Measurements of Universal Health in Ethiopia

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The UK Department for International Development (UK-DFID) has recently decided to allocate funds for establishing universal health coverage in low income countries. The Director of the Global Health Division of the UK-DFID invites you to submit a scoping report with a critical assessment of the type of indicators needed to evaluate and monitor universal health coverage in a low income country of your choice. Your report will be judged on the basis of the following criteria:

  • Illustration and critical assessment of at least 5 relevant direct or indirect indicators (statistics), their sources and overall quality of data. The sources (online) and any other supporting references cited should be numbered either in the footnote or in the Bibliography at the end of the document.
  • Use and reliability of those selected indicators for planning and programme interventions
  • Potential country-specific barriers, where applicable, in implementing the universal health coverage
  • Clarity of presentation, independent critical thinking and creativity

One of the main aims of the UK department for international development is to promote the development and eradication of poverty through the establishment of Universal Global Health coverage in low in come countries. As a result this scoping report focuses on Ethiopia a low income region which has a history of high birth rates, famine, war and the second highest population in Africa (91million) [1]. The regions health care system as consequence is among one the poorest in Africa, making it an ideal region in assigning the types indictors needed to provide UGH [2]. In order to monitor and evaluate UGH it is important to firstly acknowledge that there is no one metric measurement or indicator of health, as health differs from one individual to another and as a outcome an average or optimum is often defined to monitor the overall health of the population [3]. The World Health Report 2013 has provided a widely used framework in order to successfully monitor UGH [4]. Figure 1 illustrates the framework which focuses on three main areas of health. Service coverage: the vital health care services that are needed, Financial coverage: Ability to acquire these services without financial difficulty and Population coverage: the number people that have access to these services. The indictors used in this report aim to cover these three dimensions while also being tailored specifically to Ethiopia’s health requirements.

Table 1: Statistics adapted from WHO data repository [8]

Population using improved drinking-water sources (%)













Adequate access to clean water is a basic human right and the seventh Millennium Development Goal [5]. Clean water is essential to ample quality of life and is used in a diverse range of fields from basic hydration, irrigation, sanitation to complex health care institutions such as hospitals making it a vital component of health [6]. This indicator is categorised into ether improved or unimproved source with improved sources indicating clean water. This classification makes it a simple indicator allowing identification of areas where safe water sources are abundant and areas that need improved water source access, perhaps through water aid programs. This indicator is particularly useful as it can show the range of human impacts on the quality of water through the presence of nitrate as well as compounds and bacteria which can indicate waterborne pathogens the common cause of disease. [7]. Data is provided through national household surveys, the demographic health surveys (DHS) and RADW (Rapid assessment of drinking water quality project) which is carried out by both the WHO and UNICEF with the DHS often providing high quality statistics [4]. Table 1 illustrates that the percentage of improved water sources is disproportionate from 97% users in urban area in 2011 compared to just 39% in rural areas in 2011. This suggests that water sanitation programs should be focused in rural areas where there are less people using improved drinking sources. The results also illustrate that although there are far more users of improved sources in urban areas, the number of users in rural area over three decades have seen a greater increase from just 4% in 1990 to over 39% in 2011 which could be attribute to better surveying in these areas in recent times. The indicator however is a proxy to number of people that have access to clean water as it shows the percentage of users of improved sources and not the amount people that have access to safe drinking water, meaning some social-economic groups such as the isolated poor or elderly are not accounted for as they are less likely to have “access” to these improved sources [7]. The indictor is limited only showing percentages for rural and urban areas; an indication of sub-urban regions would provide are more in-depth analysis of overall water quality in the region. Recognition of which gender the improved water source is mainly being used by i.e. men, women or children is also unaccounted for which could be crucial indicator as children are highly impacted from waterborne pathogens [2]. Furthermore even though water is being used from an improved source, this water still needs to be obtained from larger sources leading to possible contamination during transportation or even storage invalidating the indicator. Guidelines presented by WHO for safe drinking water is also assumed constant over time by indictor limiting it accuracy [9], overall this indicator can provide an overview of water quality but accuracy of the indicator can be skewed to urban areas.

The overall health of the population is often measured by life expectancy, this indicator is widely used and data regarding this indictor is readily available. Life expectancy is a longer term measure of health and an overall indication of health over the years. Life expectancy in Ethiopia has been improving over the years from around 55 years at birth in 2004 to 62 years in 2011[8]. It is an important indicator in reflecting the overall mortality of the population; this is helpful for the governmental as it illustrates the trend through time of the overall population and improvements in life expectancy can reflect better nutrition, hygiene and effective medical intervention within the nation [10]. However unless a comprehensive cohort/period life table is developed, life expectancy at birth assumes that health conditions remain constant throughout the lifespan of the individual, an inaccurate assumption given the higher mortality rates in the first year of life and lower mortality at around middle age.

Table 3:

Data adapted from WHO, World Bank and DHS. [8], [10],[11]

BCG among 1 year’s olds (%) [8]

Under 5 mortality rate per 1000 births [10]

Children Fully Immunised (%) [11]














Vaccination is an essential component of health in many low-income countries with the fourth MDG main aim being the reduction of child morbidity and mortality [5]. Immunisation can help reduce mortality and usually is cost effective while also being an excellent indictor of the health among children. BCG is the best indicator of full immunisation coverage as the WHO states children can be classified full immunised once they have received a tuberculosis vaccination (BCG) [9] therefore a BCG indicator is vital in monitoring health of children. Table 3 illustrates the importance of BCG vaccination with the percentage of coverage improving over the years from no vaccination in 1980 to over 80% of 1 year olds having being immunised in 2012 suggesting an improvement in the protection of children against TB, this is further reinforced by the decline in under five mortality rate. The validity of the indictor can be backed up by it its correlation to under 5 mortality rate; Table 3 illustrates a linear relationship in increasing immunisation and declining child mortality, showing the success of the indictor in monitoring UGH among children. However universal health through immunisation in reality is hindered by a delay in diagnosis of tuberculosis in Ethiopia which can exacerbate the disease [12], combined with the majority of children and citizens being concentrated in rural areas where there is no real means of transportation available to attend a hospital for vaccination, [2] making the indicator biased to people who can access vaccination facilities. The BCG indicator is effectively used in TB prevention, treatment and psychological suffering through basic programmes such as stop TB strategy programme [4]. Data provides estimations between the accurately reported immunisation figures by national authorities and those where data may present misleading figures [8]. This means the data may not be fully accurate as it is a estimation of actual and misclassified figures. However this indicator is vital for monitoring and guiding disease and eradication programmes and efforts in Ethiopia. Although BCG percentage shows a high coverage over tuberculosis it does to provide accurate analysis of UGH in terms of other diseases such as malaria. The percentage of full immunised children is a better indictor for UGH as it indicates children which are protected against all diseases. However only 24% of children are fully immunised which suggest that although 80% of children are immunised this is misleading as this 80% are only immunised against TB and not other deadly diseases. Although the WHO suggests children are not fully covered against diseases until they are immunised from TB, the immunisation of other diseases prior to the TB vaccination needs to be considered.

Anaemia is defined as a condition which is characterised by low levels of haemoglobin in our blood, in the case of Ethiopia anaemia is a major concern with low come groups being among highest at risk [13]. This is an important indicator in children as anaemia is associated with impaired mental and physical development and increasing morbidity and mortality. This indicator is particularly helpful because it has allowed a number of preventions programmes to be put into place such as enhanced outreach Strategy and Targeted supplementary foods intervention programme which aim to improve nutrient in among children. More than 44% of population in 2011 is still anaemic with 21% percent of children having moderate anaemia illustrating the importance of this indicator in monitoring UGH in children and future programme intervention development. However this indicator is constraint to children limiting its capability, it is also misleading as there are also other factors related to anaemia such iron deficiency, and Vitamin A levels which this indictor does not account for providing inaccurate assessment [9].

Table 3: Indicators adapted from WHO, DHS and UN [8],[11],[14]

Maternal Mortality Ratio MMR per 100,000 live births [8]

Live Births Delivered at Health Facility (%)


Births attended by skilled heath Personnel (%) [15]














Maternal mortality in Ethiopia is among the highest in the world and it is the biggest killer of women in Sub-Saharan Africa with the fifth MDG aiming for a reduction of 75% from 1990 to 2015 [5]. Maternal health is often measured by the maternal mortality ratio which is expected to be useful in indicating the deaths among women, the risk associated with pregnancy, monitoring achievement towards MDG 5 and the capacity of health systems within Ethiopia to provide effective health care [14]. Table 1 illustrates the maternal mortality ratio, illustrating initially that there is reduction in maternal morality in Ethiopia and an improvement over the years with some considerable progress towards MDG 5. However the MMR ratio does not take into consideration several key factors that can impact women during her pregnancy. The indictor is irrespective of the duration of pregnancy and also where the birth took place giving an inaccurate assumption how amount of mortalities. The relationship between the MMR to percentages of live births that took place in health facility shows a poor correlation because although there has been a significant reduction in mortality from 1990 to 2011 this is misleading as only 9.9% of these births took place in adequate well equipped hospitals suggesting MMR should be higher. Measuring mortality is difficult and inaccurate as it is a ratio based on estimations between the total maternal deaths and total live births which does not account for women which have died during the pregnancy. The ratio also fails to show the factors which lead to high or low level of mortality which could prove vital to reducing mortality as an indication of this would allow a focus in future planning to reduce the MMR. Sources of data are varied with different methods being used to derive country estimates, with many rural areas having no data at all making results biased [14]. A more accurate indictor of UGH of maternal health is number of live births in health facilities and births attended by skills personal, both indictors show low percentages suggesting and poor health care service as an increase in number births at hospital and with better equipped personnel is likely to reduce maternal deaths. These two indictors also show why maternal death rates are so high as apposed just showing number of deaths. The MMR indictor used is not a reliable indictor of UGH among pregnant women and more focused indictors such one shown in table 3 are recommended for UGH.

As stated in the introduction there is no one measure of universal health among a country, individual, or the world. Each indicator has it own weakness and strengths as illustrated above. All the indictors in this report have been chosen as they are most suited to Ethiopia and it requirements, this report suggests that some indictors i.e. Immunisation and percentage population using improved water sources may be better indictors than other such as life expectancy and maternal health in monitoring UGH. However any indictors used to monitor UGH should be chosen for future policy planning, MDG assessments and intervention schemes.


1: The World Bank, working for a world free of poverty. (Accessed 15 February 2014).

2: Murray, J.S., Moonan, M. Recognizing the healthcare needs of Ethiopia’s children. Journal for Specialists in Pediatric Nursing 2012; 17(4):339-343. 10.1111/j.1744-6155.2012.00328.x (Accessed 15th February 2014).

3: Abraha, M.W., Nigatu, T.H. Modeling trends of health and health related indicators in Ethiopia (1995-2008): a time-series study. Health Research Policy and Systems 2009;7(1)1-17 (Accessed 12 February 2014).

4: World Health Organization, research for universal health coverage: world health report 2013. The World Health organisation 2013.

5: United Nations Millennium Development Goals: We can end poverty (Accessed 12 February 2014).

6: Onda, K., LoBuglio, J., Bartram, J. Global Access to Safe Water: Accounting for Water Quality and the Resulting Impact on MDG Progress. International Journal of Environmental Research and Public Health 2012;9(3)880–894. 10.3390/ijerph9030880 (Accessed 12 February 2014).

7: Bain, R., Gundry, S., Wright, J., Yang, H., Pedley, S., Bartram, J.. Accounting for water quality in monitoring access to safe drinking-water as part of the Millennium Development Goals: lessons from five countries. Bulletin of the World Health Organization 2012;90(3),228–235.

8: The World Health Organisation, Global Health Observatory. (Accessed 15 February 2014).

9: Central Statistical Agency [Ethiopia] and ICF International. 2012. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International.

10: The World Bank, Indicators. (Accessed 13 February 2014).

11: Demographic and Health Surveys, Country Quickstats. (Accessed 15th February 2014).

12: Demissie, M., Lindtjorn, B., Berhane, Y. Patient and health service delay in the diagnosis of pulmonary tuberculosis in Ethiopia. BMC Public Health 2002; 2(1) 1-7 (Accessed 13th February 2014).

13: Balarajan, Y., Ramakrishnan, U., Ozaltin, E., Shankar, A.H., Subramanian, S.V. Anaemia in low-income and middle-income countries. Lancet 2011;378(9809) 2123–2135 10.1016/S0140-6736(10)62304-5 (Accessed 16Th February 2014).

14: The World Health Organisation, Indicator and measurement registry. (Accessed 19th February 2014).

15: UN Data, Statistics. (Accessed 19 February 2014).

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