Chapter 9. Universal Health Coverage, SDGs, Ethiopian Health Policy and HSTP
Dr. Fantu Lombamo Untiso, Public Health Specialist Medical Doctor · St. Paul's Hospital Millennium Medical College
Everyone should be able to get the health services they need without being pushed into poverty. This is the promise of UHC and the heart of SDG 3. In this short but dense chapter, you compare global progress with Ethiopia’s own plans and numbers, and you learn to judge whether a country is on track.
Chapter 9 of 11 · Week 3 · 2 contact hours
Learning objectives for this chapter
- Define universal health coverage (UHC), its dimensions and indicators, and the role of primary health care and financing.
- Describe the Sustainable Development Goals, especially SDG 3, and evaluate progress in different contexts.
- Outline the Ethiopian Health Policy, the HSDP I to IV, HSTP I and II and the current medium-term plan.
- Analyse UHC in Ethiopia: financing, community-based health insurance, the Health Extension Programme and equity.
1. Universal health coverage
UHC means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship. It includes health promotion, prevention, treatment, rehabilitation and palliative care. It is target 3.8 of the SDGs, and the world committed to it again in the 2023 UN political declaration.
UHC is often shown as a ‘cube’ with three dimensions: who is covered (population), which services are covered, and what share of the cost is covered (financial protection). Progress means filling all three: extending to people who are left out, adding services, and reducing out-of-pocket payment.
| SDG indicator | What it measures |
|---|---|
| 3.8.1 UHC Service Coverage Index (0 to 100) | Coverage of essential services in four areas: reproductive, maternal, newborn and child health; infectious diseases; non-communicable diseases; and service capacity and access |
| 3.8.2 Financial hardship | Proportion of the population with large out-of-pocket health spending relative to household budget (catastrophic spending) and impoverishment |
Pathways to UHC: strong primary health care; public financing through general taxes and compulsory insurance with pooling of funds so that the healthy subsidise the sick and the rich subsidise the poor; strategic purchasing; a defined benefit package; a trained and motivated workforce; reliable medicines and supply; information systems; and attention to equity (‘progressive universalism’: expand first for those who are worst off).
2. The Sustainable Development Goals
The 2030 Agenda (2015) has 17 goals and 169 targets that are integrated and indivisible, and promise to ‘leave no one behind’. SDG 3 is ‘Ensure healthy lives and promote well-being for all at all ages’, with 13 targets:
| Target | Main content (by 2030) |
|---|---|
| 3.1 | Maternal mortality ratio below 70 per 100,000 live births |
| 3.2 | Neonatal mortality at most 12 and under-five mortality at most 25 per 1,000 live births |
| 3.3 | End the epidemics of AIDS, TB, malaria and neglected tropical diseases; combat hepatitis and water-borne diseases |
| 3.4 | Reduce premature mortality from NCDs by one third; promote mental health |
| 3.5 | Prevent and treat substance abuse, including harmful use of alcohol |
| 3.6 | Halve deaths and injuries from road traffic crashes |
| 3.7 | Universal access to sexual and reproductive health services |
| 3.8 | Achieve UHC, including financial risk protection |
| 3.9 | Reduce deaths and illness from hazardous chemicals and air, water and soil pollution |
| 3.a | Strengthen implementation of the Framework Convention on Tobacco Control |
| 3.b | Support research and development, and access to affordable medicines and vaccines |
| 3.c | Increase health financing and the recruitment, training and retention of the health workforce |
| 3.d | Strengthen capacity for early warning, risk reduction and management of health risks |
Health is linked to many other goals: poverty (1), hunger and nutrition (2), education (4), gender equality (5), water and sanitation (6), energy (7), work (8), cities (11), climate action (13) and peace (16).
3. Ethiopian health policy and plans
| Period | Instrument | Main features |
|---|---|---|
| 1993 | National Health Policy | Democratisation and decentralisation, emphasis on prevention and promotion, equitable access, intersectoral work, community participation, private sector participation, self-reliance |
| 1997/98 to 2014/15 | Health Sector Development Programme (HSDP) I to IV, in four five-year (or shorter) phases | Expansion of facilities and workforce; the Health Extension Programme from 2003/04; focus on MDGs, child and maternal health, malaria, HIV and TB |
| 2015/16 to 2019/20 | Health Sector Transformation Plan I (HSTP-I) | Four transformation agendas: equity and quality of health services, information revolution, caring, respectful and compassionate health workforce, and woreda transformation |
| 2020/21 to 2024/25 | HSTP-II | UHC through equitable and quality PHC, with emphasis on woredas, quality, financing and emergency preparedness; revised because of COVID-19, conflict and climate shocks |
| 2023/24 to 2025/26 | Health Sector Medium-Term Development and Investment Plan (HSDIP) | Nine strategic objectives from maternal, child and adolescent health to health financing and private sector engagement; builds on HSTP-II |
| From 2026 | New medium-term health sector transformation plan (2026 to 2030, as described by the Ministry in early 2026) | Emphasis on cost-effectiveness, digitisation and integration of services The Reporter 2026 |
The HSDIP sets targets such as a maternal mortality ratio falling from 267 to 199 per 100,000 live births, under-five mortality from 47 to 44 and neonatal mortality from 26 to 21 per 1,000 live births, skilled birth attendance from 50 to 78 percent, Pentavalent-3 coverage from 61 to 80 percent, and malaria incidence from 47.2 to 17.9 per 1,000 population at risk MoH HSDIP.
4. UHC in Ethiopia: where is the country?
- UHC index: 0.38 at the HSTP-II mid-term assessment, against a target of 0.58 for 2024/25. Progress has been limited MoH HSDIP.
- Health Extension Programme (HEP): health extension workers at health posts and in households deliver the PHC package. A revised 2020 to 2035 roadmap creates village health leaders, three types of health post and new service packages MoH HSDIP.
- Financing: the health share of the government budget was 7.2 percent in 2024/25 (down from 8.3 percent), roughly ETB 1,284 (about US$11) per person, well below the Abuja target of 15 percent. Out-of-pocket spending was 30.5 percent of total health expenditure, against the 20 percent threshold, and 4.2 percent of households faced catastrophic health costs. External sources accounted for 54.6 percent of the national capital health budget in 2024/25 UNICEF budget brief MoH HSDIP.
- Community-based health insurance (CBHI): about 85 percent of woredas run CBHI and 11.1 million households (76 percent of eligible households in those woredas) were enrolled, against a target of 90 percent of woredas by 2025/26 UNICEF budget brief. Social health insurance for formal sector workers is a separate scheme. The 2022 Health Care Financing Strategy promotes domestic resource mobilisation, equity, efficiency and private sector engagement.
- Outcomes: stunting 39 percent (2022); skilled birth attendance 50 percent (2019); modern contraceptive use 41 percent (2019) UNICEF budget brief.
- Shocks: conflict, drought, displacement, outbreaks and the fall in external aid (about 40 percent according to figures cited in 2026) strain services The Reporter 2026 UNICEF SitRep 2026.
Part of the course: Fundamentals of Public Health
Report a problem with this item
Rate this
Not enough ratings yet.
Questions and comments (0)
No comments yet. Ask the instructor a question.
Write a question or comment
For licensed professionals and students. Educational information only: always follow current national guidelines (EFDA, Ministry of Health), the product label and your facility’s procedures.