Introduction

Noncommunicable diseases (NCDs) killed at least 43 million people in 2021. Of all NCD deaths, 73% were in low- and middle-income countries (LMICs). The four major NCDs: Cardiovascular diseases (CVDs), cancers, chronic respiratory diseases (CRDs) and diabetes, account for 80% of all premature NCD deaths [1].

In 2019, Ethiopia’s estimated number of NCD deaths was 219,284, making a death rate of 204 per 100,000. CVDs, cancers, CRDs, and diabetes were found to be among the leading causes of death rates. In addition, mental, neurological and substance (MNS) use disorders become prevalent [2]. Despite NCDs accounting for about 48% of mortality, the Ethiopian government’s efforts have primarily targeted infectious diseases and maternal health, leaving NCDs underfinanced [2]. The National Health Accounts report indicates that 68% of NCD services were financed by out-of-pocket expenditures from households, with only about 1% covered by development assistance [3,4].

Conceptually, interventions to address NCDs are feasible and well-established, such as the World Health Organization (WHO) Package of Essential Noncommunicable Interventions and the WHO Best Buys [5,6]. There are several effective approaches, including national policies, service delivery strategies such as screening and the provision of essential medications, as well as individual behavioral interventions [7]. However, LMICs face substantial challenges in implementing these interventions effectively [8,9].

In response to the rising burden of NCDs and in alignment with global initiatives, the Ethiopian government launched its first National Strategic Action Plan (NSAP) for the Prevention and Control of NCDs in 2016 [10]. This was followed by a second NSAP (2020–2025), [11] which further outlines the country’s commitment to NCD control and management. Both strategies emphasize key components such as detection, screening, treatment, and palliative care as central to the national response to NCDs. Service is provided through the public and private health sectors. The public healthcare sector in Ethiopia is organized into a three-tier system of primary, secondary, and tertiary healthcare. The primary healthcare (PHC) system is composed of a primary hospital, health centres, and health posts. Tier two, the secondary healthcare system, constitutes general hospitals, while tier three is composed of specialised hospitals [12]. NCD services have been mainly concentrated in secondary and tertiary hospitals. Currently, the government is decentralizing and integrating NCD services to the PHC level, and providing training to healthcare professionals working at health centres and primary hospitals to diagnose and manage hypertension, diabetes, and mental health. A complicated case refers to the next level of healthcare facilities for further assessment and management.

Effective management of NCDs requires the consistent availability of trained health personnel, functional diagnostic tools, essential equipment, up-to-date clinical guidelines, and a reliable supply of medicines to ensure timely and quality care. While in Ethiopia, efforts have been made to expand the number of health facilities, increase the healthcare workforce, and improve the supply of diagnostic tools and essential drugs, these efforts have not translated into proportional improvements in service readiness [13]. Although the availability of NCD-related services has increased, the overall readiness of health facilities remains inadequate when compared to both national needs and global recommendations [14].

In Ethiopia, only a few studies have been conducted on the availability and readiness of health services for NCDs [15–18]. However, these studies are limited in scope, often focusing on a specific subset of NCDs such as cancer care, diabetes or hypertension and relying primarily on descriptive analyses of earlier (2014−2016) national data. There remains a lack of detailed empirical research examining the factors associated with NCD service availability and readiness in the country. One prior study [19] assessed the influence of basic facility characteristics such as location, managing authority, and facility type. However, the previous study uses a different dataset: the 2018 Ethiopian Service Availability and Readiness Assessment (SARA) survey. Furthermore, the scope of conditions assessed differed from the current study. While the earlier study focused on diabetes, CVDs, CRDs, and cervical cancer, the current study includes all of these except cervical cancer and additionally incorporates MNS use disorders. In addition, beyond facility characteristics, physical infrastructure and service inputs; governance and management practices at the facility level—such as regular administrative meetings, the presence of quality control mechanisms, functional health management information systems (HMIS), and external supervision—may significantly influence a facility’s readiness to provide NCD services [20,21]. Therefore, in the current study, we use the most recent and comprehensive Service Provision Assessment (SPA 2021−22) survey data to assess the readiness of Ethiopia’s health system to deliver NCD-related services [22]. In addition, this study extends previous research by examining health system and governance-related factors and incorporating MNS use disorder services readiness, an important disease area that has often been overlooked in earlier studies.

