Submission ID 131630
| Issue/Objective | As external financing becomes less predictable, equity in primary health care (PHC) increasingly depends on how governments replace, pool, and govern domestic resources. In Ethiopia, districts vary markedly in their ability to absorb funding shocks, protect essential services, and prevent cost-shifting to households. This study assessed the equity effects of PHC financing transition and identified governance features associated with better protection of service delivery during fiscal contraction. |
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| Methodology/Approach | We constructed a balanced district-level panel for 146 districts across 5 regions and 2 city administrations from 2019-2025, linking district expenditure ledgers, community-based health insurance claims, facility revenue records, and DHIS2 service data. Outcomes included inflation-adjusted PHC expenditure per capita, outpatient visits, DTP3 coverage, ANC4 completion, referral rates, stock-out days for tracer commodities, and the share of facility revenue derived from out-of-pocket payments. We estimated district fixed-effects and event-study models around abrupt reductions in external support, with subgroup analyses by poverty quintile and remoteness. |
| Results | Real per-capita PHC spending fell by 14.7% in the poorest district quintile, compared with 3.2% in the richest. Districts experiencing a funding replacement lag of more than 9 months had a 6.4 percentage-point decline in DTP3 coverage and a 9.1% reduction in outpatient utilization relative to pre-shock trends. Median stock-out days rose from 18 to 31 days per quarter, while facility dependence on out-of-pocket revenue increased from 8.6% to 14.2%. Districts with ring-fenced PHC transfers and stronger CBHI pooling capacity showed smaller service losses and faster recovery. |
| Discussion/Conclusion | Financing transition is not only a fiscal event; it is an equity test of governance. Ethiopia's experience shows that in fragmented and uncertain funding environments, domestic stewardship, pooling design, and speed of replacement financing determine whether shocks widen or cushion inequity. Protecting PHC through explicit equalization mechanisms is central to reclaiming global health equity. |
| Presenters and Affiliations | Kassa Fentaw Economic PolIcy and Innovation Center for Health Systems Kassa Fentaw EPIC Health Systems Kassa Fentaw EPIC Health Systems |
