Government Budget Allocation for Primary Health Care in Ethiopia

Government Budget Allocation for Primary Health Care in Ethiopia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Government Budget Allocation for Primary Health Care in Ethiopia Amanuel Haileselassie Gebremedhin, Dr. Meklit Yitbarek, Dr. Mulugeta Dile Worke, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9105032/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Ethiopia has pursued Health Care Financing (HCF) reforms for over two decades as part of its commitment to achieving Universal Health Coverage (UHC). With a health policy anchored in Primary Health Care (PHC) and a decentralized planning framework, the country has introduced numerous interventions to strengthen domestic resource mobilization, enhance autonomy at service delivery points, and build local capacity. Methods This study analyzes PHC budget allocation and expenditure trends in 15 woredas across five regions from 2010 to 2016, using mixed methods. Results Financing of the HSS-PHC system yielded a performance score of 29%, indicating significant challenges in resource allocation and financial management. Two key indicators determined this: Funding and allocation of resources (14%) and purchasing and payment systems (39%). While nominal health budget allocations have increased over time, real-term values adjusted for the non-food consumer price index have declined. The average PHC spending represented 17.3% of general government expenditure—exceeding the Abuja Declaration target—yet regional disparities were notable, ranging from 9% to 26.4%. Persistent challenges, especially in CBHI implementation, exempted service reimbursement, and provider-level autonomy, were particularly pronounced in pastoralist regions. Conclusions Inadequate budget allocation from the treasury, the expanding need of communities, shocks from different emergencies, and high inflation rates in recent years have led to widening gaps in health financing. Alternative financing mechanisms (CBHI) didn’t catch up with the widening gap because of inadequate implementation, low potential as a financing strategy due to low premium rates, and lack of mechanisms to enforce reimbursement of health facilities. These findings underscore the need to reinforce public financial management and leadership capacity at district and facility levels to ensure more equitable, efficient, and transparent PHC financing. Primary Health Care Budget Expenditure Health Financing Community Based Health Insurance Woreda Ethiopia Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Universal Health Coverage (UHC) is a global imperative that ensures individuals can access essential health services without experiencing financial hardship. Achieving this vision requires a robust health financing system with three essential functions: mobilizing revenue, pooling resources, and purchasing services—functions that directly support the building blocks of the health system and progress toward UHC objectives ( 1 ). Global commitments have guided national efforts to monitor and accelerate progress in health financing. A notable example is the Abuja Declaration, which urges governments to allocate at least 15% of their national budgets to the health sector ( 2 ). In line with such frameworks, Ethiopia’s Health Care Financing Strategy sets ambitious goals to increase domestic health resources, promote efficient resource use through decentralized planning, and improve both service coverage and quality ( 3 ). Primary Health Care (PHC) has long been recognized as Ethiopia’s strategic pathway to achieving UHC. Fiscal decisions concerning health budgets are made at the federal, regional, and woreda (district) levels, coordinated by the Ministry of Finance, Bureau of Finance, and Woreda Finance Offices, respectively ( 4 ). According to the National Health Account, approximately 65% of government resources are managed at sub-national levels; yet in 2019/20, only 8.5% of general government spending was allocated to the health sector—far below the Abuja target ( 5 ). Despite over two decades of Health Care Financing (HCF) reforms, the Ethiopian health system remains constrained by low public spending, high out-of-pocket payments, and ongoing reliance on donor funding ( 6 ). Moreover, there is a persistent gap in evidence on public health expenditure at the sub-national level. Such data is critical not only for illuminating funding gaps but also for cultivating a culture of data-informed decision-making within health sector leadership and budgeting structures. This review aims to fill that gap by analyzing trends in PHC budget allocation and expenditure at the woreda level across 15 districts in five regions. It assesses the government’s response to shrinking donor contributions, evaluates the prioritization of health in district budgeting processes, and explores the impact of these trends on health facility performance. Importantly, the study also adjusts budget data for inflation using the non-food consumer price index, providing a more accurate picture of financing capacity over the past seven years. Methods Study Setting This study was carried out in 15 woredas across the Afar, Amhara, Oromia, Sidama, and Somali regions, selected through a collaborative and participatory process designed to enable an in-depth assessment of primary health care financing at the district level. Selection was based on a strategic set of criteria, including performance across key reproductive, maternal, neonatal, and child health indicators; regional and contextual diversity aligned with the Integrated Health System Strengthening (i-HSS) project; and the demonstrated commitment of local leadership to actively engage in implementation. Importantly, the chosen woredas represent a deliberate mix of high-, medium-, and low-performing districts—creating an opportunity to draw comparative insights and identify context-specific strategies for strengthening PHC systems across varying performance landscapes. (Table 1 ). Table 1 List of woreda selected for the iHSS project by region, zone, and PHC performance Region Zone woreda Performance Somali Fafan ZHD Gursum WoHO (SM) High Somali Jarar ZHD Dhegahbur WoHO Low Somali Siti ZHD Erer WoHO (SM) Medium Afar Zone 1 ZHD Chifra WoHO Low Afar Zone 3 ZHD Gewane WoHO Low Afar Zone 5 ZHD Telalak WoHO Low Sidama Central Sidama ZHD Wensho WoHO Medium Sidama Northern Sidama ZHD Hawella WoHO Medium Sidama Southern Sidama ZHD Aleta Wondo WoHO Medium Amhara North Shewa ZHD Antsokia Gemza WoHO High Amhara North Shewa ZHD Taremaber WoHO Low Amhara South Wollo ZHD Kallu WoHO Medium Oromia Buno Bedele ZHD Gechi WoHO High Oromia Jimma ZHD Shabe Sombo WoHO Medium Oromia Ilu Aba Bora ZHD Hurumu WoHO Low High= High performing; Medium= Medium performing; Low = Low performing Study Design A cross-sectional, mixed-methods approach was employed to assess trends and performance in PHC financing at the district level. Quantitative data focused on budget allocation and expenditure trends from 2010 to 2016 EFY, while qualitative data provided contextual understanding of systemic challenges and facilitators. Measurement This assessment was guided by the World Health Organization’s Primary Health Care (PHC) Measurement Framework, with a particular focus on the domain of health financing—alongside governance, availability and distribution of inputs, and overall PHC system performance. A central line of inquiry was whether PHC funding and expenditure had grown relative to other government sectors, and how much of total health spending was financed by government sources versus other contributors. Within this, the “funding and resource allocation” indicator examined the proportion of the Woreda Health Office (WoHO) budget against the total woreda budget, measured against the 15% Abuja benchmark. It also assessed the presence of pre-payment mechanisms and emergency funding provisions at the district level. The “purchasing and payment systems” indicator evaluated financial practices surrounding exempted services and the implementation of Community-Based Health Insurance (CBHI). Findings from the assessment point to consistently low performance across financing metrics—highlighting the urgent need for stronger budgetary commitment, improved efficiency, and more robust revenue generation strategies to ensure sustainable and equitable delivery of PHC services Variables of the Study The average Woreda budget was allocated and spent over seven years. The average Woreda budget for health has been allocated and spent over seven years. Budget allocation and spending trends in the woreda over the seven years and adjusted for non-food consumer price index. Reimbursement of Health facilities for services (CBHI and Exempted health services) provided Proportion of CBHI implementing woredas in regions Financial insolvency of CBHI schemes The proportion of Health Facilities implementing