Having up-to-date and comprehensive information regarding the NCD service readiness of health facilities in Ethiopia is essential for formulating evidence-informed health policies and allocating resources appropriately. This study aims to fill a knowledge gap about NCD service readiness using the most recent SPA data.

Materials and methods

Results

Service availability by health facility characteristics

Out of 403 health facilities (excluding health posts), 338 (84%) offered at least one NCD service. Among the 205 public facilities, nearly 93% provided at least one NCD service, compared to 74% of the 198 private facilities (Table 1).

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Table 1. Weighted percentage of health facilities offering NCD services, by background characteristics, Ethiopia.

https://doi.org/10.1371/journal.pone.0336675.t001

As illustrated in Fig 1, approximately one-quarter (26%) of all facilities offered mental health services. Among facilities providing NCD services, 20% offered all four key NCD services, while nearly 70% provided services for major NCDs—diabetes, CVD, and CRD.

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Fig 1. Percentage of health facilities offering NCD services.

https://doi.org/10.1371/journal.pone.0336675.g001

Facility service-specific readiness

Table 2 shows the percentage of service-specific domains and overall service-specific readiness scores for each disease.

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Table 2. Service-specific percentage readiness and mean domain readiness scores for health facilities that offered NCD services.

https://doi.org/10.1371/journal.pone.0336675.t002

The overall median services readiness index for diabetes was 50.0 (Q1, Q3: 33.3–62.5), indicating that half of the facilities scored below this level. Based on the 70% threshold, only 15.68% of health facilities (95% CI: 12.4%–19.7%) were considered adequately ready to provide diabetes-specific services. Notably, a significant difference was observed between public and private facilities, with 12.75% and 2.93%, respectively, meeting the adequacy benchmark. The mean domain scores for the availability of guidelines and trained providers, and essential medicines and commodities related to diabetes services were all below one-third of the maximum score of 100. Except for basic equipment, public facilities reported higher availability of guidelines and trained providers, diagnostics, and essential medicines compared to private facilities (Table 2).

CVD-related service readiness had a median score of 41.66 (Q1, Q3: 31.66–71.66). The mean domain score for the availability of basic equipment was 72.03 (SD: 18.48). Private facilities had a higher average score in basic equipment availability (78.39) than public facilities (67.53). However, private facilities scored lower across other service readiness domains. Notably, the availability of medicines and commodities was significantly lower in private facilities. Overall, only 10.64% of facilities (95% CI: 8.12%–13.82%) were considered adequately ready to provide CVD-specific services, with readiness particularly low among private facilities (2.20%).

Although CRD-related services were somewhat more available across facilities compared to diabetes and CVD, the overall median availability of tracer items was low at 31.66 (Q1, Q3: 21.66–45.00). This indicates that half of the facilities scored below 31.66, and 75% scored below 45.00, highlighting a generally low level of readiness. This is further compounded by the fact that only 3.14% (95% CI: 1.96, 5.00) of facilities were adequately prepared to provide CRD services.

Finally, the readiness of MH services was assessed across two key domains: the availability of guidelines and trained providers, and essential medicines and commodities. The overall median MNS use disorder-related service readiness score was 25.00 (Q1, Q3: 5.55–47.22), indicating that half of the facilities scored below this threshold. Public facilities generally had better availability of tracer items and higher readiness scores compared to private facilities. Based on the 70% adequacy threshold, only 0.41% of private health facilities were considered adequately ready to provide MNS use disorder-specific services. The median readiness score among private facilities was 0.00 (Q1, Q3: 0.00%–25.00%), suggesting that more than half of these facilities lacked any guidelines and trained staff, or essential medicines for MNS use disorders service delivery (Table 2).

