Article Text
PDF
Abstract
Objective This study aimed to explore the perspectives of key decision makers on out-of-pocket (OOP) payment for medicines and its implications in the Ethiopian healthcare system.
Design A qualitative design that employed audiorecorded semistructured in-depth interviews was used in this study. The framework thematic analysis approach was followed in the analysis.
Setting Interviewees came from five federal-level institutions engaged in policymaking (three) and tertiary referral-level healthcare service provision (two) in Ethiopia.
Participants Seven pharmacists, five health officers, one medical doctor and one economist who held key decision-making positions in their respective organisations participated in the study.
Result Three major themes were identified in the areas of the current context of OOP payment for medicines, its aggravating factors and a plan to reduce its burden. Under the current context, participants’ overall opinions, circumstances of vulnerability and consequences on households were identified. Factors identified as aggravating the burden of OOP payment were deficiencies in the medicine supply chain and limitations in the health insurance system. Suggested mitigation strategies to be implemented by the health providers, the national medicines supplier, the insurance agency and the Ministry of Health were categorised under plans to reduce OOP payment.
Conclusion The findings of this study indicate that there is widespread OOP payment for medicines in Ethiopia. System level constraints such as weaknesses in the supply system at the national and health facility levels have been identified as critical factors that undermine the protective effects of health insurance in the Ethiopian context. Ensuring steady access to essential medicines requires addressing health system and supply constraints in addition to a well-functioning financial risk protection systems.
- Health policy
- Health Services Accessibility
- Health Equity
- Rationing
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study. This is a qualitative in-depth interview based study. As such, there is no dataset to share. The only raw data available are audio-records of interviews and verbatim transcripts. While de-identified transcripts can be shared, audio-records cannot.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
Strengths and limitations of this study
The qualitative design of the study allowed an in-depth understanding of the situation of medicine out-of-pocket payments from the perspectives of key decision makers at different levels of the health system in Ethiopia.
The study respondents were policymakers and healthcare providers and do not necessarily represent the views of patients and caregivers.
Data based on individuals’ opinions could be subject to potential respondent bias.
Background
The overall purpose of the health-financing system is to maintain accessibility by giving financial assistance to the poor, promoting smooth resource mobilisation and sharing risks.1 For this reason, there is a global commitment to overhauling the health-financing system to realise the aim of universal health coverage.2 Globally, solidarity-based and non-solidarity-based health-financing schemes are widely employed.1 Solidarity-based health financing systems aim to share risk and enhance accessibility for lower-income clients through government tax, community prepayment or social health insurance (SIH).3 Non-solidary-based health-financing systems rely on out-of-pocket (OOP) payments, private risk-based health insurance, medical savings accounts and casual fees.4–6
OOP payment is defined as a one-time payment made by the patient for healthcare services received in the public or private healthcare sectors. According to the WHO, OOP healthcare expenditure is considered catastrophic if it amounts to more than or equals 40% of non-food household expenditure or 10% of total household consumption.7 Due to the absence of robust financial protection mechanisms, OOP is a common mode of payment for healthcare, often leading to catastrophic expenditures, in many developing countries.1 4 Households could experience economic or psychological consequences as a result of OOP payment.8 For example, stress, poverty and health complications (as a result of skipping critical medical care due to unaffordability) could occur because of OOP.9 Likewise, as compared with other payment methods, OOP health payments are widely recognised to result in a significant level of inequity in health service access.7 In particular, developing countries rely largely on OOP payments for health expenditures, even in public healthcare facilities.10 Because it is the primary source of health finance in Sub-Saharan African (SSA) countries, the impact of OOP health payments is also a subject of concern.11 For example, OOP health payment was catastrophic for about 61% of insured households in Togo,12 Malawi (0.73%),13 Nigeria (13.7%)14 at a 40% threshold of non-food household expenditure and 1.52% (at a 30% threshold) in Kenya.15