revenue retention and reuse. Data Sources and Analysis Data cleaning and analysis were performed using STATA version 16.0. Descriptive statistics were applied to summarize the background characteristics of the selected woredas, while trends in health budget allocation and spending were analyzed using mean values across all 15 districts from 2010 to 2016 Ethiopian Fiscal Years (EFY). To account for the effects of inflation, health budget data were adjusted using the non-food consumer price index provided by the Ethiopian Statistical Services. Complementing the quantitative analysis, thematic content analysis was employed to extract insights from qualitative data, offering a richer understanding of the contextual factors influencing PHC financing performance. Results Description of Woredas The 15 study woredas are home to a combined population of 1,786,502 people and are served by 56 health centers—resulting in an average facility-to-population ratio of approximately 1:31,900. In the 2016 Ethiopian Fiscal Year (EFY), the average total woreda budget across all sectors reached 237 million ETB, marking a 2.2-fold increase compared to 2010 EFY. During the same period, the average health budget per woreda rose to 39.4 million ETB—2.5 times higher than in 2010. However, when adjusted for inflation using the non-food consumer price index from the Ethiopian Statistical Services, the real value of the 2016 EFY health budget was 20.3% lower than that of 2010, underscoring the diminishing purchasing power of woreda-level health financing. (Fig. 1 ). Over the past seven fiscal years, recurrent expenditures consistently dominated woreda health budgets, averaging 94% of total health spending. Throughout this period, the proportion of the woreda budget allocated to health remained relatively stable at around 15%—closely aligning with the Abuja Declaration benchmark. An exception occurred in 2012 EFY, when health received an unusually high 31.1% of the total woreda budget, likely driven by the heightened demands of the COVID-19 pandemic (Fig. 2 ). Across the 15 study woredas, performance scores for PHC financing and resource allocation stood at 43%, while purchasing and payment systems scored 39%, resulting in an overall PHC financing performance score of 41%—highlighting notable room for improvement in both financial commitment and implementation effectiveness. (Fig. 2 ). Government health allocation and spending at the woreda level In the 2015 Ethiopian Fiscal Year (EFY), Primary Health Care (PHC) spending at the woreda level accounted for an average of 17.3% of general government expenditure across the 15 study districts—exceeding the Abuja Declaration benchmark. However, this aggregate figure masks significant variation both across and within regions. For example, PHC’s share of spending ranged from as low as 9.0% in Hurumu woreda (Oromia region) to as high as 26.4% in Kallu woreda (Amhara region), with other districts such as Tarmaber allocating 14.2% (Fig. 3 ). These disparities highlight the uneven prioritization of PHC financing at the sub-national level and underscore the importance of localized strategies to close the equity gap in health investment. Purchasing and payment systems While 73% of health facilities across the study woredas maintained a list of exempted health services, only one-third (33%) of the woredas had formal, binding agreements in place requiring local administrations to reimburse facilities for delivering these services. This gap between policy and practice places considerable financial strain on providers. Moreover, fewer than half of the health centers—just 30 out of 63—reported implementing revenue retention and reuse mechanisms, limiting their ability to reinvest internally generated funds into service improvements and operational needs. CBHI Implementation Community-Based Health Insurance (CBHI) financial data from the 2015 EFY were available for ten of the study woredas, revealing that four had carried over outstanding reimbursements to health facilities—indicating early signs of financial strain. As of 2024, 12 of the 15 woredas have implemented CBHI, with schemes ranging in maturity from 1 to 8 years (Fig. 4). Facilitators and challenges of PHC financing Qualitative data collected from key informant interviews, focus group discussions, and validation workshops shed valuable light on both the enablers and persistent challenges of healthcare financing in the study woredas. On the positive side, several factors were cited as having strengthened PHC financing systems. These included: ( 1 ) the introduction of healthcare financing reforms that enabled health facilities to retain and budget internally generated revenue—facilitating the procurement of essential medicines and supplies; ( 2 ) the adoption of Community-Based Health Insurance (CBHI) as a mechanism to pool community resources; ( 3 ) additional funding secured through performance-based financing arrangements; and ( 4 ) community contributions to health initiatives, which helped supplement local health system resources. However, these gains are tempered by a range of systemic and operational challenges. Chronic underfunding and inefficient budget utilization emerged as recurring concerns. Delays in budget disbursement contributed to frequent stockouts of drugs and medical supplies, while also hampering the ability to compensate health workers for overtime duties. Facilities also struggled to utilize their internal revenues effectively, citing difficulties in convening board meetings in a timely manner—often a prerequisite for budget approval. One of the most pressing issues raised was the lack of autonomy in financial decision-making at the woreda level. Health offices frequently operate under centralized financial systems where decisions are controlled by finance offices, leaving little room for responsiveness or flexibility. As one nurse and facility CEO explained, “There is limited decision-making authority for healthcare financing. We rely entirely on the finance office, which constrains our ability to purchase essential items or utilize internal revenue.” Resistance to CBHI was another barrier, particularly in pastoralist and remote areas. Low community awareness, dissatisfaction with service quality, and concerns over mandatory referral systems led to poor enrollment. Health facilities also faced practical barriers to implementing CBHI—such as insufficient numbers of trained providers, skill gaps among new recruits, limited access to banking infrastructure, and a lack of startup capital to operationalize health financing reforms. Another major constraint involves the provision of exempted services. These services, which are supposed to be free, often rely on medications and consumables that must be drawn from revolving drug funds. Without corresponding reimbursements or dedicated program commodities, facilities are forced to dip into their revolving funds—gradually depleting this critical resource. As one woreda health officer put it, “ The principle of healthcare financing says facilities can generate and use their income to serve the community, but the lack of reimbursement for services provided freely undermines that promise .” Health posts also reported specific limitations, including the absence of separate budgets, minimal allocations, and no mechanisms to generate or retain revenue. Even minor but essential expenses—such as transporting water—often went unfunded. Participants in the PHC assessment validation workshops identified deeper structural issues contributing to financing gaps. These included outdated budget baselines that failed to reflect inflation, the low prioritization of health during cabinet-level budget negotiations, and the reallocation of health budgets to non-health priorities—sometimes without the knowledge or consent of Woreda Health Offices (WoHOs). In addition, delays in establishing financial management systems, such as opening bank accounts (often due to collateral requirements), further impeded progress. Governance weaknesses—including irregular board meetings, lack of procurement transparency, and poor drug inventory management—also contributed to inefficiencies. Limited infrastructure to support revolving drug funds, minimal community cost-sharing, and the absence of formal reimbursement frameworks for exempted services further exacerbated the challenges. Combined, these issues underscore the urgent need for a more supportive policy and operational environment to fully realize the goals of healthcare financing reform at the district level. Discussion When viewed in relation to total woreda budgets, the health sector demonstrated a comparatively higher rate of budget growth—suggesting that, at least nominally, health was given increasing priority in local resource allocation. Across most of the study period, average health expenditure at the woreda level ranged between 12.56% and 16.93%, aligning