I am currently conducting research on transparency and oversight of financial systems in the health sector in Ethiopia. My time here has allowed me to reflect on a number of challenges to health service delivery that this large – and extremely diverse – country is facing. I’ll probably be mulling over most of what I have observed for some time, so expect any overload of info on Ethiopia in the coming weeks – provided I have access to electricity and internet that is!

The Federal Ministry of Health in Ethiopia tends to think big and has recently implemented a number of really large health reforms, including a major expansion in the number of health posts available across the country and the creation of a health extension worker programs to provide basic services in rural communities. The rationale for both of these initiatives is to expand the quantity of basic primary health services available.

Core maternal and chid health indicators in this country are startling – and upsetting. Nationally, only about 5% of births are supervised by trained medical personnel or take place in any sort of medical facility – the lowest I have ever seen. The WHO recommends that about this fraction of births should be receiving a caesarian section – not just the fraction that should be supervised – so the low use of modern delivery services is certainly contributing to the high rates of maternal mortality. It also helps to explain why I have seen so many fistula hospitals scattered across the country.

But I wonder how much of the Ethiopian story can be explained by just the availability of basic services? I suspect that there is a big cultural story that these reforms do not address. But I also think it might have a lot to do with the quality and sophistication of services available. Last week I visited a rural woreda (like a district) about 50 km from a regional capital city in Northwestern Ethiopia The woreda had a population of approximately 350,000 people and while the area had seen substantial expansion in health centers and health extension workers, the woreda still did not have a single health professional qualified to perform a caesarian section. My back of the envelope calculations suggest that roughly 10,000-15,000 births take place in the woreda each year (4% of population), and that about 1000 caesarian sections should be conducted every year (5-8% of births), more than enough to justify a skilled health professional to conduct caesarean sections alone (2 a day, essentially a full workload). But such a professional did not exist.

There is an emerging literature that suggests that poor patients in developing countries demand more than just basic services – it suggests that they are intelligent consumers willing to pay more for higher quality services. A recent Health Policy and Planning article by Margaret Kruk and co-authors makes this point for delivery services in Tanzania – a substantial share of women bypassed the primary services available to them in their communities for services that they perceive to be of higher quality at a substantially higher price. It may very well be the case that Ethiopian women don’t value the types of services that are available to them and that even large scale expansions of basic health services will never satisfy their needs.

It is unfortunate that trade offs between quantity and quality must be made – but usually that is the reality in a resource constrained environment like Ethiopia. Donors have shown that ensuring both is possible for HIV/AIDS treatment programs – the HIV wing is always the fanciest place at every health center – but it is too bad that there is not more emphasis on quality in other aspects of the health sector. Until such concerns are address, I fear that little progress will be made.

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1 Response » to “Quantity and quality trade-offs in health service delivery”

  1. Sarah says:

    Great blog Karen.
    Yes, quantity does not necessarily translate into quality.
    I wish you do a comparative study on Eritrean health service delivery as well, where I volunteered over 10 years ago. Incredible dedication but with out much funding,yet I guess if one has something to prove, that can make a whole lot of difference.

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