Elsevier

The Lancet

Volume 392, Issue 10156, 20–26 October 2018, Pages 1473-1481
The Lancet

Review
Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in Ethiopia

https://doi.org/10.1016/S0140-6736(18)32215-3Get rights and content

Summary

Weakness of primary health-care (PHC) systems has represented a challenge to the achievement of the targets of disease control programmes (DCPs) despite the availability of substantial development assistance for health, in resource-poor settings. Since 2005, Ethiopia has embraced a diagonal investment approach to strengthen its PHC systems and concurrently scale up DCPs. This approach has led to a substantial improvement in PHC-system capacity that has contributed to increased coverage of DCPs and improved health status, although gaps in equity and quality in health services remain to be addressed. Since 2013, Ethiopia has had a decline in development assistance for health. Nevertheless, the Ethiopian Government has been able to compensate for this decline by increasing domestic resources. We argue that the diagonal investment approach can effectively strengthen PHC systems, achieve DCP targets, and sustain the gains. These goals can be achieved if a visionary and committed leadership coordinates its development partners and mobilises the local community, to ensure financial support to health services and improve population health. The lessons learnt from Ethiopia's efforts to improve its health services indicate that global-health initiatives should have a proactive and balanced investment approach to concurrently strengthen PHC systems, achieve programme targets, and sustain the gains, in resource-poor settings.

Introduction

The 1978 Declaration of Alma-Ata1 advocated primary health care (PHC) as the main strategy to achieve the goal of health for all.2 The principles underlying PHC systems continue to be recognised as essential to the achievement of universal health coverage (UHC).3, 4 However, the debate between advocates of comprehensive PHC approaches and those of more targeted strategies represents an ongoing challenge.5, 6 Some have argued that comprehensive PHC is too idealistic and expensive, and that UHC should be pursued with a more selective model that focuses on diseases with cost-effective interventions.7, 8

As a result, during the past two decades, there has been an increase in the number of disease control programmes (DCPs) and disease-specific global-health initiatives (GHIs) that leverage additional resources for targeted health interventions.9 Estimates suggest that The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), the President's Emergency Plan for AIDS Relief (PEPFAR), and the World Bank have contributed more than two-thirds of all development assistance for health (DAH) to prevent and control HIV/AIDS, tuberculosis, and malaria in resource-poor settings.10, 11

Since 2005, GHIs have provided Ethiopia with substantial resources to support DCPs. However, the implementation of these DCPs was soon found to be compromised by underlying weaknesses in the Ethiopian health system, and the strategy of targeted funding was found to undermine efforts to strengthen the health system.12 Criticisms have also been raised by the global health community that weak health systems hinder progress towards DCP targets and that GHIs overburden already fragile health systems.13 Acknowledging these issues, key GHIs—ie, PEPFAR, The Global Fund, and Gavi, the Vaccine Alliance (Gavi)—have collaborated with other donors to increase their financial support towards health-systems strengthening,13 in what has been called the diagonal investment approach.14, 15

A diagonal investment approach is a proactive and balanced approach that concurrently strengthens PHC systems and scales up DCPs. The diagonal investment approach addresses the requirements of specific priorities while providing opportunities for strengthening health systems.16, 17, 18 The approach has been employed in Mexico, where specific intervention priorities (such as immunisation services) were used to drive improvements to the health system.14, 15 Other resource-poor countries, such as Rwanda and Malawi, have also benefited from this approach as HIV/AIDS investments have been channelled to strengthen health systems.13, 19

Key messages

  • Weak primary health-care (PHC) systems have hindered progress in meeting the targets of programmes in resource-poor settings

  • Ethiopia has embraced a diagonal investment approach to strengthen its PHC systems and scale up disease control programmes (DCPs); this approach has led to increased PHC-system capacity and has improved programme coverage and health status

  • Despite the decrease in development assistance for health, Ethiopia has sustained its financial support for health and has promoted PHC systems' capacity with increased domestic resources (such as public, private, and out-of-pocket funds)

  • The lessons from Ethiopia have implications for future investments on DCPs so that effective, sustainable, and resilient PHC systems can be built to progressively realise universal health coverage in resource-poor settings

With this Review, we aim to present the experience of Ethiopia as a case study of how diagonal investments from key GHIs can be used to broaden funding effectiveness (ie, the degree to which the objectives of targeted and complementary health systems are achieved) and sustainability (ie, the ability to maintain achievements at the desired standard after the intervention is completed). Our manuscript combines a narrative review of both published and grey literature and a quantitative analysis of national programmes and health-account data from government offices and financial-disbursement data from GHIs.