closely with the Abuja Declaration’s 15% target. A notable outlier was observed in 2012 EFY, when health spending surged to 31.14%, likely in response to the COVID-19 emergency and its extraordinary funding needs. This trend contrasts with national-level estimates reported in Ethiopia’s 2019/20 National Health Accounts (NHA), which found that only 8.5% of total government spending was allocated to health. This difference largely stems from methodological variations: while the NHA aggregates health expenditure across federal, regional, and local levels, the present study focuses exclusively on district-level spending. Importantly, the NHA also recorded a significant rise in health spending during the 2020 COVID-19 response—reporting that pandemic-related spending accounted for 5% of total health expenditure and nearly 50% of government health spending that year ( 5 ). This surge may be attributed to the proactive engagement of the national resource mobilization sub-committee, which played a pivotal role in securing emergency funding during the crisis ( 7 ). Despite the upward trend in nominal health budget allocations, high inflation rates significantly eroded the real purchasing power of woreda-level health financing. When adjusted using the non-food consumer price index from the Ethiopian Statistical Services, the average woreda health budget in 2016 EFY was 20.3% lower in real terms than in 2010 EFY. This decline signals that, despite budget growth on paper, actual capacity to meet expanding population health needs has diminished. Spending patterns further underscore this limitation. In the study woredas, capital investments accounted for only 6% of the total health budget, with the remaining 94% allocated to recurrent expenditures. This mirrors national trends reported in the 2019/20 National Health Accounts (NHA), which noted that capital, training, and research combined represented just 7.7% of total health spending, while recurrent costs dominated at 92.4% ( 5 ). The persistently low capital investment highlights a critical shortfall in health infrastructure development—suggesting that systems may be increasingly strained by demand without the necessary long-term investments to expand service capacity. Seventy-three percent of health facilities in the study woredas reported having a defined list of exempted health services, and one-third (33%) of the woredas had established binding agreements to reimburse facilities for these services—aligned with regional health service provision proclamations and healthcare financing directives. However, significant gaps remain in the clarity and implementation of these policies. Studies in Ethiopia have highlighted that current guidelines lack specificity around benefit packages and co-financing arrangements, often leading to confusion and inconsistent application at the facility level ( 8 , 9 ). As a result, exempted services are frequently delivered without reimbursement, depleting internal revenue streams that health facilities depend on for operational sustainability. Local evidence suggests that this financial strain has forced some facilities to shift part of the cost burden to clients—particularly for medical supplies. In instances where patients are unable to pay these costs, access to services may be denied, undermining both financial protection goals and equitable access to care ( 10 ). The financial instability of Community-Based Health Insurance (CBHI) schemes emerged as a critical gap in this study. Among the ten woredas for which CBHI financial data were available, four had pending overpayments to health facilities, while only two reported expenditures lower than the revenue collected in the same fiscal year—suggesting that most schemes were operating at a deficit. This aligns with findings from other districts in Ethiopia, such as Tehulederie and Kallu, where CBHI schemes recorded negative net income for three and four consecutive fiscal years, respectively. A likely contributing factor is the relative infancy of these district-level CBHI programs, many of which are still in the early stages of implementation and primarily focused on community enrollment and awareness-raising rather than delivering robust, timely services. Additional barriers to scheme effectiveness include limited community understanding of how to use insurance cards, navigate claims processes, or access covered services. Compounding this are structural issues like moral hazard and adverse selection, which can further destabilize scheme viability. Persistent deficits and operational inefficiencies point to the need for strategic adjustments in scheme design, implementation, and community engagement to ensure the long-term sustainability of CBHI ( 11 ). This study underscores that Primary Health Care (PHC) financing at the woreda level remains both inadequate and inefficient. A range of systemic issues were identified, including delays in budget disbursement and reimbursements, rigid pooled financial systems, irregular convening of health facility board meetings, unclear procurement procedures, inconsistent auditing practices, and poor drug inventory management. These challenges are further compounded by low levels of community satisfaction with the quality of care. The findings are consistent with previous studies in Ethiopia, which have highlighted similar obstacles to effective healthcare financing. These include limited technical capacity among facility governing boards, difficulties finance personnel face in interpreting and applying Health Care Financing (HCF) guidelines, untimely budget flows, and low client satisfaction—collectively undermining the delivery and sustainability of PHC services ( 6 , 12 ). Addressing these entrenched issues will be essential to unlocking the full potential of HCF reforms and improving service delivery outcomes at the community level. Conclusion While PHC budget allocation across regions appears relatively strong on the surface, significant disparities remain in how internal revenue is generated, utilized, and managed at the provider level. These inconsistencies in financial autonomy and purchasing practices highlight the urgent need to strengthen public financial management systems. Enhancing capacity in these areas will be critical to ensuring that increased budget allocations translate into meaningful improvements in service delivery and health outcomes. Abbreviations AMREF: African Medical and Research Foundation CBHI: Community Based Health Insurance HCF: Health Care Financing I-HSS: Integrated Health System Strengthening MERQ PLC: Monitoring, Evaluation, Research and Quality improvement Private Limited Company NHA: National Health Account PHC: Primary Health Care OOP: Out of Pocket Payments UHC: Universal Health Coverage WHO: World Health Organization WoHO: Woreda Health Office ZHD: Zonal Health Department Declarations Ethical Considerations Ethical clearance was secured from Ethiopian Public Health Association Institutional Review Board, and the necessary approval was obtained. While conducting interviews with experts and focus group discussions with community representatives, we adhered to strict ethical guidelines in Ethiopia and the Helsinki Statement of ethical principles for research involving human subjects. All research team members were trained on research ethics to meet the highest ethical research standards throughout the assessment period. All respondents were informed about the key features of the study, and verbal informed consent was obtained as an initial step in conducting interviews. All respondents were allowed to consent or refuse to participate in the assessment. Confidentiality of information was assured through secure data management practices. Consent to publish statement Not Applicable. Data availability statement Datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Limitations For one of the budget years included in this study, actual expenditure data were unavailable, and allocated budget figures were used as a proxy. Additionally, the study did not incorporate the perspectives of beneficiaries, which could have provided important insights into the relationship between financing and health program outcomes. Finally, the analysis of payment mechanisms focused primarily on reimbursement practices and did not explore the broader effectiveness or efficiency of existing provider payment models—an area that warrants further investigation. Funding This study was funded by the Bill & Melinda Gates Foundation through the AMREF Health Africa–led Integrated Health System Strengthening (I-HSS) project in Ethiopia. The research was conducted by MERQ Consultancy PLC in collaboration with AMREF. The findings and conclusions presented in this manuscript are those of the authors and do not necessarily reflect the views or policies of the funders. Disclosure statement No potential conflict of interest was reported by the author (s). Authors’ contributions AHG, MY designed and conceptualized the study and wrote the first draft of the manuscript. MDW and ST contributed in the design of the study and analysis of data, and were major contributors in writing the manuscript. AHG, MY, MDW, ST and MAH supported the interpretation of the data, critically reviewed and provided improvements to the draft manuscript and read and approved the final manuscript. Acknowledgments The authors gratefully acknowledge the Ministry of Health, Regional Health Bureaus, and Woreda Health Offices for their invaluable technical support throughout the study process. We also extend our sincere appreciation to all individuals who contributed their time, insights, and constructive feedback, which greatly enhanced the quality and clarity of this manuscript. References Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ. 