Factors associated with facility service readiness

Table 3 shows the multivariable logistic regression for diabetes, CVDs, CRDs and MNS use disorder-specific service readiness index by, facility level, managing authority, location, region, administration meeting, quality control, HMIS unit and external supervision.

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Table 3. Factors associated with the readiness of health facilities to provide NCD services.

https://doi.org/10.1371/journal.pone.0336675.t003

After adjusting for facility background characteristics, the analysis revealed that secondary and tertiary level health facilities were at least twice as likely to be “ready” to provide services for diabetes, CVDs, CRDs, and MNS use disorders compared to primary-level facilities. Health facilities located in urban areas demonstrated significantly higher readiness than their rural counterparts. Specifically, urban health facilities were 2.42 times more likely to be ready to provide diabetes services (95% CI: 1.10–5.31; p < 0.05), 13.66 times more likely for CRDs (95% CI: 5.10–36.58; p < 0.001), and 10.85 times more likely for MNS use disorder-related services (95% CI: 4.05–29.09; p < 0.001). Private facilities were notably less prepared to deliver MH services, with an AOR of 0.07 (95% CI: 0.02–0.24; p < 0.001), indicating they were 93% less likely to meet readiness criteria compared to public facilities. Regional disparities were also evident. Facilities in Oromia were significantly less likely to be ready for diabetes and CVD service provision. Conversely, facilities in the Southern Nations, Nationalities, and Peoples’ (SNNP) region were 87% less likely to be ready for CVD services (AOR = 0.13; 95% CI: 0.03–0.49; p < 0.01), while facilities in Sidama were 5.23 times more likely to be ready for CRD services compared to those in Addis Ababa (95% CI: 1.59–17.13; p < 0.01). Facility-level management practices also showed significant associations with service readiness. Facilities that held routine administrative meetings were substantially more likely to be ready to provide CVD and CRD services, with AORs of 9.76 and 13.38, respectively. Similarly, facilities with a functional HMIS unit were 4.74 times more likely to be ready to deliver CVD services. Finally, external supervision from higher or immediate administrative levels was a significant predictor of service readiness. Facilities that received external supervision were 8.02 times more likely to be ready for diabetes services and 14.39 times more likely for CVD services, compared to those that did not receive such supervision.

Discussion

This study investigates the availability and readiness of health facilities in Ethiopia for diagnose and manage of NCDs services such as diabetes, CVDs, CRDs, and MNS use disorders. Two aspects of NCD-specific services were evaluated: service availability, service readiness, and the factors associated with the readiness of health facilities to provide NCD care. Readiness was assessed based on the availability of predefined tracer items for service domains: trained staff and guidelines, basic equipment, basic diagnostics, and essential medicines and commodities. The findings show that the majority of health facilities (83.95%) offer at least one NCD service. However, most of them demonstrated inadequate readiness to manage these conditions across all four disease categories, indicating a lack of standard treatment guidelines, adequately trained personnel, essential equipment, and necessary medications for effective NCD care and management. Public health facilities were generally better prepared to provide NCD-related services than private facilities. In addition, facilities operated in urban areas were more likely to be prepared to provide NCD services.

In the current study, the majority of health facilities (83.95%) reported offering at least one of the four NCD services. Among these, approximately one-fifth (20%) provide all four NCD services. This represents a prominent improvement in service availability compared to the study conducted in Ethiopia using 2018 SARA survey data, where only 67.9% of facilities offered at least one NCD service and just 8% provided all four services [19]. This may result from the expansion of NCD services, mainly rolled out into primary health facilities as part of a priority action under the National Strategic Plan for the Prevention and Control of major NCDs (2020–2025) [11]. This strategic initiative aims to strengthen the health system’s preparedness to manage NCDs. Among the four conditions assessed, three of them (diabetes, CVDs, and CRDs), often referred to as major NCDs, were available in approximately 93% of the facilities. However, there was a substantial disparity in the availability of services for MNS use disorder, with only 26% of facilities offering these services, highlighting a critical service gap compared to the other NCD categories. This level of service availability is below the annual target of 35% set for 2021 in Ethiopia’s National Mental Health Strategy (2020–2025) [12]. Overall, the availability of NCD services in this study is higher compared to findings from similar studies conducted in other African and South Asian countries [20,25–27].

One of the key pillars of the national NCD strategic plan is strengthening health service delivery through the development of human resources and improvements in infrastructure, diagnostics, medical supplies, and technologies. These interventions are intended to build the capacity of the health system—particularly at the primary care level—to provide timely, effective, and comprehensive NCD-related services. While there has been progress compared to the 2018 SARA survey, the current findings indicate that the overall readiness of health facilities remains significantly below the 70% service readiness threshold. Only 15.68% of facilities met the readiness threshold for diabetes, 10.64% for CVDs, 3.14% for CRDs, and 11.52% for MNS use disorder-related services. Notably, although CVD is the most prevalent NCD, facilities were less prepared to manage it than diabetes. There is therefore a need for services to be prioritised according to disease burden.

The median overall readiness scores for diabetes, CVDs, CRDs, and MNS use disorders were 50.00, 41.66, 31.66, and 25.00, respectively. These median values indicate a generally low level of preparedness across all conditions, with at least 50% of facilities scoring below these levels. This suggests that the majority of facilities lack essential components such as trained personnel, clinical guidelines, diagnostic equipment, and essential medicines needed to manage NCDs effectively. Such low levels of readiness highlight critical gaps in the health system’s capacity to respond to the growing burden of NCDs. A study on the integration of mental health and substance abuse services into primary health care in Ethiopia identified delayed support and supervision, high staff turnover and interruptions in the supply of essential medicines, among other key challenges [28]. Compared to other studies, our findings indicate a higher level of service readiness than reported in Nepal [26], but lower than that observed in Kenya, Vietnam, Bangladesh, and Tanzania [20,25,27,29]. These variations may be attributed to differences in health system structures, the tools used for data collection, and the extent to which NCD prevention and control are prioritised within national policies. For instance, the Kenyan study employed the WHO-PEN tool, which is specifically designed to monitor NCD service implementation at the primary healthcare level. When disaggregating service readiness by facility ownership, public facilities were generally more prepared than private ones across all four NCD conditions. This may be attributed to their integration into national health strategies, better access to public resources, provision of more comprehensive care, and stronger accountability mechanisms.

At the domain level, the mean percentage scores for guidelines and trained staff, and essential medicines were consistently low across all conditions, with values falling below nearly one-third of the maximum score of 100. In contrast, the mean availability score for basic equipment was relatively higher, particularly for diabetes, CVDs, and CRDs. A notable finding is that, except for MNS use disorders, which were assessed using only two domains (guidelines and trained staff, and essential medicines), private facilities had relatively better availability of basic equipment, while public facilities scored higher in the availability of guidelines and trained staff, and essential medicines. Furthermore, the readiness of private facilities to deliver MH-related services was extremely poor. Almost none of the private facilities (only 0.41%) met the 70% readiness threshold for MHservices. Notably, the median overall readiness score was 0.00 (Q1, Q3: 0.00, 25.00), indicating that 75% of these facilities completely lacked trace items for guidelines and trained staff, as well as essential medicines, and even the top 25% of performers fell short of the 70% cut-off. This highlights a severe gap in the capacity of private facilities to manage MNS use disorders. This may be explained by regulatory restrictions in Ethiopia, where private clinics (primary, medium, higher, and speciality) are prohibited from holding or dispensing non-emergency medicines in these health facilities at any time [30,31]. As a result, private facilities are less likely to stock essential NCD medicines and impact their medication domain of readiness. Moreover, private facilities are poorly integrated into the health systems. This leads to poor access to clinical guidelines and training related to health services, including NCD management. Short-term and refreshment training for private facilities is provided by the government through public–private partnership (PPP) programs [12]. These partnerships are collaborative arrangements between the government and private sector actors aimed at addressing health issues. The observed differences in capacity between public and private facilities may, in part, be attributed to the government’s stronger emphasis on supporting the public sector, alongside existing gaps in the implementation of effective PPP. A case study on the PPP revealed gaps that the federal and regional governments have not yet addressed in their efforts to effectively implement PPP policies through private sector engagement endeavors. The regulatory standards, by the Ethiopian Food and Drug Administration, in place were considered too stringent and not conducive to service delivery by private health facilities [32]. Another study on private sector assessment revealed that the overall regulatory framework contains many barriers to growing and harnessing the private health sector. Market conditions present the biggest constraint to private sector investment and growth and limit their ability to prepare for the service provision. Furthermore, there are limited economic and financial incentives to provide NCD services. Limited private sector understanding of government priorities. The private sector representatives interviewed stressed that they have little access to information from the MOH [33].

