Download Ethiopia, Vietnam, Ecuador

Sarah Nuttbrock
April 11, 2016
PA 510: Global Health Systems
Country Health System Overviews
Country Health System Overview: Ethiopia
Ethiopia is moving towards a health system of universal coverage. Key health services
are provided free of charge, and include: immunizations; counseling, testing, and treatment for
HIV/AIDS and TB; and treatment that prevents mother-to child transmission of HIV. Vulnerable
populations are targeted in this system – those with HIV/AIDS, women, and children.
Payers of health care in Ethiopia are private households (out-of pocket costs), the
government (general taxes), and international donors/NGO’s. To help reduce financial barriers to
accessing health services, the Government initiated a community-based health insurance for rural
populations and those who work in informal sectors. A social health insurance was created for
formal sector employees. The private sector (households, private employers, and non-profits)
manages 44% of the National Health Account (NHA), the Government manages 42% of the
NHA, and international investors manage 14% of the NHA.
Delivery of health care occurs through a three-tiered system with primary care being the
lowest tier, which includes satellite health posts, health centers, and primary care hospitals all at
the district level. This infrastructure at the first tier is referred to as a primary health care unit
(PHCU). The general hospital is the next level, and the top tier is devoted to specialized
hospitals.
Physicians, midwives, and nurses are the main providers of care within the health system.
The majority of these workforce groups are located in urban areas. In rural and pastoral areas
access to health care providers/staff is limited. The system uses health extension workers
(HEWs) at the community level to address the lack of access to professional providers,
2
particularly in non-urban areas. Health officers provide intermediate care in health centers.
Health officers have four years education, with a focus on primary care and minor surgical
procedures. They provide care in urban and rural health centers: however, they are mostly used
in rural areas.
The Health Extension Program (HEP) is a major strength of the system. The program
operates under the philosophy that with the right education, resources, and support, households
can take responsibility for generating and maintaining their own health. The HEP is the main
avenue for implementing the community centered, primary care model within the system and the
method for increasing access to the appropriate level of care through a referral system. Another
strength of the system at the community level is the use of trained, paid community health
workers (HEW’s).
The health care system is moving toward a decentralized or devolved system. This leads
to challenges with local capacity to organize, plan, and manage health. The referral system is
also lacking and has not developed as extensively as was hoped. Another weakness of the health
system involves hospital care. Although Ethiopia is working toward a decentralized system, the
management of hospital facilities is still more centralized and governed at the regional and
national level. Hospital quality and efficiency is an issue. Performance data is often inaccurate,
as hospital management has not been educated or trained regarding data collection, analysis, and
reporting regarding quality measures. Lack of human resources within the health system is an
ongoing weakness.
Retaining HEW’s will be a challenge to the health care system. As HEW’s fulfill their
commitment to their communities, they have been be known to further their education and move
3
on to higher paying positions within the health system, or move from rural areas into urban areas
where more resources are available personally and professionally.
Country Health System Overview: Vietnam
As a socialist country, Vietnam strives to provide health services to all citizens. The
system has been moving towards universal coverage. The health care system provides free
primary care and referral care services to the public. There is a focus on providing care to
vulnerable populations.
A national social health insurance program functions to help the poor access care, to raise
funds for the public health sector, and to protect households from catastrophic health care costs.
The social health insurance program covered about 60% of the population in 2010. The national
government (MOH), businesses/employers, and individuals/households/employees all contribute
to the payment of health care costs. The national government provides subsidies to the provincial
governments to provide health services. There is a private health care system that can be
accessed through private pay.
Health services are provided through a three-tiered system. The primary level of care
focuses on basic health care provided through village health workers (VHWs), commune health
stations, and district health centers. At the provincial level, there are 63 health bureaus that are
required to follow policies from the Ministry of Health (MOH), but they are actually part of the
local provincial government structure. The top tier of the system is the MOH, which is the main
national authority in the health sector. The MOH creates and implements health policy and
programs for the country. Medical doctors, nurses, and medical technicians provide care within
the health care system. Village health workers provide health services in communities.
4
A strength of the system in Vietnam is the decentralization of implementation of health
services and budgeting for health services to the local/provincial level. This allows health
services and health care to be tailored to the local health needs. However, this can also be a
weakness, as noted below. The focus on primary care and the referral system within the health
system is a strength, as is the philosophy to provide primary care for all citizens.
There is a shortage of nurses in the health care system, which creates problems with
patient care and affects quality of care within health care facilities. There is also an imbalance in
the distribution of the health care workforce, with the highest qualified workforce condensed in
urban areas and a lack of workforce in rural areas. Financing at the local/provincial level can be a
weakness of the system. Health care spending at the local level is based on the health interests of
local authorities and their ability to raise funds. This can make prioritizing health care an issue at
the local/provincial level.