2013;91(8):602 – 11. doi: 10.2471/BLT.12.113985. Epub 2013 Jun 17. PMID: 23940408; PMCID: PMC3738310. Organization of African Unity. Abuja Declaration on HIV/AIDS, tuberculosis and other related infectious diseases. Abuja. 2001. Woldie M, Yitbarek K, Dinsa GD. Resource Mobilisation and Allocation for Primary Health Care: Lessons from the Ethiopian Health System. Lancet Global Health Commission on Financing Primary Health Care. Working Paper No. 4. 2022. Kelly R, Hemming R, Glenday G, Bharali I, Alebachew A. January. Public financial management perspectives on health sector financing and resource allocation in Ethiopia. The Center for Policy Impact in Global Health. Duke Global Working Paper Series: number 18, 2020. Ministry of Health. Ethiopia National Health Accounts Report, 2019/20. Addis Ababa, Ethiopia: Ministry of Health, Partnership and Cooperation Directorate; 2022. Debie A, Khatri RB, Assefa Y. Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis. BMC Health Serv Res. 2022;22:866. https://doi.org/10.1186/s12913-022-08151-7 . Mitike G, Nigatu F, Wolka E, Defar A, Tessema M, Nigussie T. Health system response to COVID-19 among primary health care units in Ethiopia: A qualitative study. PLoS ONE. 2023;18(2):e0281628. https://doi.org/10.1371/journal.pone.0281628 . Alebachew A, Mitiku W, Mann C, Berman P. Exempted health services in Ethiopia: cost estimates and its financing challenges. Harvard T.H. Chan School of Public Health and Breakthrough International Consultancy. Boston, Massachusetts and Addis Ababa, Ethiopia; 2018. Ethiopia Health Insurance Service. Strategic health purchasing in Ethiopia: an assessment and strategic actions to improve purchasing. Ethiopia Health Insurance Service; 2022. USAID Health Financing Improvement Program. December 2022. Policy Brief: Revenue Retention and Utilization in Ethiopia: An Investment to Improve Quality of Care. Rockville, MD: USAID Health Financing Improvement Program, Abt Associates. Hussien M, Azage M, Bayou NB. Financial viability of a community-based health insurance scheme in two districts of northeast Ethiopia: a mixed methods study. BMC Health Serv Res. 2022;22:1072. https://doi.org/10.1186/s12913-022-08439-8 . Koricho M, Zerayacob T, Abebe F, Argaw M, Mengistu D, Birhane F, Gatome-Munyua A. An Assessment of Provider Payment Mechanisms (PPMs) in Ethiopia: Implications for Redesign of PPMs and Progress Toward Universal Health Coverage. Health Syst Reform. 2024;10(1). https://doi.org/10.1080/23288604.2024.2377620 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 16 May, 2026 Reviews received at journal 09 May, 2026 Reviewers agreed at journal 26 Apr, 2026 Reviewers invited by journal 19 Apr, 2026 Editor invited by journal 16 Apr, 2026 Editor assigned by journal 21 Mar, 2026 Submission checks completed at journal 21 Mar, 2026 First submitted to journal 21 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9105032","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":624559248,"identity":"ac31fe26-53c8-474e-9093-63e4ab54a7b5","order_by":0,"name":"Amanuel Haileselassie 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Health","correspondingAuthor":false,"prefix":"Dr.","firstName":"Muluken","middleName":"Argaw","lastName":"Haile","suffix":""}],"badges":[],"createdAt":"2026-03-12 12:54:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9105032/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9105032/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107142414,"identity":"0233ce81-d373-4021-8733-f32c73b8bb05","added_by":"auto","created_at":"2026-04-17 09:13:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":162851,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe average woreda health budget for the 2010-2016 EFY.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9105032/v1/dbba82ea1e79eb3e9aa4b572.png"},{"id":107142421,"identity":"d9284e33-4532-4119-9c19-d8c794a36ebe","added_by":"auto","created_at":"2026-04-17 09:13:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":74298,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe average Woreda health budget share from the 2010-2016 EFY budget.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9105032/v1/c7117eadd1196df452f98bc7.png"},{"id":107142415,"identity":"013e2cff-439b-4358-aa25-58fd27051556","added_by":"auto","created_at":"2026-04-17 09:13:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":109056,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eShare of PHC expenditure from the Woreda government budget for the 2010-2016 EFY.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9105032/v1/fb6a6a12808293c5c7253c6b.png"},{"id":107142342,"identity":"29db78aa-c0bb-4af3-8c85-2bcc7919bafd","added_by":"auto","created_at":"2026-04-17 09:13:33","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":52695,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNumber of CBHI implementing Woredas\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9105032/v1/3f7305d2d742812e6a3fa822.png"},{"id":107142417,"identity":"9c4354d6-ca17-4395-8772-084c27e861c0","added_by":"auto","created_at":"2026-04-17 09:13:51","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":74542,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCBHI coverage among implementing Woredas.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-9105032/v1/a03f87f2db2ee9e373cd02f2.png"},{"id":107142468,"identity":"638089f1-70df-45cf-8c27-ee0dbbdd8e93","added_by":"auto","created_at":"2026-04-17 09:14:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":717649,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9105032/v1/e1fca2ba-aa46-466c-aa15-e6d17807f7bf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Government Budget Allocation for Primary Health Care in Ethiopia","fulltext":[{"header":"Background","content":"\u003cp\u003eUniversal Health Coverage (UHC) is a global imperative that ensures individuals can access essential health services without experiencing financial hardship. Achieving this vision requires a robust health financing system with three essential functions: mobilizing revenue, pooling resources, and purchasing services\u0026mdash;functions that directly support the building blocks of the health system and progress toward UHC objectives (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGlobal commitments have guided national efforts to monitor and accelerate progress in health financing. A notable example is the Abuja Declaration, which urges governments to allocate at least 15% of their national budgets to the health sector (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In line with such frameworks, Ethiopia\u0026rsquo;s Health Care Financing Strategy sets ambitious goals to increase domestic health resources, promote efficient resource use through decentralized planning, and improve both service coverage and quality (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrimary Health Care (PHC) has long been recognized as Ethiopia\u0026rsquo;s strategic pathway to achieving UHC. Fiscal decisions concerning health budgets are made at the federal, regional, and woreda (district) levels, coordinated by the Ministry of Finance, Bureau of Finance, and Woreda Finance Offices, respectively (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). According to the National Health Account, approximately 65% of government resources are managed at sub-national levels; yet in 2019/20, only 8.5% of general government spending was allocated to the health sector\u0026mdash;far below the Abuja target (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite over two decades of Health Care Financing (HCF) reforms, the Ethiopian health system remains constrained by low public spending, high out-of-pocket payments, and ongoing reliance on donor funding (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Moreover, there is a persistent gap in evidence on public health expenditure at the sub-national level. Such data is critical not only for illuminating funding gaps but also for cultivating a culture of data-informed decision-making within health sector leadership and budgeting structures.