Our study revealed that secondary and tertiary-level health facilities— hospitals—were more likely to be ready to provide NCD-related services compared to primary-level facilities, such as health centers and private clinics. This finding aligns with similar studies conducted in Zambia, Kenya, and Nepal [24,25,34]. Except for CVD services, facilities located in urban areas were generally more prepared to deliver NCD care than those in rural areas, a pattern also observed in other studies [24,25]. Additionally, health system and management practice-related factors were significantly associated with service readiness. Facilities that received external supervision from higher administrative levels—such as district, regional, or ministerial offices—demonstrated significantly higher readiness scores for diabetes and CRDs. This is consistent with findings from studies in Uganda and Nepal [24,35]. Furthermore, facilities with functional quality control units and regular administrative meetings were more likely to be adequately prepared to provide NCD services.

Strengths and limitations

A key strength of this study is the use of a nationally representative and comprehensive dataset, ensuring national representativeness in terms of general health facilities’ characteristics within the country’s health system. The survey employed an objective facility assessment approach, whereby the availability and functionality of tracer items within each domain were verified through direct observation, enhancing the reliability of the findings. Another strength lies in the use of an adapted DHS Service Provision Assessment survey tool, which is widely recognized for its robustness and validity in health systems research. The application of this tool ensures a high degree of accuracy in characterizing the current service readiness landscape. Moreover, the SPA tool is increasingly being used in other LMICs, thereby enhancing the comparability of our results with similar studies conducted elsewhere. Additionally, the estimates presented in this study were adjusted and weighted to account for non-response and disproportionate sampling, further improving the representativeness and precision of the findings.

The main limitation of this study is its cross-sectional design, which restricts the ability to draw causal inferences. Additionally, the study focused predominantly on the supply side of the health system, with limited attention to demand-side factors, such as health-seeking behaviours, financial barriers, and community-level perceptions, that are also critical for informing effective interventions. While the study assessed key readiness components, including the availability of essential medicines, diagnostics, and clinical guidelines, these evaluations were largely basic. More advanced diagnostic tools and technologies required for the comprehensive management of NCDs, such as electrocardiograms and imaging equipment, were not included in the assessment. Furthermore, the study did not evaluate facility readiness for cancer and chronic kidney diseases due to the absence of data on relevant tracer items. Therefore, a primary study is needed to assess the level of facility readiness to provide these services. Finally, because of the security issue, the Tigray region was excluded from the survey sample. These gaps limit the study’s ability to provide a full picture of the health system’s preparedness to address the broader spectrum of NCDs.

Conclusion

This study found that the Ethiopian health system is insufficiently prepared for CVDs, diabetes, CRDs and MHservices. The service readiness was higher in public health facilities compared to private health facilities. Given Ethiopia’s commitment under Global Action Plan on NCDs, and commitments under periodic plans and policies, the country needs to strengthen service delivery platforms while improving the overall readiness of the health system through increasing the number of qualified health staff, training and provision of equipment and medicines. A number of factors have been associated with better service readiness, including the location of the facility, the level of the facility, having a quality control unit, conducting regular administrative meetings and receiving external supervision.

Supporting information

Acknowledgments

We would like to acknowledge DHS program for providing us data for further analysis. We would also like to thank Mr. Tsegaye Gebremedhin for his assistance with data analysis.