This month, we explore the type of health care system experienced by much of the developing world. Termed the “voluntary system,” other than for some basic primary care, many countries that function this way do not offer comprehensive health care coverage to their citizens who often witness high out-of-pocket costs. Technically speaking, prior to the Affordable Care Act, much of the United States was part of a voluntary system of private health care insurers often only available to people holding a job with good benefits or for individuals purchasing their own plans. 

Tsion Firew, MD, MPH, FACEP, is an emergency physician, assistant professor of emergency medicine at Columbia University in New York City, and an advisor to the Ministry of Health for the Federal Democratic Republic of Ethiopia. She has previously written for ACEP Now about her work for the World Health Assembly at the World Health Organization (WHO). Our conversation focused on Ethiopia’s health care situation and how their government tackles key issues. 

Share a little bit of your background and why you’re so passionate about health care in Ethiopia. 

Dr. Tsion Firew: I interned at WHO when I was a fellow in 2017. We worked on developing emergency care toolkits that could be used at first level entry hospitals in most places around the world. A year later, I joined the Ministries of Ethiopia’s advisory team. One thing we realized at that time was that a resolution on emergency care at WHO-level had not been passed for almost a decade. And that was a very important distinction because a lot of the medical priorities are set by donor markets. Most philanthropists and a lot of money for global health purposes go toward infectious diseases like tuberculosis (TB), HIV, and malaria, but not so much on health care system strengthening, like emergency care.

Dr. Firew (middle) demonstrates an ultrasound to medical students.

We were able to galvanize the support of the executive board committee at WHO to pass a resolution on emergency care. The resolution passed in 2019 and outlined the needs and the gaps to make emergency care a reality. This victory happened coincidentally right before the pandemic, which as we know, emergency physicians have been at the forefront all over the world. 

Ethiopia is the second largest country in Africa by population with 115 million people. And going back to 1978, there is the Alma-Ata Declaration for Primary Health Care. There‘s been a focus in trying to get primary care universalized in Ethiopia.

Dr. Firew: This has been the case for the past 20–30 years to make primary care at the center of most of the discussions at the decision table. Emergency care is the other side of the coin of primary care. Because we see acute emergencies in the primary care settings mostly handled inappropriately by physicians who are not able to address many emergencies. 

One other tidbit that was interesting to me is when we talk about the split of the Ethiopian population, about 80 percent is rural and only 20 percent is urban. That discrepancy really leads to some disparities in care.

Dr. Firew: Ethiopia is one of the poorest countries in Sub-Saharan Africa. The per capita income is only 850 dollars per year and a lot of people who live in urban areas (20 percent) usually pay out of pocket for their health care, while 80 percent of the population living in rural areas have access to community health services and primary level hospitals. Most of the health care is subsidized by the government to what we call the Community Based Health Insurance (CBHI). People pay very low amount of money per year to participate in CBHI and it’s government subsidized for most care. But again, that’s for very basic, preventative care and it doesn’t cover surgical care and other subspecialty care.

Winding roads in the Ethiopian highlands.

What are some of the difficulties with having such a large proportion of health care being paid for out-of-pocket?

Dr. Firew: One of my first experiences working in Ethiopia as a senior resident was at a hospital called Black Lion Hospital, which is in the capital city, and it’s also the hospital where I was born. And there were patients who were being referred from all over the country because it’s the only hospital that has all the subspecialty surgical programs. And there are people that have waited for years for elective surgeries. Unfortunately for 80 percent of the population, that’s the reality. For other people that live in the urban areas, people are willing to pay out of pocket. They’re private hospitals and they’re also private groups that you can pay out of pocket and be able to get that surgical care immediately. Many people will wait for knee replacements or hip replacements because in addition to the subspecialty services, it’s the materials you’re waiting  to get imported from outside the country. For some people, waiting for elective surgery might be months to years.

What about things that are hopefully a little less expensive, like medications, as opposed to surgical procedures? 

Dr. Firew: Some medications are available widely, and they’re also subsidized by the CBHI program, especially for people in the rural areas. They’re also restricted in a way, too. For example, there might be only five medications that are available for a specific disease like hypertension. And if you want to buy other medications outside of that selection, or if your doctor recommends other medications outside of those five medications, you most likely will have to pay out of pocket. There are also a lot of issues with counterfeit medications.

One thing we saw during COVID, especially with the shutdowns, people closing their borders, and when India was suffering from the peak of the pandemic, they stopped exporting most of their medication. And because the medications are not being imported to Ethiopia, there were a lot of shortages that we witnessed all over the country. 

Where else have you worked internationally?

Dr. Firew: I’ve worked clinically in Haiti and in Mosul, Iraq.

Taking your experiences from those three places, comparing it to Columbia University, how would you say they‘re different? How are they the same?

Dr. Firew: I think the personality of emergency physicians in general, including from our sarcasm, our problem-solving skills, our drive to help people, is very similar. When I worked in Mosul, Iraq, I was at a trauma stabilization point, which is a makeshift hospital in the middle of a war zone. There are missiles and bombs going off. And it’s very difficult even to compare that to the stable clinical environment. All that said, there was nothing compared to what I experienced here in New York City during the pandemic. Even working in the richest countries, overnight, can become resource poor, and those skills come very handy in certain times. 

Have you actually been a patient in Ethiopia where you can remember what happened? If so, how was that experience?

Dr. Firew: When I was pregnant and traveling in Ethiopia, I was about eight months pregnant and I made sure there was going to be a place that would give me an epidural in case I went into labor. I had to navigate that and there are not a lot of places that offer epidurals and I was very surprised, and only public hospitals and only a few anesthesiologists can administer it. I made sure to contact them, so I was kind of preparing for the worst. But, that’s just typical emergency physician attitude in case I went into labor and did not want to go through this naturally. Thankfully, I was back in the U.S. by that time and had a planned birth.

Anything else you’d like to share to the readers about your experiences? 

Dr. Firew: It’s a little bit of a caveat, but emergency physicians are addicted to coffee and Ethiopia is seen as the birth place of coffee in an area called Kaffa. So, every time you drink coffee, thank an Ethiopian for discovering that for you! 

Dr. Dark is assistant professor of emergency medicine at Baylor College of Medicine and the medical editor in chief of ACEP Now.