\u003c/p\u003e \u003cp\u003eThis review aims to fill that gap by analyzing trends in PHC budget allocation and expenditure at the woreda level across 15 districts in five regions. It assesses the government\u0026rsquo;s response to shrinking donor contributions, evaluates the prioritization of health in district budgeting processes, and explores the impact of these trends on health facility performance. Importantly, the study also adjusts budget data for inflation using the non-food consumer price index, providing a more accurate picture of financing capacity over the past seven years.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eThis study was carried out in 15 woredas across the Afar, Amhara, Oromia, Sidama, and Somali regions, selected through a collaborative and participatory process designed to enable an in-depth assessment of primary health care financing at the district level. Selection was based on a strategic set of criteria, including performance across key reproductive, maternal, neonatal, and child health indicators; regional and contextual diversity aligned with the Integrated Health System Strengthening (i-HSS) project; and the demonstrated commitment of local leadership to actively engage in implementation. Importantly, the chosen woredas represent a deliberate mix of high-, medium-, and low-performing districts\u0026mdash;creating an opportunity to draw comparative insights and identify context-specific strategies for strengthening PHC systems across varying performance landscapes. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eList of woreda selected for the iHSS project by region, zone, and PHC performance\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZone\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eworeda\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePerformance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomali\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFafan ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGursum WoHO (SM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomali\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJarar ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDhegahbur WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomali\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSiti ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eErer WoHO (SM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZone 1 ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChifra WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZone 3 ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGewane WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZone 5 ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTelalak WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSidama\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral Sidama ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWensho WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSidama\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorthern Sidama ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHawella WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSidama\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouthern Sidama ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAleta Wondo WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmhara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth Shewa ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAntsokia Gemza WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmhara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth Shewa ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTaremaber WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmhara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Wollo ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKallu WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOromia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBuno Bedele ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGechi WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOromia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJimma ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eShabe Sombo WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOromia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlu Aba Bora ZHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHurumu WoHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eHigh= High performing; Medium= Medium performing; Low\u0026thinsp;=\u0026thinsp;Low performing\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003eA cross-sectional, mixed-methods approach was employed to assess trends and performance in PHC financing at the district level. Quantitative data focused on budget allocation and expenditure trends from 2010 to 2016 EFY, while qualitative data provided contextual understanding of systemic challenges and facilitators.\u003c/p\u003e\n\u003ch3\u003eMeasurement\u003c/h3\u003e\n\u003cp\u003eThis assessment was guided by the World Health Organization\u0026rsquo;s Primary Health Care (PHC) Measurement Framework, with a particular focus on the domain of health financing\u0026mdash;alongside governance, availability and distribution of inputs, and overall PHC system performance. A central line of inquiry was whether PHC funding and expenditure had grown relative to other government sectors, and how much of total health spending was financed by government sources versus other contributors. Within this, the \u0026ldquo;funding and resource allocation\u0026rdquo; indicator examined the proportion of the Woreda Health Office (WoHO) budget against the total woreda budget, measured against the 15% Abuja benchmark. It also assessed the presence of pre-payment mechanisms and emergency funding provisions at the district level. The \u0026ldquo;purchasing and payment systems\u0026rdquo; indicator evaluated financial practices surrounding exempted services and the implementation of Community-Based Health Insurance (CBHI). Findings from the assessment point to consistently low performance across financing metrics\u0026mdash;highlighting the urgent need for stronger budgetary commitment, improved efficiency, and more robust revenue generation strategies to ensure sustainable and equitable delivery of PHC services\u003c/p\u003e\n\u003ch3\u003eVariables of the Study\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe average Woreda budget was allocated and spent over seven years.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe average Woreda budget for health has been allocated and spent over seven years.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBudget allocation and spending trends in the woreda over the seven years and adjusted for non-food consumer price index.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eReimbursement of Health facilities for services (CBHI and Exempted health services) provided\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProportion of CBHI implementing woredas in regions\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFinancial insolvency of CBHI schemes\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe proportion of Health Facilities implementing revenue retention and reuse.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eData Sources and Analysis\u003c/h3\u003e\n\u003cp\u003eData cleaning and analysis were performed using STATA version 16.0. Descriptive statistics were applied to summarize the background characteristics of the selected woredas, while trends in health budget allocation and spending were analyzed using mean values across all 15 districts from 2010 to 2016 Ethiopian Fiscal Years (EFY). To account for the effects of inflation, health budget data were adjusted using the non-food consumer price index provided by the Ethiopian Statistical Services. Complementing the quantitative analysis, thematic content analysis was employed to extract insights from qualitative data, offering a richer understanding of the contextual factors influencing PHC financing performance.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDescription of Woredas\u003c/h2\u003e \u003cp\u003eThe 15 study woredas are home to a combined population of 1,786,502 people and are served by 56 health centers\u0026mdash;resulting in an average facility-to-population ratio of approximately 1:31,900. In the 2016 Ethiopian Fiscal Year (EFY), the average total woreda budget across all sectors reached 237\u0026nbsp;million ETB, marking a 2.2-fold increase compared to 2010 EFY. During the same period, the average health budget per woreda rose to 39.4\u0026nbsp;million ETB\u0026mdash;2.5 times higher than in 2010. However, when adjusted for inflation using the non-food consumer price index from the Ethiopian Statistical Services, the real value of the 2016 EFY health budget was 20.3% lower than that of 2010, underscoring the diminishing purchasing power of woreda-level health financing. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOver the past seven fiscal years, recurrent expenditures consistently dominated woreda health budgets, averaging 94% of total health spending. Throughout this period, the proportion of the woreda budget allocated to health remained relatively stable at around 15%\u0026mdash;closely aligning with the Abuja Declaration benchmark. An exception occurred in 2012 EFY, when health received an unusually high 31.1% of the total woreda budget, likely driven by the heightened demands of the COVID-19 pandemic (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Across the 15 study woredas, performance scores for PHC financing and resource allocation stood at 43%, while purchasing and payment systems scored 39%, resulting in an overall PHC financing performance score of 41%\u0026mdash;highlighting notable room for improvement in both financial commitment and implementation effectiveness. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGovernment health allocation and spending at the woreda level\u003c/h3\u003e\n\u003cp\u003eIn the 2015 Ethiopian Fiscal Year (EFY), Primary Health Care (PHC) spending at the woreda level accounted for an average of 17.3% of general government expenditure across the 15 study districts\u0026mdash;exceeding the Abuja Declaration benchmark. However, this aggregate figure masks significant variation both across and within regions. For example, PHC\u0026rsquo;s share of spending ranged from as low as 9.0% in Hurumu woreda (Oromia region) to as high as 26.4% in Kallu woreda (Amhara region), with other districts such as Tarmaber allocating 14.2% (Fig. \u003cspan refid=\"Fig3\"\u003e3\u003c/span\u003e). These disparities highlight the uneven prioritization of PHC financing at the sub-national level and underscore the importance of localized strategies to close the equity gap in health investment.\u003c/p\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003ePurchasing and payment systems\u003c/h2\u003e\n \u003cp\u003eWhile 73% of health facilities across the study woredas maintained a list of exempted health services, only one-third (33%) of the woredas had formal, binding agreements in place requiring local administrations to reimburse facilities for delivering these services. This gap between policy and practice places considerable financial strain on providers. Moreover, fewer than half of the health centers\u0026mdash;just 30 out of 63\u0026mdash;reported implementing revenue retention and reuse mechanisms, limiting their ability to reinvest internally generated funds into service improvements and operational needs.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eCBHI Implementation\u003c/h2\u003e\n \u003cp\u003eCommunity-Based Health Insurance (CBHI) financial data from the 2015 EFY were available for ten of the study woredas, revealing that four had carried over outstanding reimbursements to health facilities\u0026mdash;indicating early signs of financial strain. As of 2024, 12 of the 15 woredas have implemented CBHI, with schemes ranging in maturity from 1 to 8 years (Fig. 4).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eFacilitators and challenges of PHC financing\u003c/h2\u003e\n \u003cp\u003eQualitative data collected from key informant interviews, focus group discussions, and validation workshops shed valuable light on both the enablers and persistent challenges of healthcare financing in the study woredas.\u003c/p\u003e\n \u003cp\u003eOn the positive side, several factors were cited as having strengthened PHC financing systems. These included: (\u003cspan citationid=\"CR1\"\u003e1\u003c/span\u003e) the introduction of healthcare financing reforms that enabled health facilities to retain and budget internally generated revenue\u0026mdash;facilitating the procurement of essential medicines and supplies; (\u003cspan citationid=\"CR2\"\u003e2\u003c/span\u003e) the adoption of Community-Based Health Insurance (CBHI) as a mechanism to pool community resources; (\u003cspan citationid=\"CR3\"\u003e3\u003c/span\u003e) additional funding secured through performance-based financing arrangements; and (\u003cspan citationid=\"CR4\"\u003e4\u003c/span\u003e) community contributions to health initiatives, which helped supplement local health system resources.\u003c/p\u003e\n \u003cp\u003eHowever, these gains are tempered by a range of systemic and operational challenges. Chronic underfunding and inefficient budget utilization emerged as recurring concerns. Delays in budget disbursement contributed to frequent stockouts of drugs and medical supplies, while also hampering the ability to compensate health workers for overtime duties. Facilities also struggled to utilize their internal revenues effectively, citing difficulties in convening board meetings in a timely manner\u0026mdash;often a prerequisite for budget approval.\u003c/p\u003e\n \u003cp\u003eOne of the most pressing issues raised was the lack of autonomy in financial decision-making at the woreda level. Health offices frequently operate under centralized financial systems where decisions are controlled by finance offices, leaving little room for responsiveness or flexibility. As one nurse and facility CEO explained, \u0026ldquo;There is limited decision-making authority for healthcare financing. We rely entirely on the finance office, which constrains our ability to purchase essential items or utilize internal revenue.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003eResistance to CBHI was another barrier, particularly in pastoralist and remote areas. Low community awareness, dissatisfaction with service quality, and concerns over mandatory referral systems led to poor enrollment. Health facilities also faced practical barriers to implementing CBHI\u0026mdash;such as insufficient numbers of trained providers, skill gaps among new recruits, limited access to banking infrastructure, and a lack of startup capital to operationalize health financing reforms.\u003c/p\u003e\n \u003cp\u003eAnother major constraint involves the provision of exempted services. These services, which are supposed to be free, often rely on medications and consumables that must be drawn from revolving drug funds. Without corresponding reimbursements or dedicated program commodities, facilities are forced to dip into their revolving funds\u0026mdash;gradually depleting this critical resource. As one woreda health officer put it, \u0026ldquo;\u003cem\u003eThe principle of healthcare financing says facilities can generate and use their income to serve the community, but the lack of reimbursement for services provided freely undermines that promise\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003eHealth posts also reported specific limitations, including the absence of separate budgets, minimal allocations, and no mechanisms to generate or retain revenue. Even minor but essential expenses\u0026mdash;such as transporting water\u0026mdash;often went unfunded.\u003c/p\u003e\n \u003cp\u003eParticipants in the PHC assessment validation workshops identified deeper structural issues contributing to financing gaps. These included outdated budget baselines that failed to reflect inflation, the low prioritization of health during cabinet-level budget negotiations, and the reallocation of health budgets to non-health priorities\u0026mdash;sometimes without the knowledge or consent of Woreda Health Offices (WoHOs). In addition, delays in establishing financial management systems, such as opening bank accounts (often due to collateral requirements), further impeded progress.\u003c/p\u003e\n \u003cp\u003eGovernance weaknesses\u0026mdash;including irregular board meetings, lack of procurement transparency, and poor drug inventory management\u0026mdash;also contributed to inefficiencies. Limited infrastructure to support revolving drug funds, minimal community cost-sharing, and the absence of formal reimbursement frameworks for exempted services further exacerbated the challenges. Combined, these issues underscore the urgent need for a more supportive policy and operational environment to fully realize the goals of healthcare financing reform at the district level.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhen viewed in relation to total woreda budgets, the health sector demonstrated a comparatively higher rate of budget growth\u0026mdash;suggesting that, at least nominally, health was given increasing priority in local resource allocation. Across most of the study period, average health expenditure at the woreda level ranged between 12.56% and 16.93%, aligning closely with the Abuja Declaration\u0026rsquo;s 15% target. A notable outlier was observed in 2012 EFY, when health spending surged to 31.14%, likely in response to the COVID-19 emergency and its extraordinary funding needs.