In Ethiopia, OOP payments at the point of service continue to be the most common method of healthcare financing. According to the Ethiopian Federal Ministry of Health (FMOH) data from 2016 to 2017, 31% of the health finance system raised funds from OOP payments by consumers.16 Hence, based on the 2015/2016 national representative survey, approximately 2% of households encountered catastrophic health expenses (at 10% of total household expenditure), with about 0.9% forced into poverty as a result of excessive health OOP payments.17 Despite encouraging results, the Ethiopian healthcare-financing system is still a long way from ensuring the universal health coverage targets due to reliance on OOP and resource constraints.18–20 The health-financing system relies on health insurance (typically through the implementation of community-based health insurance (CBHI)), a fee waiver scheme, the retention of collected revenue at health facilities and the empowerment of public health facilities to focus on clinical services.21–23 However, despite the increase in the number of people enrolled in CBHI, the proportion has remained low.24 Consequently, the majority of Ethiopian households are dependent on OOP health expenses.25
Over the last two decades, patient OOP spending on prescribed medicines has increased globally, accounting for a larger share of household and national health spending.26 Particularly, OOP medicine expenses remain the primary payment option for households in SSA countries. For example, according to the studies done in SSA countries, payment for medicines was not only the largest but also the most expensive type of health service OOP expenditure.27 28 Generally, a large number of people endure financial hardships as a result of the high cost of medicines.8 9 Nearly 7% and 3% (38 million) of the population in the Philippines and India were pushed below the poverty line due to OOP payments for medicine, respectively.29 30 In Ethiopia, medicines constitute the most expensive component of healthcare services.31 32 The likelihood of catastrophic health expenditure can be influenced by factors such as availability, capacity to pay and the lack of effective protection mechanisms (eg, health insurance).18
Given the high proportion of OOP expenditures on medicines, a large number of the Ethiopian population is being pushed into poverty.33 In the Ethiopian context, the data on OOP payments for medicines come from surveys and national-level household consumption expenditure studies. Hence, there is a paucity of evidence on the system level contexts and constraints resulting in the high burden and impact of the OOP payments for medicines in the country. The purpose of this study was, therefore, to explore the level of OOP payment for medicines and its implications from the perspectives of key decision-makers in the Ethiopian healthcare system.
Methods
Study design
A qualitative study design employing in-depth interviews using semistructured interview guides with flexible probing techniques was done to explore the perspectives of participants from key federal-level institutions in Ethiopia.
Study settings
Addis Ababa, the capital of Ethiopia, is home to the federal ministers of the country. Therefore, relevant federal-level governmental institutions in Addis Ababa city, such as the FMOH, Ethiopian Health Insurance Agency (EHIA), Ethiopian Pharmaceutical Supply Agency (EPSA) and public hospitals such as Tikur Anbesa Specialised Hospital (TASH) and St Paul’s Hospital Millennium Medical College (SPHMMC) were used as a study setting. These institutions are key federal institutions in meeting Ethiopia’s universal healthcare coverage.18
Sampling strategy
Participants
The study used a purposive sampling strategy to identify key informants from the FMOH (policy and planning and health service quality directorates), EHIA (finance and investment; member affairs and contributor collection; and research and plan directorates), EPSA (quantification and market shaping; pharmaceuticals and medical supplies procurement contract management, distribution and fleet management directorates) and public hospitals (TASH and SPHMMC; administrative office and pharmacy departments).
Participant recruitment
Snowball sampling procedures were used to collect data in a systematic and planned manner. Each organisation’s director appoints one or two officers, who are then requested to propose their colleagues in the subject of discussion after an interview. The following criteria were used to select candidates: Ethiopian citizenship, the current position of responsibility (specific discussion topic), prior work experience with policy-related issues, accessibility and willingness to participate in open discussions.
Data collection
The data collection was conducted from January to February 2021 G.C (Gregorian Calendar) by a graduate-level training data collector (GAM) and supervised by a senior researcher (EEA) who has experience in qualitative research methodologies. A semistructured, open-ended interview guide with flexible probing techniques was employed (see online supplemental file 1). The overall goal of the interview was to address a variety of topics related to participants’ understanding of the current status of medicine OOP payment and its consequences on patients, caregivers, households and the country, and the implementation of strategies for the promotion of access to medicine and financial risk protection interventions to combat catastrophic medicine OOP expenditure. Participants from hospitals were further asked their views on the practice of their respective hospital’s non-cash delivery healthcare service utilisation, funding and patient economic status. During the interviews, the assessment of participants concerning the effectiveness of interventions that had been implemented over the previous 10 years was also discussed. By its very design, the study followed an iterative approach where interviews were done with one informant influenced the subsequent interviews.
Supplemental material
GAM gathered the information from the interview. The Amharic language aided the interview, and the audio was recorded after gaining informed consent. Before the interview, sociodemographic information such as gender, degree of training and certification, and years of experience in the current role was obtained. The interviews followed an emergent approach where prior interviews were used to improve the interview guide and include critical questions for the next interview.34 The interviewer had taken detailed notes of the interview with two of the participants (one from FMOH and the other from TASH) who declined to be audio recorded. In all cases, the interviewer had taken field notes at the end of each interview. The occurrence of information saturation dictated the final number of participants. Saturation was determined by the absence of new information from the interview with the next person. After saturation was detected, three interviews were conducted in a row to see if any new codes or themes emerged. The length of the recorded interviews ranged from 25 to 40 min.
Data quality assurance
None of the involved authors had any relationships with the participants before the start of the study. GAM, WA and DLA have taken different pieces of training regarding qualitative study before as well as during the research periods. All interviews were conducted in their respective workplaces, and the participants chose specific places and times that were convenient for them. GAM and DLA transcribed the interview and transcribers cross-checked each data entry they had transcribed. GAM and EEA independently translated and back-translated the analysed data into English and then exchanged translations. Discrepancies in the translations were discussed among the authors, and consensus was reached on the most appropriate meaning. Two authors (GAM and EEA) independently analysed the data to maximise the detection of participants’ ideas. After the discussions, consensus was reached on the themes and subthemes that best reflected the ideas raised by the participants. An inductive process was used until saturation was achieved. The research team discussed and decided on data saturation. Participants also provided feedback and validated the findings.
Data processing and analysis
The audiorecorded interview was transcribed verbatim. R-Based Qualitative Data Analysis software was utilised for the analysis. We began by transcribing and analysing the interview in the language of the interview (Amharic) and then translated the discovered themes and subthemes into English.35 The framework analysis approach was used to analyse the obtained data. Framework analysis is the preferred method for research that has specific research questions, limited time, predesigned samples and identified prior topics.34 Moreover, it is the recommended method in applied health policy research. According to Ritchie and Spencer (1994), even though framework analysis can lead to theories, its main objective is to explore and explain what is occurring in a particular setting.32 Which is the major focus of this study. In the analysis, data were selected, charted and organised under key ideas and themes using five steps such as familiarisation, identifying a thematic framework, indexing, charting, and mapping and interpretation. Following the completion of the interview, we carefully listened to the audio and studied the transcription details and field notes to overview the collected data. As a result, we familiarised ourselves with future themes and important messages and made a mental note of them. The thematic framework was identified by classifying the important issues and concepts based on the notes taken during familiarisation. The coding was flexible to add codes when a new concept of participants was identified during the analysis. The third step was indexing; in this stage, we developed subthemes of coded data followed by themes that formed from particular subthemes. Charting involved placing or ordering the themes and subthemes consistently to allow convenient research reporting. Finally, an explanation and recommendations were made. The relevance of the idea, possible connections between concepts and compliance with the research purpose have all been checked throughout the analysis processes.
Patient and public involvement
Patients or the public were not involved in the design of the study.