One of the current challenges of the system is the retaining highly trained and qualified
workforce in the public health sector. The growing private health care sector is drawing
workforce from the public sector. Retaining health care workforce in the public sector will
require improved and refined financial management techniques and non-monetary benefits to
working in the public health sector.
Country Health System Overview: Ecuador
Ecuador adopted a new constitution in 2008 that mandates access to health care for all
citizens and legal residents. Since this time the health care system has under gone rapid growth
and change. The new health system in Ecuador provides full medical coverage, including
doctors’ visits with no co-pays or deductibles, dental care, and free or discounted prescription
5
medicine. For emergencies, members can go to any hospital in the country for care and the
government will pay for the services provided.
The Social Security Administration manages Ecuador’s national health care plan. In the
last few years they have decided to remove age requirements and pre-existing medical conditions
as exclusionary mechanisms. Voluntary membership is opened to all citizens and legal residents
for a monthly cost of $70.00 per month. Ecuadorian’s working (or who have worked) in the
country pay into the Social Security System.
Most of the care is provided at Social Security hospitals and clinics; however, it is
possible to get care at private health care facilities that contract with the government. There is
also the ability to pay privately (out-of-pocket costs and through private insurance) for services
offered in private health care facilities. The majority of the health services workforce in the
system is physicians, nursing assistants, and nurses.
Ecuador’s system provides fairly comprehensive health care services from basic primary
care to dental and emergency care. This is strength of the system, particularly from the
standpoint of the citizens served under the health system. Another strength of the system entails
the recent expansion and reform of services, which led to the building of new facilities and
hospitals and the purchase of new equipment particularly in larger hospital facilities. As long as
the new infrastructure and equipment can be supported, maintained, and staffed they will be
strengths of the system.
The rapid expansion and growth of the health system and increase in utilization has led to
waits to access certain types of care, specifically specialty care. The government run system also
has a lot of bureaucracy that can make it challenging to navigate the system. As with most
6
health systems, there is unequal access to services between rural and urban areas with rural areas
having considerably less access to quality health services within their communities.
One emerging challenge of the health system is the ability to recruit, train, and
qualify/license workforce to keep up with the recently expanded system and increased utilization
of public health services.
7
References
Ethiopia
African Health Observatory (n.d.). Analytical summary: service delivery. Country Profiles:
Ethiopia. Retrieved April 9, 2016, from
http://www.aho.afro.who.int/profiles_information/index.php/Ethiopia:Analytical_summa
ry_-_Service_delivery
African Health Observatory (n.d.). Analytical summary: health financing system. Country
Profiles: Ethiopia. Retrieved April 9, 2016, from
http://www.aho.afro.who.int/profiles_information/index.php/Ethiopia:Analytical_summa
ry_-_Health_financing_system
Cobb, N.M. (2014). Ethiopia’s health officers. Transformative Education for Health
Professionals. Retrieved April 9, 2016, from
http://whoeducationguidelines.org/content/ethiopia%E2%80%99s-health-officers
Wang, H. & Ramana, G.N.V. (2014). Universal health coverage for inclusive and sustainable
development: country summary report for Ethiopia. Retrieved April 9, 2016, from
http://wwwwds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2014/10/08/00047043
5_20141008093527/Rendered/PDF/912150WP0UHC0C00Box385329B00PUBLIC0.pdf
WHO (2013). WHO country cooperation strategy 2012-2015: Ethiopia. WHO Regional Office
for Africa. Retrieved April 8, 2016, from
http://www.who.int/countryfocus/cooperation_strategy/ccs_eth_en.pdf
Vietnam
Ministry of Health (2010). Five-year health sector development plan 2011-2015. Retrieved April
9, 2016, from http://www.wpro.who.int/health_services/VTN_2011-2015.pdf
Tien, T.V., Phuong, H.T., Mathauer, I. & Phoung, N.T.K. (2011). A health financing review of
Vietnam: with a focus on social health insurance. World Health Organization. Retrieved
April 9, 2016, from http://www.who.int/health_financing/documents/oasis_f_11vietnam.pdf
WHO (2012). Health service delivery profile: Vietnam 2012. World Health Organization.
Retrieved from April 9, 2016, from
http://www.wpro.who.int/health_services/service_delivery_profile_vietnam.pdf
Ecuador
Peddicord, K. (2014). Full medical coverage for just $70 per month: new health care option for
residents is one more reason to think about retiring to Ecuador.
USAID & PAHO (2008). Health systems profile Ecuador: monitoring and analysis: health
systems change/reform. Retrieved April 9, 2016, from
http://www1.paho.org/hq/dmdocuments/2010/Health_System_Profile-Ecuador_2008.pdf
WHO (2013). Country cooperation strategy at a glance: Ecuador. World Health Organization.
Retrieved April 9, 2016, from
http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_ecu_en.pdf?ua=1