\u003c/p\u003e \u003cp\u003eThis trend contrasts with national-level estimates reported in Ethiopia\u0026rsquo;s 2019/20 National Health Accounts (NHA), which found that only 8.5% of total government spending was allocated to health. This difference largely stems from methodological variations: while the NHA aggregates health expenditure across federal, regional, and local levels, the present study focuses exclusively on district-level spending. Importantly, the NHA also recorded a significant rise in health spending during the 2020 COVID-19 response\u0026mdash;reporting that pandemic-related spending accounted for 5% of total health expenditure and nearly 50% of government health spending that year (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This surge may be attributed to the proactive engagement of the national resource mobilization sub-committee, which played a pivotal role in securing emergency funding during the crisis (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the upward trend in nominal health budget allocations, high inflation rates significantly eroded the real purchasing power of woreda-level health financing. When adjusted using the non-food consumer price index from the Ethiopian Statistical Services, the average woreda health budget in 2016 EFY was 20.3% lower in real terms than in 2010 EFY. This decline signals that, despite budget growth on paper, actual capacity to meet expanding population health needs has diminished.\u003c/p\u003e \u003cp\u003eSpending patterns further underscore this limitation. In the study woredas, capital investments accounted for only 6% of the total health budget, with the remaining 94% allocated to recurrent expenditures. This mirrors national trends reported in the 2019/20 National Health Accounts (NHA), which noted that capital, training, and research combined represented just 7.7% of total health spending, while recurrent costs dominated at 92.4% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The persistently low capital investment highlights a critical shortfall in health infrastructure development\u0026mdash;suggesting that systems may be increasingly strained by demand without the necessary long-term investments to expand service capacity.\u003c/p\u003e \u003cp\u003eSeventy-three percent of health facilities in the study woredas reported having a defined list of exempted health services, and one-third (33%) of the woredas had established binding agreements to reimburse facilities for these services\u0026mdash;aligned with regional health service provision proclamations and healthcare financing directives. However, significant gaps remain in the clarity and implementation of these policies. Studies in Ethiopia have highlighted that current guidelines lack specificity around benefit packages and co-financing arrangements, often leading to confusion and inconsistent application at the facility level (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs a result, exempted services are frequently delivered without reimbursement, depleting internal revenue streams that health facilities depend on for operational sustainability. Local evidence suggests that this financial strain has forced some facilities to shift part of the cost burden to clients\u0026mdash;particularly for medical supplies. In instances where patients are unable to pay these costs, access to services may be denied, undermining both financial protection goals and equitable access to care (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe financial instability of Community-Based Health Insurance (CBHI) schemes emerged as a critical gap in this study. Among the ten woredas for which CBHI financial data were available, four had pending overpayments to health facilities, while only two reported expenditures lower than the revenue collected in the same fiscal year\u0026mdash;suggesting that most schemes were operating at a deficit.\u003c/p\u003e \u003cp\u003eThis aligns with findings from other districts in Ethiopia, such as Tehulederie and Kallu, where CBHI schemes recorded negative net income for three and four consecutive fiscal years, respectively. A likely contributing factor is the relative infancy of these district-level CBHI programs, many of which are still in the early stages of implementation and primarily focused on community enrollment and awareness-raising rather than delivering robust, timely services.\u003c/p\u003e \u003cp\u003eAdditional barriers to scheme effectiveness include limited community understanding of how to use insurance cards, navigate claims processes, or access covered services. Compounding this are structural issues like moral hazard and adverse selection, which can further destabilize scheme viability. Persistent deficits and operational inefficiencies point to the need for strategic adjustments in scheme design, implementation, and community engagement to ensure the long-term sustainability of CBHI (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study underscores that Primary Health Care (PHC) financing at the woreda level remains both inadequate and inefficient. A range of systemic issues were identified, including delays in budget disbursement and reimbursements, rigid pooled financial systems, irregular convening of health facility board meetings, unclear procurement procedures, inconsistent auditing practices, and poor drug inventory management. These challenges are further compounded by low levels of community satisfaction with the quality of care.\u003c/p\u003e \u003cp\u003eThe findings are consistent with previous studies in Ethiopia, which have highlighted similar obstacles to effective healthcare financing. These include limited technical capacity among facility governing boards, difficulties finance personnel face in interpreting and applying Health Care Financing (HCF) guidelines, untimely budget flows, and low client satisfaction\u0026mdash;collectively undermining the delivery and sustainability of PHC services (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Addressing these entrenched issues will be essential to unlocking the full potential of HCF reforms and improving service delivery outcomes at the community level.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile PHC budget allocation across regions appears relatively strong on the surface, significant disparities remain in how internal revenue is generated, utilized, and managed at the provider level. These inconsistencies in financial autonomy and purchasing practices highlight the urgent need to strengthen public financial management systems. Enhancing capacity in these areas will be critical to ensuring that increased budget allocations translate into meaningful improvements in service delivery and health outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAMREF: African Medical and Research Foundation\u003c/p\u003e\n\u003cp\u003eCBHI: Community Based Health Insurance\u003c/p\u003e\n\u003cp\u003eHCF: Health Care Financing\u003c/p\u003e\n\u003cp\u003eI-HSS: Integrated Health System Strengthening\u003c/p\u003e\n\u003cp\u003eMERQ PLC: Monitoring, Evaluation, Research and Quality improvement Private Limited Company\u003c/p\u003e\n\u003cp\u003eNHA: National Health Account\u003c/p\u003e\n\u003cp\u003ePHC: Primary Health Care\u003c/p\u003e\n\u003cp\u003eOOP: Out of Pocket Payments\u003c/p\u003e\n\u003cp\u003eUHC: Universal Health Coverage\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e\n\u003cp\u003eWoHO: Woreda Health Office\u003c/p\u003e\n\u003cp\u003eZHD: Zonal Health Department\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was secured from Ethiopian Public Health Association Institutional Review Board, and the necessary approval was obtained. While conducting interviews with experts and focus group discussions with community representatives, we adhered to strict ethical guidelines in Ethiopia and the Helsinki Statement of ethical principles for research involving human subjects. All research team members were trained on research ethics to meet the highest ethical research standards throughout the assessment period. All respondents were informed about the key features of the study, and verbal informed consent was obtained as an initial step in conducting interviews. All respondents were allowed to consent or refuse to participate in the assessment. Confidentiality of information was assured through secure data management practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDatasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor one of the budget years included in this study, actual expenditure data were unavailable, and allocated budget figures were used as a proxy. Additionally, the study did not incorporate the perspectives of beneficiaries, which could have provided important insights into the relationship between financing and health program outcomes. Finally, the analysis of payment mechanisms focused primarily on