Ethical issues and participant consent
Ethical clearance was obtained from the ethical review committee of the School of Pharmacy, Addis Ababa University (ethics approval reference number: ERB/SOP/233/13/2020). Before giving their written informed consent to be involved, the key informants received explanations of the purposes of the study, what will be required of them and how they can benefit from the findings. Each participant was also aware that involvement in the study is voluntary, she/he could leave at any time and the leaving of consent would not disturb his/her relationship with the institution or anybody else. Participants were also informed that their information would be kept confidential and that only the research team would have access to it.
Results
Characteristics of participants
The interviews were conducted with 14 individuals, and none of them refused to participate or dropped out of the study (table 1). Eleven of the participants were men, and nine had a master’s degree. Five of the respondents have participated from EHIA. Seven were pharmacists, and five were health officers, according to their professional backgrounds. Furthermore, at the time of the study, two of the participants held director-level positions in their respective institutions, while four were coordinators, and eight were officers. The average length of time that participants stayed in their jobs at the time of the interview was 5 years, ranging from 1 to 15 years.
Characteristics of participants for the qualitative interview, Addis Ababa, Ethiopia, 2021
Major themes identified in the analysis
The analysis revealed three major themes in the domains of the current context of medicine OOP payment in Ethiopia, aggravating factors for medicine OOP payment, and plans to reduce OOP medicine payment. Each theme was further split into its respective subthemes where the factors and challenges emerged.
The current context of medicine OOP payment in Ethiopia
The ideas raised under this theme were categorised under overall opinion, circumstances of vulnerability and consequences on households (table 2). Overall, the participants considered OOP healthcare service payments as a widespread problem in the country. Even the insured and individuals eligible for subsidised services were not immune to OOP health expenditures. Payment for medicines was identified as one of the major reasons for OOP payment. Patients in urban areas, those who had to go to the emergency room and those with non-communicable disorders were also more likely to be charged OOP medicine payments.
Current context of medicine OOP payment in Ethiopia, 2021
Regarding the impact of medicine OOP payment in Ethiopia, many of the participants agreed that the cost of medicines is expensive as compared with other healthcare services, and it could lead to impoverishment as it could expose households to high loans and the sale of property. Additional consequences of OOP payments mentioned by participants include a decrease in community healthcare-seeking behaviour, driving households to illegal institutions and affecting the nation’s economic well-being (table 2).
Aggravating factors for medicine OOP payment
Deficits in the medicines supply chain and limitations in the health insurance system were two recurring ideas highlighted under this theme (figure 1). Each of the two concepts is discussed in more detail below.
Aggravating factors for medicine out-of-pocket (OOP) payment in Ethiopia, 2021.
Deficiencies in the medicines supply chain
According to participants, the reason for frequent medicine stockouts in public health institutions ranges from challenges within the health facility to nationwide supply chain issues. Inadequate health facility medicine budgets and low-forecasting capabilities were noted as facility-level issues contributing to medicine shortages. Nationally, foreign currency shortages, the involvement of multiple actors at various levels of the pharmaceutical supply chain and procedural hurdles contributed to supply challenges. Foreign currency shortages have been accused of causing protracted delays in the procurement of pharmaceuticals, resulting in market shortages. As participants indicated, the drug supply chain management process involves a variety of parties with varying capacities and interests. Participants named stakeholders such as national pharmaceuticals regulators, airlines, shipping lines, purchasers, banks and the customs authority as important actors. The lack of coordination in their efforts was identified as a key source of medicine shortages. Procedural hurdles such as delays in purchase approvals and clearance for the release of acquired goods by the Ethiopian Food and Drug Administration contributed to problems in the timely availability of medicines (figure 1).
According to participants, the unavailability of medicines in public healthcare facilities forces patients to purchase them from the private sector at higher prices. Some participants also claimed that private pharmacies that are aware of the lack of medicines in the public sector raise their already high costs dramatically. Participants from the insurance agency claimed to have stopped reimbursing medicine expenditures due to widespread stockouts in various parts of the country, implying that persons covered by CBHI could still be subject to OOP payments (figure 1).
