Strengthening primary health care in Ethiopia: A scoping review of successes, challenges, and pathways towards universal health coverage using the WHO monitoring framework.

introductionThe ultimate goal of primary health care (PHC), as a whole-of-government and whole-of-society approach, is to achieve the highest level of health by bringing health services closer to the users. This entails that PHC should be viewed as the all-inclusive strategy to achieve universal health coverage (UHC) of the sustainable development goals (SDG). Ethiopia has been implementing PHC since the Alma-Ata Declaration. The World Health Organization (WHO) has recently released a PHC Monitoring Framework to support the monitoring of progress in PHC implementation. However, an evidence gap highlights the need for studies investigating PHC progress towards UHC using this progress monitoring framework. This study aims to evaluate Ethiopia's PHC system using the WHO PHC monitoring framework and identify successes and challenges towards UHC and health security.

methodThis scoping review was conducted and structured based on Arksey and O'Malley's methodological framework. We searched five databases (PubMed, Scopus, Embase, Web of Science, CINAHL) and hand-searched for relevant articles. We used the WHO PHC monitoring conceptual framework to summarise findings qualitatively. We reported our findings using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework.

resultsWe included a total of 110 papers - 56 cross-sectional/national surveys, 19 qualitative studies, 16 mixed-method studies, five fiscal/cost/formative or project model analyses, three ecological/ethnographic studies, three longitudinal/quasi-experimental studies, and two each of implementation/participatory research, cohort studies, and case studies. The Ethiopian PHC system has achieved encouraging success in improving healthcare access and coverage, driven by growing political and leadership commitments through implementing a national health extension package (HEP), service integration and multisectoral approaches to achieve UHC. However, Ethiopia's efforts to achieve UHC have faced many challenges, including inadequate service integration, lack of resources and budgets, uneven distribution of health workers and infrastructure, gaps in priority setting, service innovation, stakeholder engagement and funding PHC research. These are affecting access to affordable care and hindering the progress towards UHC.

conclusionEthiopia's PHC system has achieved significant progress in expanding infrastructure and improving access to health services towards UHC. However, challenges remain, particularly in underserved rural areas, with inequitable access, weak governance, and limited integration of essential services. Hence, by improving resource allocation, addressing rural inequities, systemic and infrastructural challenges and fostering stronger governance and service integration, Ethiopia can further improve and build on the successes of the PHC system, making it more resilient and better equipped to meet the health needs of its population.