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.