Limitations in the health insurance system
Another aggravating issue for medicine OOP payments was claimed to be the country’s limitations in the health insurance system functioning. Although the number of administrative units (woredas) offering the CBHI has expanded substantially, there are still certain obstacles. The low number of enrolled households, the national health insurance agency’s inability to implement planned and/or better reimbursement policies and guidelines, the health sector’s weak system of checks and balances, the insurance system’s financial constraints and the low level of government subsidy were all mentioned as potential factors that limit the types of services and medicines covered by the insurance system (figure 1). According to participants from EHIA and FMOH, many of the policies and strategies designed to institute a functional insurance system in the previous 5 to 10 years were either not executed or had limitations during implementation. The failure to implement SHI, limitations in the implementation of the third-party contract strategy and the difficulty of issuing a proclamation making CBHI membership mandatory were cited as the primary issues in this respect (figure 1).
Plan to reduce OOP medicine payment
Participants were asked if their institutions have any plans to decrease the impact of OOP payment in the future (table 3). Participants from the EHIA disclosed their preparations to implement the SHI system, in addition to plans to expand the CBHI coverage. Those participants also declared their intentions to put the medicines selection, pricing and reimbursement policies into action. Participants from healthcare facilities discussed strategies to improve the quality of data used in forecasting medicine demand by increasing the digitalisation of the medicine supply system at the health facility level. Some participants also indicated plans to make service price revisions to solve their budget shortage problems. FMOH participants also mentioned that the establishment of an organisation that provides emergency health treatment on a loan basis to the general public is one of their priorities. Furthermore, the national procurement agency has prepared to procure pharmaceuticals regardless of data gathered from health facilities to reduce forecasting errors.
Institutions’ plans to reduce the impact of OOP payment in Ethiopia, 2021
Discussion
The analysis shows that the interviewees and their respective institutions understand the extent and impact of high OOP medicine payment in the Ethiopian healthcare system. It was indicated that OOP payments on medicine are currently the most expensive component of healthcare service expenses, which could potentially lead households to impoverishment. These findings were in agreement with the quantitative analysis based on the household report in 2010/2011 and 2015/2016 Ethiopian surveys.33 These findings could imply the significance of OOP medicine payment in the healthcare-financing system in Ethiopia. The high prevalence of OOP medicine payments was also reported by other developing countries.4 In our context, patients residing in urban areas, those who had to go to the emergency room and those with non-communicable diseases were listed as more likely exposed to high medicine OOP payments. Similarly, several studies, including those done in Ethiopia, reported that socioeconomic status, type of disease, type of healthcare service (inpatient/outpatient service) and health insurance status were frequently identified as contributing factors in the incidence of catastrophic medicine expenditure among households.33 36 37 However, further explorations from a household perspective are required. Because the listed factors in this study are only the perception of participants from decision makers, they do not necessarily represent the views of patients and caregivers.
