When I landed in Addis Ababa, I had a feeling that many aid workers no doubt experience: ‘I’m coming to contribute with my work, but I will end up learning much more than I give.’ This initial impression was borne out, and that’s one of the things that makes development cooperation so stimulating and educational.

And when the country is Ethiopia, these feelings can be more intense, because it’s a very special country. The altitude, the temperate climate; a conservative culture that dates back to the dawn of Christianity; the tolerance of the people with only occasional animosity between the Christian majority and the sizeable Muslim minority; the absence of European colonisation; and the suffering of the past, still palpable, make it a unique country.

For several years, the Ethiopian government has been committed to achieving universal health coverage and providing access to healthcare services. A public care network currently exists that requires co-payment for each healthcare service received and includes payment exemptions for childbirth, malaria, and extreme poverty. The main challenge is to achieve a level of quality sufficient to make this universal coverage a reality, as people who can afford to, even if it means enormous sacrifices, prefer private healthcare, and the poor endure much greater risks.

When I reviewed the most general demographic and health indicators, I wasn’t really surprised, but confirming the existence of such gaping needs never ceases to be shocking. With a population of over 80 million people, nearly half are under 15 years of age. Preventable transmissible diseases and malnutrition-related disorders continue to be widespread. The infant mortality rate is around 75 per thousand, and 90% of this is due to pneumonia, diarrhoea, malaria, neonatal complications, malnutrition, and AIDS.

The maternal mortality rate continues to be high, around 600 cases per 100,000, almost always due to avoidable causes. The problems include a shortage of qualified midwives, defects in procedures for referring patients to clinics, substandard care, and a paucity of funds for key services.

One of the principal measures for improving healthcare is financial reform aimed at achieving more efficient, suitable, and equitable care, eliminating the need for patients to pay out-of-pocket in the case of illness, especially in cases of very serious financial difficulties.

The main financial reform measures are the following: allowing healthcare centres to retain their own revenues for use in providing better care; suitable design of a system of payment exemptions for certain cases; outsourcing of non-medical services in healthcare centres; allowing hospitals to have private wings; autonomy for healthcare centres by allowing them to have their own governing bodies; and the use of social insurance to finance the public healthcare system.

The establishment of social insurance as a means of financing healthcare means transitioning from a system where people are bankrupted when illness strikes to one where the policyholder pays only a monthly or annual premium, which transfers the financial risk of getting sick to an insurance company, in this case the Ethiopian Health Insurance Agency. Being a social insurance system, this premium is not affected by age, gender, or pre-existing conditions.

Two schemes are planned for establishment of the insurance coverage, aimed at different segments of the population. A Social Health Insurance scheme for the formal sector: civil servants, public enterprises, and private companies with more than ten employees; and a Community Health Insurance scheme for the informal and agricultural sector.

The Ethiopian Health Insurance Agency is in operation and ready for the Social Health Insurance scheme for the formal sector to begin functioning whenever the government decides; as regards the Community Health Insurance scheme for the informal sector, this is in the pilot phase in various regions with promising results. But the health insurance programme will only be effective if it is financially healthy and has a clear vision of the resources needed to sustain it over the long term.

To achieve this, the central part of our technical assistance involved ensuring that the Agency has the necessary financial management tools, especially for assessment of its financial sustainability and analysis of statistical information, and that the technical staff responsible for these tasks develops the knowledge and skills to do so.

Thus, we developed a computerised model designed to estimate the future income and expenses of health insurance policies for a ten-year period, so that the user can enter data and relevant demographic and economic hypotheses, with the model supplying the desired results. These results are the estimated trends according to the hypotheses put forth, in the form of a ‘what if’ scenario. For people to use this tool, it was also necessary for us to provide training to the technical staff on the accompanying statistical software, methods of calculating payments to hospitals for inpatient treatment, the data needed for income and expense projections, and the financial basis of social health insurance.

With this, we hope that the Ethiopian health insurance scheme will be able to determine and estimate for the future the portion of the population to be covered; the premium rates and other revenues that will be needed; the financial burden on the government as an employer; different operating scenarios with different employment and inflation levels; the evolution of the population structure, the costs of healthcare services, etc.

As part of our project, an Ethiopian delegation travelled to Madrid and Toledo to learn first-hand about the Spanish National Health System and exchange experiences. I know that this visit was enormously helpful for them.

I have the hope that all of this has contributed in some way to improving the prospects for Spanish cooperation with Ethiopia in health.

Juan José Charro is an expert from the International and Ibero-American Foundation for Administration and Public Policies (FIIAPP) who works in the APIA Programme (Support for Inclusive Public Policies in Sub-Saharan Africa), which is managed jointly with the Spanish Agency for International Development Cooperation (AECID).

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