Section snippets

Advocacy for strengthening primary health-care systems in Ethiopia

Ethiopia's health-service delivery is structured in a three-tier system: primary, secondary, and tertiary levels. The primary level is the most accessible service-delivery point, where basic health care is provided and managed (panel, figure 1, and appendix).24, 30

Since 2005, the Ministry of Health (MOH) of Ethiopia has embraced the vision, committed to, and sustained the technical requirements for the establishment of strong PHC systems. To reconcile the divergence between DCPs and health

Health-care financing in Ethiopia

Ethiopia's health sector is financed by multiple sources including the government treasury, bilateral and multilateral donors, household out-of-pocket expenditures, non-governmental organisations, and private and parastatal employers.36, 37 Substantial resources have been mobilised from different GHIs, such as The Global Fund, Gavi, the US Government, and other sources. This increase in resources has resulted in a marked growth in total health expenditure,35, 38 which has increased from US$357

Strengthening the primary health-care systems in Ethiopia

Ethiopia has been designing and implementing several reforms, such as the business-process re-engineering (ie, analysis and renewed design of workflows and structures).47 These reforms have resulted in the development of system-wide strategies: the Pharmaceutical Logistic Master Plan, the Laboratory Master Plan, the Health-Management Information Reform Scale-Up, the Health-Sector Financing Reform and Health Insurance, the Human Resource For Health (HRH) strategy, and second-generation HEP.48, 49

Improved health status in Ethiopia

Enhanced PHC-system capacity through increased and strategic investment, which have accompanied the health-reform initiatives, has substantially improved service coverage and health status in Ethiopia.24, 30 Given that the MDGs were effective proxies for essential PHC services, Ethiopia achieved most of the health-related MDGs, with a 67% reduction in mortality of children younger than 5 years, a 71% decline in maternal mortality ratio, and a greater than 50% decrease in mortality due to

Decreasing development assistance for health in Ethiopia

Ethiopia is now experiencing a decline in DAH (figure 3). The share of DAH for the total health expenditure has also decreased from 50% in 2010–11, to 36% in 2013–14.42 This decline is substantial, since the cuts in funding from The Global Fund (which contributes 59% of the total DAH) and PEPFAR (which contributes 30% of the total DAH) have resulted in a combined decrease of total funding of almost 50%.82, 83 The national health accounts42 indicate that the resources for HIV/AIDS decreased from

Sustaining the gains from investments by GHIs in Ethiopia

Ethiopia has visibly stronger health systems now than a decade ago. The remarkable progress that has been made can be identified, in particular, in the increased number of PHC facilities and HRH, the improvements to the supply-chain management, and the decentralisation of services.24, 35 Furthermore, programme activities have been transferred from PEPFAR to local authorities smoothly, so that continuity of care will not be compromised.87, 88 This successful transition was possible because of

Conclusions

A diagonal investment approach has enabled Ethiopia to attain both short-term goals (ie, MDGs 4, 5, and 6) and long-term goals (ie, strengthened PHC system).70 It is commendable that the government is responding to a decrease in DAH with additional domestic resources, which are essential to sustain the gains that have been achieved in health development. However, achieving UHC necessitates greater and more consistent political awareness and commitment than has been displayed thus far, increased

Search strategy and selection criteria

We reviewed the medical literature within the framework of the objectives of this Review, which were to understand what contributed to strengthen the primary health-care systems in Ethiopia and how this process happened. We searched the PubMed, Embase, and Google Scholar databases. We extracted data on health expenditure and related statistics from databases or webpages of WHO; the World Bank; The Global Fund to Fight AIDS, Tuberculosis, and Malaria; and Gavi, the Vaccine Alliance. We used the

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