The current study revealed the potential role of the actions and inactions of federal level institutions such as policymakers and healthcare providers in exacerbating the impact of OOP payment on medicine in the Ethiopian healthcare system. In this regard, one of the findings as an aggravating factor was the insufficient medicine supply system, which resulted in frequent medicine stockouts in public healthcare facilities. A framework of challenges was developed with input from the national medicine supply agency and healthcare providers. Similarly, other studies have found that medicines were frequently unavailable in Ethiopian public health facilities.32 38 These findings emphasised the significance of resolving medicine supply chain issues in public healthcare facilities. This is particularly important because purchasing medicines in the private sector can be costly for low-income households.39 For example, in Ghana, due to a lack of medicine in public healthcare facilities, most households (including the insured) incurred catastrophic OOP medicine purchases from private sources.40 The second aggravating factor investigated in this study was limitations in the health insurance system. Hence, the CBHI has only covered a few medicines. The finding was consistent with another study done in Ethiopia.41 This could imply that insured patients might have to pay OOP for medicines that are not covered by their insurance scheme. This is important because failures in the insurance system are more often linked to socioeconomic devastations as a result of OOP health payments.14 The other revealed challenge was a limitation in the implementation of policies and strategies prepared in the respective institutions. The majority of interventions, particularly those related to health insurance, encountered implementation limitations, which was consistent with other findings in the Ethiopian context. For example, recent studies in Ethiopia reported that implemented financial risk protection strategies are insufficient.42–47 Recognising that the Ethiopian government has been implementing a fee waiver mechanism for the poor since 2004, it was reported that it was ineffective to target the beneficiaries, citing limited service coverage, ineffective poor targeting and poor documentation as some of the reasons.48 49 The consequences of household financial insecurity can be exacerbated by the presence of high poverty prevalence and healthcare accessibility challenges in developing countries.50
The findings of this study may lead to a better understanding of the impact of medicine OOP payment on healthcare accessibility. The current context of OOP medicine payment in the healthcare-financing system can be an indicator of the effectiveness status of various financial risk protection policies implemented in Ethiopia. Despite the protective impact of strategies such as health insurance, fee waiver systems and national medicine supply systems, it should be noted that the desired protection is yet to come. Therefore, various strategies could be considered to prevent high OOP medicine payment and its consequences. Thus, addressing financial access barriers (such as prepayment packages and borrowed funds), enhancing financial policies (such as SHI or population-based tax-funded health-financing systems) and enhancing medicine availability and affordability are all beneficial.4 51 Furthermore, efficient implementation of existing policies, preparing financial protection policies focusing on access to medicines and other innovative strategies are required to combat the financial burden due to medicine OOP payment.
Limitations
Primarily, the smaller number of interview participants may limit the amount of information gained. However, during the interview, the participants were extremely experienced and motivated as a result of which rich data was obtained. This could make the study’s findings significant. Another potential limitation of this study was that the findings were from the perspectives of participants who hold various decision-making administrative positions in government institutions. As such, they do not reflect the lived experiences of patients, caregivers and the general public in relation to OOP payments for medicines.
Conclusion
The findings of this study suggested that OOP medicine payments play the largest role when consumers face financial burdens due to health expenditures, and key informants from policymakers and healthcare providers indicated that their institutions contributed to the impact. From their perspective, the situation was aggravated further by a lack of medicine supply chain capacity, limitation of the health insurance system and lack of financial protection policies and initiatives focusing on access to medicines. This implies that people, particularly the poor, have been facing devastating consequences such as catastrophic health expenditures and difficulty accessing quality healthcare services. In general, the findings of this study can be used as a framework for further assessment and analysis of access to medicine and the financial risk reduction programme in Ethiopia’s healthcare-financing system. This might be managed by identifying the current context of OOP payment on medicine, the status of interventions pertaining to access to medicine and financial risk protection, and policy implementation challenges.
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study. This is a qualitative in-depth interview based study. As such, there is no dataset to share. The only raw data available are audio-records of interviews and verbatim transcripts. While de-identified transcripts can be shared, audio-records cannot.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Ethical Review Committee of the School of Pharmacy, Addis Ababa University (Ethics approval reference number: ERB/SOP/233/13/2020) Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We would like to express our heartfelt gratitude to all of the study participants for their insights during the in-depth interviews.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @AEskinder
Contributors All the concerned authors of this study are men. GAM and EEA conceived the study. GAM conducted all interviews, and EEA guided the process of data collection. GAM, DLA, DT and WA did the literature review. GAM and EEA performed the data analysis. GAM, DLA, DT and WA worked together in transcribing the data, confirming the accuracy of transcripts and themes that emerged from the analysis. GAM drafted the manuscript, and EEA, DLA, DT and WA critically reviewed the manuscript. EEA is the responsible for the overall content as the guarantor. The manuscript has been read and approved by all authors in this study.
Funding Data collection expenses for this research were supported by the Addis Ababa University postgraduate student fund.
Disclaimer No other grant was obtained for the study. The contents of this study only reflect the authors' opinions and do not reflect the interests of the funding organisation.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.