Takemi Program in International Health
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Quality, equity, and effective coverage of child health services in Ethiopia
Theodros Getachew,1 Stephane Verguet,2 Margaret E. Kruk2,3
¹ Takemi Program in International Health, Harvard T.H. Chan School of Public Health, Boston, MA
² Harvard University, Harvard T.H. Chan School of Public Health, Boston, MA
³ School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
Background
Conventional coverage measures overlook care quality. Effective coverage evaluates health care impact by considering utilization and quality. This approach ensures that the services provided are not only accessible but also of high quality, leading to better health outcomes.
We analyzed data from two time points encompassing major health sector reforms as well as significant external challenges, including conflict and COVID-19. This analysis provides insights for program improvements by assessing progress and setbacks in equity and quality of child health services in Ethiopia.
Objectives
- To measure trend in readiness, care competency, and user perception in child health service in Ethiopia between 2014 and 2021-22.
- To evaluate the effective coverage cascades for common childhood illnesses and inequities in quality-adjusted coverage in Ethiopia in 2021-22.
Method
- To compute quality in health care, we used data from the 2014 and 2021-22 Service Provision Assessments (SPA).
- The SPA data covered health facilities, workers, and clients attending sick child consultations. Child care utilization were calculated using a household survey from 2022.
- The effective coverage cascade analysis included 7,376 household data.
- Administrative boundaries were used to link a health facilities data with population survey data for the effective coverage cascade analysis.
- These datasets are publicly available and received ethical approval from the Ethiopian Public Health Institute and the Measure DHS.
Results
- Care component: 4 in 100 and 2 in 100 observed consultations with sick children included an assessment of all danger signs in 2024 and 2021-22, respectively.
- Effective coverage
- Childhood illness utilization in the two weeks before the survey was suboptimal, with poor quality adjusted effective coverage.
- We found a gap between crude and effective coverage, indicating that despite improved access and physical contact with health facilities, many children did not receive good quality care due to inadequate interventions.
- Facility readiness and equity of quality adjusted effective coverage
- The concentration curve indicated quality-adjusted effective coverage is concentrated among the wealthiest except for symptom of malaria.
- The relative difference (Q5: Q1) revealed the better-off group (Q5) is 5.2, 3.3, and 3.9 times more likely to receive effective quality services for pneumonia, diarrhea, and common childhood illnesses, respectively, compared to the poorest group (Q1).
- The positive concentration index values for these illnesses (24.92%, 10.95%, and 24.79%) also indicate a disparity in quality healthcare utilization, favoring wealthier individuals over the poorest.
- User perception on child health services
- User-reported quality, confidence in the health system, and overall satisfaction were higher. However, this varied by managing authorities.
- Client perceptions of the health system were better for private facilities compared to public ones.
Conclusions
- Moderate Readiness: The health care system demonstrates an average level of preparedness to provide services over time.
- Declining Competence: There is a low and noticeable decrease in the ability of health care providers to effectively examine and diagnose sick children over the study period.
- Low Effective Coverage: Despite positive perceptions, the actual reach and impact of services for sick children remain inadequate.
- Access and Quality Disparities: Lower socioeconomic groups face challenges accessing high-quality care, resulting in variations in care quality.
- Positive User Perception: Despite with low care competency, users tend to view the services positively, indicating satisfaction.
Acknowledgements
Takemi Program in International Health and Ethiopian Public Health Institute