reimbursement practices and did not explore the broader effectiveness or efficiency of existing provider payment models\u0026mdash;an area that warrants further investigation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Bill \u0026amp; Melinda Gates Foundation through the AMREF Health Africa\u0026ndash;led Integrated Health System Strengthening (I-HSS) project in Ethiopia. The research was conducted by MERQ Consultancy PLC in collaboration with AMREF. The findings and conclusions presented in this manuscript are those of the authors and do not necessarily reflect the views or policies of the funders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential conflict of interest was reported by the author (s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAHG, MY designed and conceptualized the study and wrote the first draft of the manuscript. MDW and ST contributed in the design of the study and analysis of data, and were major contributors in writing the manuscript. AHG, MY, MDW, ST and MAH supported the interpretation of the data, critically reviewed and provided improvements to the draft manuscript and read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge the Ministry of Health, Regional Health Bureaus, and Woreda Health Offices for their invaluable technical support throughout the study process. We also extend our sincere appreciation to all individuals who contributed their time, insights, and constructive feedback, which greatly enhanced the quality and clarity of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ. 2013;91(8):602\u0026thinsp;\u0026ndash;\u0026thinsp;11. doi: 10.2471/BLT.12.113985. Epub 2013 Jun 17. PMID: 23940408; PMCID: PMC3738310.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization of African Unity. Abuja Declaration on HIV/AIDS, tuberculosis and other related infectious diseases. Abuja. 2001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoldie M, Yitbarek K, Dinsa GD. Resource Mobilisation and Allocation for Primary Health Care: Lessons from the Ethiopian Health System. Lancet Global Health Commission on Financing Primary Health Care. Working Paper No. 4. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelly R, Hemming R, Glenday G, Bharali I, Alebachew A. January. Public financial management perspectives on health sector financing and resource allocation in Ethiopia. The Center for Policy Impact in Global Health. Duke Global Working Paper Series: number 18, 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health. Ethiopia National Health Accounts Report, 2019/20. Addis Ababa, Ethiopia: Ministry of Health, Partnership and Cooperation Directorate; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDebie A, Khatri RB, Assefa Y. Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis. BMC Health Serv Res. 2022;22:866. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-022-08151-7\u003c/span\u003e\u003cspan address=\"10.1186/s12913-022-08151-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitike G, Nigatu F, Wolka E, Defar A, Tessema M, Nigussie T. Health system response to COVID-19 among primary health care units in Ethiopia: A qualitative study. PLoS ONE. 2023;18(2):e0281628. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0281628\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0281628\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlebachew A, Mitiku W, Mann C, Berman P. Exempted health services in Ethiopia: cost estimates and its financing challenges. Harvard T.H. Chan School of Public Health and Breakthrough International Consultancy. Boston, Massachusetts and Addis Ababa, Ethiopia; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEthiopia Health Insurance Service. Strategic health purchasing in Ethiopia: an assessment and strategic actions to improve purchasing. Ethiopia Health Insurance Service; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUSAID Health Financing Improvement Program. December 2022. Policy Brief: Revenue Retention and Utilization in Ethiopia: An Investment to Improve Quality of Care. Rockville, MD: USAID Health Financing Improvement Program, Abt Associates.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussien M, Azage M, Bayou NB. Financial viability of a community-based health insurance scheme in two districts of northeast Ethiopia: a mixed methods study. BMC Health Serv Res. 2022;22:1072. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-022-08439-8\u003c/span\u003e\u003cspan address=\"10.1186/s12913-022-08439-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoricho M, Zerayacob T, Abebe F, Argaw M, Mengistu D, Birhane F, Gatome-Munyua A. An Assessment of Provider Payment Mechanisms (PPMs) in Ethiopia: Implications for Redesign of PPMs and Progress Toward Universal Health Coverage. Health Syst Reform. 2024;10(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/23288604.2024.2377620\u003c/span\u003e\u003cspan address=\"10.1080/23288604.2024.2377620\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Primary Health Care, Budget, Expenditure, Health Financing, Community Based Health Insurance, Woreda, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-9105032/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9105032/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEthiopia has pursued Health Care Financing (HCF) reforms for over two decades as part of its commitment to achieving Universal Health Coverage (UHC). With a health policy anchored in Primary Health Care (PHC) and a decentralized planning framework, the country has introduced numerous interventions to strengthen domestic resource mobilization, enhance autonomy at service delivery points, and build local capacity.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study analyzes PHC budget allocation and expenditure trends in 15 woredas across five regions from 2010 to 2016, using mixed methods.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFinancing of the HSS-PHC system yielded a performance score of 29%, indicating significant challenges in resource allocation and financial management. Two key indicators determined this: Funding and allocation of resources (14%) and purchasing and payment systems (39%). While nominal health budget allocations have increased over time, real-term values adjusted for the non-food consumer price index have declined. The average PHC spending represented 17.3% of general government expenditure\u0026mdash;exceeding the Abuja Declaration target\u0026mdash;yet regional disparities were notable, ranging from 9% to 26.4%. Persistent challenges, especially in CBHI implementation, exempted service reimbursement, and provider-level autonomy, were particularly pronounced in pastoralist regions.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eInadequate budget allocation from the treasury, the expanding need of communities, shocks from different emergencies, and high inflation rates in recent years have led to widening gaps in health financing. Alternative financing mechanisms (CBHI) didn\u0026rsquo;t catch up with the widening gap because of inadequate implementation, low potential as a financing strategy due to low premium rates, and lack of mechanisms to enforce reimbursement of health facilities. These findings underscore the need to reinforce public financial management and leadership capacity at district and facility levels to ensure more equitable, efficient, and transparent PHC financing.\u003c/p\u003e","manuscriptTitle":"Government Budget Allocation for Primary Health Care in Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-17 09:12:11","doi":"10.21203/rs.3.rs-9105032/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"59539189867496242442730042248717665273","date":"2026-05-16T10:41:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-09T07:44:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225219164266403493822477564199278158634","date":"2026-04-27T00:49:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-19T08:32:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-16T18:15:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-21T23:34:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-21T06:22:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Health Systems","date":"2026-03-21T06:17:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6af5814d-ab75-4766-8382-9a637eb05ec1","owner":[],"postedDate":"April 17th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"59539189867496242442730042248717665273","date":"2026-05-16T10:41:09+00:00","index":58,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-09T07:44:19+00:00","index":35,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-19T08:38:43+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-17 09:12:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9105032","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9105032","identity":"rs-9105032","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}