and it complemented my on-the-ground perspective with holistic view of the entire ecosystem. Additionally, it was instructive to see the process and structure of a ministry-level governmental working group.

As we launched into the program, the discussion started with a snapshot of healthcare institutions and workforce. In terms of hospitals, there were approximately 25 tertiary hospitals, 80 general hospitals, and less than 200 primary hospitals which tend to be the center of care for almost all non-urban populations. Yet that 200, was far below the WHO recommendations which would translate to roughly 1000. Additionally, there was a little less than 1 healthcare worker per 1000 people which was similarly below the WHO goal level. The landscape for healthcare financing was also striking. Average healthcare expenditures/capita came out at roughly $33USD, but 70% of NCD services were  financed as out-of-pocket which also meant that health care was the number of cause of bankruptcy or financial distress for the population. This reaffirmed the importance of their objectives to identify essential NCD services, understand how to finance their provision with public dollars, and most importantly, how and where to actually deliver the care needed.

At Non-Communicable Diseases and Injuries (NCDI) Health
Sector Interventions Summit hosted by Ethiopia's Federal Ministry
of Health 

The next point of discussion was to review the previously determined package of essential health services in the context of the delivery platforms available to the health system. The key levels were tertiary care hospitals, general/primary hospitals (which were realistically the most accessible level of care for the majority of Ethiopians), health centers, community-based care through health workers, and population-based approaches. Our conversation focused on the interface between tertiary care hospitals and general hospitals, as this postulated to be a key leverage point to advance the decentralization of NCD care which was currently limited for the most part to Tertiary hospitals. What became clear to the group was that although an excellent and well-evidenced list of recommendations of what needs to be delivered, and ideally where it should be delivered, there wasn’t any data on how many of the selected interventions were actually being delivered at different levels, who was delivering those services, and why recommended packages were not being delivered. To see the hypothesis-generation and methodological refinement occur in real-time was amazing, and by the end of the workshop there was a proposed framework for assessing what is actually occurring at the primary hospital-level and tertiary-hospital level.

The group was gracious in welcoming me and were intentional about engaging me throughout the discussion. It was an honor to join the workshops, and I was thankful to spend the day learning from their perspective and experience.