Progress in health among regions of Ethiopia, 1990–2019: a subnational country analysis for the Global Burden of Disease Study 2019
Authors: Awoke Misganaw, Mohsen Naghavi, Ally Walker, Alemnesh H Mirkuzie, Ababi Zergaw Giref, Tezera Moshago Berheto, Ebba Abate Waktola, John H Kempen, Getachew Tollera Eticha, Tsigereda Kifle Wolde, Dereje Deguma, Kalkidan Hassen Abate, Kedir Hussein Abegaz, Muktar Beshir Ahmed, Yonas Akalu, Addis Aklilu, Biresaw Wassihun Alemu, Mulusew A Asemahagn, Atalel Fentahun Awedew, Senthilkumar Balakrishnan, Tariku Tesfaye Bekuma, Addisu Shunu Beyene, Misrak Getnet Beyene, Yihienew Mequanint Bezabih, Biruk Tesfaye Birhanu, Tesfaye Yitna Chichiabellu, Berihun Assefa Dachew, Amare Belachew Dagnew, Feleke Mekonnen Demeke, Getu Debalkie Demissie, Meseret Derbew Molla, Nebiyu Dereje, Kebede Deribe, Abebaw Alemayehu Desta, Munir Kassa Eshetu, Tomas Y Ferede, Eyob Alemayehu Gebreyohannes, Abraham Geremew, Hailay Abrha Gesesew, Lemma Getacher, Scott D Glenn, Aregash Samuel Hafebo, Abdiwahab Hashi, Hamid Yimam Hassen, Simon I Hay, Diriba Fufa Hordofa, Dawit Hoyiso Huluko, Ayele Semachew Kasa, Getinet Kassahun Azene, Ermiyas Mulu Kebede, Hafte Kahsay Kebede, Bayew Kelkay, Samuel Z Kidane, Samson Mideksa Legesse, Wondimu Ayele Manamo, Yohannes Adama A Melaku, Endalkachew Worku Mengesha, Sisay Derso Mengesha, Hayimro Edemealem Merie, Abera M Mersha, Amanual Getnet Mersha, Mizan Kiros Mirutse, Ammas Siraj Mohammed, Hussen Mohammed, Salahuddin Mohammed, Henok Biresaw Netsere, Dabere Nigatu, Mohammed Suleiman Obsa, Daniel Bogale Odo, Muktar Omer, Lemma Demissie Regassa, Biniyam Sahiledengle, Mohammed Feyisso Shaka, Wondimeneh Shibabaw Shiferaw, Negussie Boti Sidemo, Abiy H Sinke, Yitagesu Sintayehu, Muluken Bekele Sorrie, Birkneh Tilahun Tadesse, Eyayou Girma Tadesse, Zemenu Tamir, Animut Tagele Tamiru, Amare Abera Tareke, Yonas Getaye Tefera, Yohannes Tekalegn, Ayenew Kassie Tesema, Tefera Tadele Tesema, Fisaha Haile Tesfay, Zemenu Tadesse Tessema, Tadesse Tilahun, Gebiyaw Wudie Tsegaye, Biruk Shalmeno Tusa, Geremew Tassew Weledesemayat, Taklo Simeneh Yazie, Yordanos Gizachew Yeshitila, Birhanu Wubale Yirdaw, Desalegn Tegabu Zegeye, Christopher J L Murray, Lia Tadesse Gebremedhin
Journal: The Lancet (2022)

<h2>Summary</h2><h3>Background</h3> Previous Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) studies have reported national health estimates for Ethiopia. Substantial regional variations in socioeconomic status, population, demography, and access to health care within Ethiopia require comparable estimates at the subnational level. The GBD 2019 Ethiopia subnational analysis aimed to measure the progress and disparities in health across nine regions and two chartered cities. <h3>Methods</h3> We gathered 1057 distinct data sources for Ethiopia and all regions and cities that included census, demographic surveillance, household surveys, disease registry, health service use, disease notifications, and other data for this analysis. Using all available data sources, we estimated the Socio-demographic Index (SDI), total fertility rate (TFR), life expectancy, years of life lost, years lived with disability, disability-adjusted life-years, and risk-factor-attributable health loss with 95% uncertainty intervals (UIs) for Ethiopia's nine regions and two chartered cities from 1990 to 2019. Spatiotemporal Gaussian process regression, cause of death ensemble model, Bayesian meta-regression tool, DisMod-MR 2.1, and other models were used to generate fertility, mortality, cause of death, and disability rates. The risk factor attribution estimations followed the general framework established for comparative risk assessment. <h3>Findings</h3> The SDI steadily improved in all regions and cities from 1990 to 2019, yet the disparity between the highest and lowest SDI increased by 54% during that period. The TFR declined from 6·91 (95% UI 6·59–7·20) in 1990 to 4·43 (4·01–4·92) in 2019, but the magnitude of decline also varied substantially among regions and cities. In 2019, TFR ranged from 6·41 (5·96–6·86) in Somali to 1·50 (1·26–1·80) in Addis Ababa. Life expectancy improved in Ethiopia by 21·93 years (21·79–22·07), from 46·91 years (45·71–48·11) in 1990 to 68·84 years (67·51–70·18) in 2019. Addis Ababa had the highest life expectancy at 70·86 years (68·91–72·65) in 2019; Afar and Benishangul-Gumuz had the lowest at 63·74 years (61·53–66·01) for Afar and 64.28 (61.99-66.63) for Benishangul-Gumuz. The overall increases in life expectancy were driven by declines in under-5 mortality and mortality from common infectious diseases, nutritional deficiency, and war and conflict. In 2019, the age-standardised all-cause death rate was the highest in Afar at 1353·38 per 100 000 population (1195·69–1526·19). The leading causes of premature mortality for all sexes in Ethiopia in 2019 were neonatal disorders, diarrhoeal diseases, lower respiratory infections, tuberculosis, stroke, HIV/AIDS, ischaemic heart disease, cirrhosis, congenital defects, and diabetes. With high SDIs and life expectancy for all sexes, Addis Ababa, Dire Dawa, and Harari had low rates of premature mortality from the five leading causes, whereas regions with low SDIs and life expectancy for all sexes (Afar and Somali) had high rates of premature mortality from the leading causes. In 2019, child and maternal malnutrition; unsafe water, sanitation, and handwashing; air pollution; high systolic blood pressure; alcohol use; and high fasting plasma glucose were the leading risk factors for health loss across regions and cities. <h3>Interpretation</h3> There were substantial improvements in health over the past three decades across regions and chartered cities in Ethiopia. However, the progress, measured in SDI, life expectancy, TFR, premature mortality, disability, and risk factors, was not uniform. Federal and regional health policy makers should match strategies, resources, and interventions to disease burden and risk factors across regions and cities to achieve national and regional plans, Sustainable Development Goals, and universal health coverage targets. <h3>Funding</h3> Bill & Melinda Gates Foundation.