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Ethiopia: A Multi-Faceted Approach to Expanding Access to Quality Health Care

For more than 15 years, Abt Associates has worked with Ethiopian government leaders in health care, health facility managers, and health workers through USAID-funded projects to strengthen Ethiopia’s health system.

“We’ve seen Ethiopia make great strides in expanding health coverage and access to essential primary care,” said Diana Silimperi, M.D, division vice president for International Health at Abt Associates.

Abt’s work in Ethiopia began with health sector financing reform and expanded to broader health system strengthening, including supporting the private sector and promoting public-private partnerships.

Abt has been Ethiopia’s principal partner in health financing reform since the Partnerships for Health Reform (PHR) plus project (2000-06). We have continued our support through successive bilateral and global projects, including Essential Services for Health in Ethiopia (ESHE I and II, 2001-08), Health Systems 20/20 (2006-12), Health Sector Financing Reform (HSFR, 2008-13), and the Health Finance and Governance project (HFG, 2012-17). Abt also has supported indoor residual spraying and entomological monitoring and surveillance to control and prevent the spread of malaria and other vector-borne diseases.

Abt has also been the main partner to Ethiopia and USAID on private sector health. Abt led the Private Sector Program in Ethiopia (2004-09) and the Private Health Sector Program (2009 – 2015) and is implementing the Private Health Sector Project (2015 – 2020). All of these projects have supported private sector engagement in Ethiopia’s health system and partnership between the public and private sectors to deliver critical public health services.


A man with community-based health insurance (CBHI) talks during a meeting held at Gimbichu woreda in Ethiopia. CBHI has helped Ethiopians access more health services and better protect themselves from catastrophic health spending.
A man with community-based health insurance (CBHI) talks during a meeting held at Gimbichu woreda in Ethiopia. CBHI has helped Ethiopians access more health services and better protect themselves from catastrophic health spending.


A Long History of Steady Health Reform Assistance

A cornerstone of achievement during Abt’s assistance is supporting the Government of Ethiopia to pilot and expand community-based health insurance (CBHI) across Ethiopia.

In 2011, with Abt support, Ethiopia piloted CBHI for the informal and rural sector in 13 districts, or woredas. An evaluation of the pilot conducted in 2014 under the HFG project found that:

  • More than half of eligible households – 157,000 out of over 300,000 – were enrolled in the pilot schemes, which covered more than 700,000 people;
  • CBHI scheme members had better health seeking behavior and higher health services utilization rates; and
  • CBHI members were better protected from catastrophic spending than non-members.

Based on the pilot’s results, HFG helped the government to design a national strategy to scale up CBHI. Through June 2016, CBHI schemes have been established in an additional 227 woredas, and 10.9 million people in 2.4 million households have enrolled in CBHI. Health seeking behavior has improved among enrolled families to almost double the national average.

Ethiopia’s goal is to cover 80 percent of the country’s eligible population in 80 percent of Ethiopia’s woredas by 2020.

Increasing Local Decision-Making and Financial Independence

Another significant body of Abt-assisted work is decentralizing health care and health finance decision-making.

HSFR/HFG has strengthened health facility governance structures in 161 hospitals and more than 3,095 health centers by supporting the establishment of facility governing boards. HSFR/HFG – continuing work begun by previous projects – trained staff on health finance reform, board member/management, committee/facility finance, and administration staff roles and responsibilities across a range of issues.

Now nearly all hospitals and health centers in Ethiopia have functioning governing boards, fostering greater autonomy and decentralization of facility-level planning, management, and decision-making. This ensures more local input and control over resources and that health centers and hospitals retain revenue and better respond to client needs.

Also, the Abt-led Strengthening Health Outcomes through the Private Sector (SHOPS) project (2011-16) worked directly with private health providers to strengthen the financial and business management of private health care facilities to operate on a sustainable and viable basis, and improve their credit-worthiness.

Abt, through a new SHOPS associate award (2015-20), is continuing to build the capacity of Ethiopia’s private sector to provide priority health services and sustain quality assurance systems.

More Flexible Hospitals, Better Health Care for the Poor

Abt assistance has helped produce other significant results, including:

  • A sizeable increase in public hospitals’ budgets by allowing them retain more of their fees, outsource non-clinical services, and create private wings – which also helps them to better retain health professionals;
  • An expansion in Ethiopians’ overall access to care by standardizing health services and fees – and fee exemptions for the poor – and supporting an expansion of private health insurance; and
  • Improvements in the quality of care by creating a framework for accreditation of private laboratories and through the creation and strengthening of national and local private health facility associations and professional provider associations.

Read more about Abt’s work in Ethiopia: