Seasonal variations of household costs of illness in Burkina Faso

The redistributive effect of the public health system: the case of Sierra Leone

Universal health coverage (UHC), health equity and reduction of income inequalities are key objectives for the Sierra Leone government. While investing in health systems may drive economic growth, it is less clear whether investing in health systems reduces income inequality. Therefore, a crucial issue is to what extent the Sierra Leone public healthcare system reduces income inequality, and finances and provides healthcare services equitably. We use data from the Sierra Leone Integrated Household Survey 2018 to complete a financing and benefit incidence analysis of the Sierra Leone public healthcare system. We extend these analyses by assessing the redistributive effect of the public healthcare system (i.e. fiscal incidence analysis). We compute the redistributive effect as the change in Gini index induced by the payments for, and provision of, public healthcare services. The financing incidence of the Sierra Leone public healthcare system is marginally progressive (i.e. Kakwani index: 0.011*, P-value <0.1). With regard to public healthcare benefits, while primary healthcare (PHC) benefits are pro-poor, secondary/tertiary benefits are pro-rich. The result is that overall public healthcare benefits are equally distributed (concentration index (CI): 0.008, not statistically different from zero). However, needs are concentrated among the poor, so benefits are pro-rich when needs are considered. We find that the public healthcare system redistributes resources from better-off quintiles to worse-off quintiles (Gini coefficient reduction induced by public healthcare system = 0.5%). PHC receives less financing than secondary/tertiary care but delivers a larger reduction in income inequality. The Sierra Leone public healthcare system redistributes resources and reduces income inequality. However, the redistributive effect occurs largely thanks to PHC services being markedly pro-poor, and the Sierra Leone health system could be more equitable. Policy-makers interested in improving Sierra Leone public health system equity and reducing income inequalities should prioritize PHC investments.

The Macroeconomic Impact of Increasing Investments in Malaria Control in 26 High Malaria Burden Countries: An Application of the Updated EPIC Model

BACKGROUND

Malaria remains a major public health problem. While globally malaria mortality affects predominantly young children, clinical malaria affects all age groups throughout life. Malaria not only threatens health but also child education and adult productivity while burdening government budgets and economic development. Increased investments in malaria control can contribute to reduce this burden but have an opportunity cost for the economy. Quantifying the net economic value of investing in malaria can encourage political and financial commitment.

METHODS

We adapted an existing macroeconomic model to simulate the effects of reducing malaria on the gross domestic product (GDP) of 26 high burden countries while accounting for the opportunity costs of increased investments in malaria. We compared two scenarios differing in their level of malaria investment and associated burden reduction: sustaining malaria control at 2015 intervention coverage levels, time at which coverage levels reached their historic peak and scaling-up coverage to reach the 2030 global burden reduction targets. We incorporated the effects that reduced malaria in children and young adolescents may have on the productivity of working adults and on the future size of the labour force augmented by educational returns, skills, and experience. We calibrated the model using estimates from linked epidemiologic and costing models on these same scenarios and from published country-specific macroeconomic data.

RESULTS

Scaling-up malaria control could produce a dividend of US$ 152 billion in the modelled countries, equivalent to 0.17% of total GDP projected over the study period across the 26 countries. Assuming a larger share of malaria investments is paid out from domestic savings, the dividend would be smaller but still significant, ranging between 0.10% and 0.14% of total projected GDP. Annual GDP gains were estimated to increase over time. Lower income and higher burden countries would experience higher gains.

CONCLUSION

Intensified malaria control can produce a multiplied return despite the opportunity cost of greater investments.

Factors associated with health-seeking behavior amongst children in the context of free market: Household study in Ouagadougou, Burkina Faso, 2011

BACKGROUND

Limited access to healthcare among children in sub-Saharan Africa (SSA) is a major cause of poor infant health indicators. Although many speculate that the private sector expansion has overwhelmingly reinforced health systems' utilization, little is known as to whether and where children are cared for when they are sick. This study investigated health-seeking behavior (HSB) among children from an urban area of Burkina Faso, with respect to disease severity and the type of provider versus children's characteristics.

METHODS

A cross-sectional population-based study was conducted in Ouagadougou, Burkina Faso using a two-stage sampling strategy. 1,098 households (2,411 children) data were collected. Generalized estimating equations (GEE) were used to analyze providers' choice for emergency, severe and non-severe conditions; sex-preference was further assessed with a χ2 test.

RESULTS

Thirty-six percent of children requiring emergency care sought private providers, as did 38% with severe conditions. Fifty-seven percent with non-severe conditions were self-medicated. A multivariable GEE indicated that University-educated household-heads would bring their children to for-profit (instead of public) providers for emergency (OR = 3.51, 95%CI = 1.90; 6.48), severe (OR = 4.05, 95%CI: 2.24; 7.30), and non-severe (OR = 3.25, 95%CI = 1.25; 8.42) conditions. A similar pattern was observed for insured and formal jobholders. Children's sex, age and gender was not associated with neither the type of provider preference nor the assessed health condition.

CONCLUSION

Private healthcare appeared to be crucial in the provision of care to children. The household head's socioeconomic status and insurance coverage significantly distinguished the choice of care provider. However, the phenomenon of son-preference was not found. These findings spotlighted children's HSB in Burkina Faso.

The effect of community engagement on healthcare utilization and health insurance enrollment in Ghana: Results from a randomized experiment

Health insurance enrollment in many Sub-Saharan African countries is low, even with highly subsidized premiums and exemptions for vulnerable populations. One possible explanation is low service quality, which results in a low valuation of health insurance. Using a randomized control trial in 64 primary health care facilities in Ghana, this study assesses the impact of a community engagement intervention designed to improve the quality of healthcare and health insurance services on households living nearby the facilities. Although the intervention improved the medical-technical quality of health services, our results show that households' subjective perceptions of the quality of healthcare and insurance services did not increase. Nevertheless, the likelihood of illness and concomitant healthcare utilization reduced, and especially households who were not insured at baseline were more likely to enroll in health insurance. The results show that solely increasing the technical quality of care is not sufficient to increase households' subjective assessments of healthcare quality. Still, improving technical quality can directly contribute to health outcomes and further increase health insurance coverage, especially among the previously uninsured.

On the Measurement of Financial Protection: An Assessment of the Usefulness of the Catastrophic Health Expenditure Indicator to Monitor Progress Towards Universal Health Coverage

Ensuring financial protection (FP) against health expenditures is a key component of Sustainable Development Goal (SDG) 3.8, which aims to achieve Universal Health Coverage (UHC). While the proportion of households with catastrophic health expenditures exceeding a proportion of their total income or consumption has been adopted as the official SDG indicator, other approaches exist and it is unclear how useful the official indicator is in tracking progress toward the FP sub-target across countries and across time. This paper evaluates the usefulness of the official SDG indicator to measure FP using the RACER framework and discusses how alternative indicators may improve upon the limitations of the official SDG indicator for global monitoring purposes. We find that while all FP indicators have some disadvantages, the official SDG indicator has some properties that severely limit its usefulness for global monitoring purposes. We recommend more research to understand how alternative indicators may enhance global monitoring, as well as improvements to the quality and quantity of underlying data to construct FP indicators in order to improve efforts to monitor progress toward UHC.

Examining the relation between the subjective and objective social status with health reported needs and health-seeking behaviour in Dande, Angola

BACKGROUND

Assessing subjective social status (SSS) may be easily accommodated in the context of a Health and Demographic Surveillance System (HDSS). To our knowledge, no prior studies have examined the association of SSS and health in Angola. Subjective socioeconomic measures may provide a rapid assessment of a relevant social status construct, important for studying health inequalities. In this study, we addressed social determinants of health by examining the relationship between the subjective and objective social status, reported health and healthcare-seeking behaviour.

METHODS

This research results from a cross-sectional study performed during 2015 in the Dande HDSS, in Angola. We tested the application of the MacArthur scale as a measure of SSS in a developing setting, in a sample of 12,246 households. First, we investigated its relation to objective socioeconomic indicators, and then we explored how subjective and objective social status associate with health reported needs and health-seeking behaviour of the surveyed population. Chi-square, ANOVA tests, and Receiver Operating Characteristics (ROC) Curves analysis were computed for testing relationships between subjective status ladder quartiles, sociodemographic and household characteristics. Logistic regression was used to examine the influence of subjective perception of status in self-reported health and health-seeking behaviour.

RESULTS

Our findings suggest that the SSS follows a gradient distribution obtained with more objective socioeconomic indicators. Additionally, we found that subjective perception of status influence health needs reporting and health-seeking behaviour and its significant effect remained after controlling for the objective socioeconomic markers. Individuals standing in the second quartile of the social ladder have more odds of reporting illness and those in the highest quartiles of the ladder were twice more likely (OR = 2.23, 95% CI = 1.52-3.26) to seek help from formal health services than those at the bottom of the ladder.

CONCLUSIONS

The MacArthur Scale is a valuable tool to measure SSS in the Dande HDSS, relevant for studying socioeconomic disparities and health inequalities. It is also an easier alternative to traditional measures such as income, usually difficult to measure in developing settings. The social perception of status should be considered as a complement with objective indicators when exploring social determinants of health.

Decomposition of changes in socioeconomic inequalities in catastrophic health expenditure in Kenya

BACKGROUND

Catastrophic health expenditure (CHE) is frequently used as an indicator of financial protection. CHE exists when health expenditure exceeds a certain threshold of household consumption. Although CHE is reported to have declined in Kenya, it is still unacceptably high and disproportionately affects the poor. This study examines the socioeconomic factors that contribute to inequalities in CHE as well as the change in these inequalities over time in Kenya.

METHODS

We used data from the Kenya household health expenditure and utilisation (KHHEUS) surveys in 2007 and 2013. The concertation index was used to measure the socioeconomic inequalities in CHE. Using the Wagstaff (2003) approach, we decomposed the concentration index of CHE to assess the relative contribution of its determinants. We applied Oaxaca-type decomposition to assess the change in CHE inequalities over time and the factors that explain it.

RESULTS

The findings show that while there was a decline in the incidence of CHE, inequalities in CHE increased from -0.271 to -0.376 and was disproportionately concentrated amongst the less well-off. Higher wealth quintiles and employed household heads positively contributed to the inequalities in CHE, suggesting that they disadvantaged the poor. The rise in CHE inequalities overtime was explained mainly by the changes in the elasticities of the household wealth status.

CONCLUSION

Inequalities in CHE are persistent in Kenya and are largely driven by the socioeconomic status of the households. This implies that the existing financial risk protection mechanisms have not been sufficient in cushioning the most vulnerable from the financial burden of healthcare payments. Understanding the factors that sustain inequalities in CHE is, therefore, paramount in shaping pro-poor interventions that not only protect the poor from financial hardship but also reduce overall socioeconomic inequalities. This underscores the fundamental need for a multi-sectoral approach to broadly address existing socioeconomic inequalities.

An empirical evaluation of the performance of financial protection indicators for UHC monitoring: Evidence from Burkina Faso

Achieving Universal Health Coverage (UHC) has been recognized as one of the Sustainable Development Goals (SDGs) and includes both ensuring access to health services and providing financial protection (FP) against using these services. Currently, progress towards achieving the FP component of UHC is assessed using the catastrophic health expenditure budget share indicator, which estimates the proportion of the population with health expenditures exceeding 10% of total income or consumption. Other indicators exist, however, and are widely used in the literature, yet few studies have compared the usefulness of these indicators for UHC monitoring. Using panel data from Burkina Faso, this paper seeks to evaluate the performance of common FP indicators based on three properties: (1) their ability to identify those most at risk of financial hardship (i.e. the poor), (2) their ability to detect households with health shocks, and (3) their sensitivity to seasonal variation. Our results indicate that, while some indicators perform better in certain conditions than others, none are without limitation. Indeed, despite being the best able to differentiate households who have experienced a health shock, the official SDG indicator performs the worst at identifying the poorest group of the population and is the most sensitive to seasonal variation. As such, more research is needed in order to improve the measurement of FP such that progress towards achieving UHC can be accurately monitored.

Potential impact of eradicating malaria on gender inequality within agricultural households in sub-Saharan Africa

The international development community has shown an increased interest in the links between malaria and gender inequality over the past two decades. Working towards the ambitious goal of eradicating malaria by 2040, suppressing the malaria burden could accelerate progress in reducing gender inequality within agricultural households in sub-Saharan Africa. Although numerous studies have examined narrow aspects of the relationship between malaria and gender inequality, little progress has been made in understanding how eliminating malaria could affect gender inequality within agricultural households. This Open Letter focuses on the amount of time women farmers dedicate to caregiving for malaria cases among children in agricultural households, and how reducing time spent on this activity could reduce gender inequalities and impact agricultural productivity. We argue that a research agenda is needed to inform a multi-disciplinary approach to gain this understanding. We conclude by discussing the means through which a reduction in gender inequalities in agricultural households could impact the effectiveness of vector control interventions.

Socio-economic inequality in health service utilisation: Does accounting for seasonality in health-seeking behaviour matter?

Seasonal variation exists in disease incidence. The variation could occur across the different regions in a country. This paper argues that using national household data that are not adjusted for seasonal and regional variations in disease incidence may not be directly suitable for assessing socio-economic inequality in annual outpatient service utilisation, including for cross-country comparison. In fact, annual health service utilisation may be understated or overstated depending on the period of data collection. This may lead to miss-estimation of socio-economic inequality in health service utilisation depending, among other things, on how health service utilisation, across geographical areas, varies by socio-economic status. Using a nationally representative dataset from South Africa, the paper applies a seasonality index that is constructed from the District Health Information System, an administrative dataset, to annualise public outpatient health service visits. Using the concentration index, socio-economic inequality in health service visits, after accounting for seasonal variations, was compared with that when seasonal variations are ignored. It was found that, in some cases, socio-economic inequality in outpatient health service visits depends on the socio-economic distribution of the seasonality index. This may justify the need to account for seasonal and geographical variations.

The score of integrated disease surveillance and response adequacy (SIA): a pragmatic score for comparing weekly reported diseases based on a systematic review

BACKGROUND

The Integrated Disease Surveillance and Response (IDSR) strategy implemented by the World Health Organization (WHO) in Africa has produced a large amount of data on participating countries, and in particular on the Democratic Republic of Congo (DRC). These data are increasingly considered as unevaluable and, therefore, as requiring a rigorous process of validation before they can be used for research or public health purposes. The aim of this study was to propose a method to assess the level of adequacy of IDSR morbidity data in reflecting actual morbidity.

METHODS

A systematic search of English- and French-language articles was performed in Scopus, Medline, Science Direct, Springer Link, Cochrane, Cairn, Persée, and Erudit databases. Other types of documents were identified through manual searches. Selected articles focused on the determinants of the discrepancies (differences) between reported morbidity and actual morbidity. An adequacy score was constructed using some of the identified determinants. This score was applied to the 15 weekly reported diseases monitored by IDSR surveillance in the DRC. A classification was established using the Jenks method and a sensitivity analysis was performed. Twenty-three classes of determinants were identified in 35 IDSR technical guides and reports of outbreak investigations and in 71 out of 2254 researched articles. For each of the 15 weekly reported diseases, the SIA was composed of 12 items grouped in 6 dimensions.

RESULTS

The SIA classified the 15 weekly reported diseases into 3 categories or types: high score or good adequacy (value > = 14), moderate score or fair adequacy (value > = 8 and < 14), and low score or low or non-adequacy (value < 8). Regardless of the criteria used in the sensitivity analysis, there was no notable variation in SIA values or categories for any of the 15 weekly reported diseases.

CONCLUSION

In a context of sparse health information in low- and middle-income countries, this study developed a score to help classify IDSR morbidity data as usable, usable after adjustment, or unusable. This score can serve to prioritize, optimize, and interpret data analyses for epidemiological research or public health purposes.

Evidence for the impact of malaria on agricultural household income in sub-Saharan Africa

Background: Progress in suppressing malaria over the next two decades may have a significant impact on poverty among agricultural households in sub-Saharan Africa. A recent study found that if malaria were eradicated by 2040, poverty rates among such households would fall by 4 to 26 percentage points more from 2018 to 2040 than if the burden of malaria remained at its current level. The relatively wide range of these estimates is due to a lack of evidence regarding the long-term impact of suppressing malaria on the incomes of agricultural households. The objective of this study is to describe a research framework that would generate the necessary evidence for developing more precise estimates. Methods: First, we developed a conceptual framework for understanding the potential long-term impact of suppressing malaria on the incomes of agricultural households. Next, we established a research framework for examining each component of the conceptual framework. Results: Our proposed research framework enables a comprehensive examination of how malaria affects the decisions, productivity, harvest value and expenditures due to morbidity and mortality within an agricultural household. This contrasts with the 27 existing relevant studies that we have identified, of which 23 focused only on household productivity and expenditures, two focused on decisions, and two focused on harvest values. Conclusion: By implementing the research framework presented in this study, we will increase our knowledge of how suppressing malaria over the next two decades would affect the incomes of agricultural households in sub-Saharan Africa. Evidence generated from the framework will inform funding allocation decisions for malaria elimination initiatives.

The impact of reducing and eliminating user fees on facility-based delivery: a controlled interrupted time series in Burkina Faso

User fee reduction and removal policies have been the object of extensive research, but little rigorous evidence exists on their sustained effects in relation to use of delivery care services, and no evidence exists on the effects of partial reduction compared with full removal of user fees. We aimed to fill these knowledge gaps by assessing sustained effects of both partial reduction and complete removal of user fees on utilization of facility-based delivery. Our study took place in four districts in the Sahel region of Burkina Faso, where the national user fee reduction policy (SONU) launched in 2007 (lowering fees at point of use by 80%) co-existed with a user fee removal pilot launched in 2008. We used Health Management Information System data to construct a controlled interrupted time-series analysis and examine both immediate and sustained effects of SONU and the pilot from January 2004 to December 2014. We found that both SONU and the pilot led to a sustained increase in the use of facility-based delivery. SONU produced an accumulative increase of 31.4% (P < 0.01) over 8 years in the four study districts. The pilot further enhanced utilization and produced an additional increase of 23.2% (P < 0.001) over 6 years. These increasing trends did not continue to reach full coverage, i.e. ensuring that all women had a facility-based delivery. Instead, they stabilized 3 years and 4 years after the onset of SONU and the pilot, respectively. Our study provides further evidence that user fee reduction and removal policies are effective in increasing service use in the long term. However, they alone are not sufficient to achieve full coverage. This calls for the need to implement additional measures, targeting for instance geographical barriers and knowledge gaps, to achieve the target of all women delivering in the presence of a skilled attendant.

Out-of-pocket expenditure for health care: District level estimates for Haryana state in India

INTRODUCTION

In this paper, we present district level out-of-pocket (OOP) expenditures with respect to outpatient consultation within last 15 days and hospitalization in last 1 year for Haryana state.

METHODS

The data from a large cross-sectional household survey covering all 21 districts of Haryana comprising of randomly selected 79 742 households were analyzed. Of the total sample, 56 056 households consisting of 314 639 individuals in 21 districts of Haryana state were surveyed to gather information on OOP expenditure incurred on outpatient consultation within last 15 days. Similarly, 59 901 households and 324 977 respondents were interviewed to elicit OOP expenditures for any hospitalization during the 1 year preceding the survey. Mean OOP expenditure per OP consultation, per hospitalization as well as per capita were computed. Mean OOP expenditure was also estimated by the type of provider, gender, and district.

RESULTS

The mean OOP expenditure for OP consultation and hospitalization in Haryana was Indian National Rupees (INR) 1005 (US Dollar [USD] 16.1; 95% CI: INR 934-1076) and INR 22 489 (USD 360.0; 95% CI: INR 21 375-23 608), respectively. Mean per capita OOP expenditure for OP consultation, which was INR 85 (USD 1.3) in Haryana, varied from INR 595 (USD 9.5) in district Panipat to INR 29 (USD 0.5) in district Kaithal.

CONCLUSION

This is the first study to comprehensively present district level estimates for OOP expenditure for health care. These estimates are useful for policy planning, and preparation for district and state health accounts.

Estimating benefit equity of government health subsidy in healthcare Services in Shandong Province, China: a cross-sectional study

Background

Government health subsidy (GHS) is an effective tool to improve population health in China. Ensuring an equitable allocation of GHS, particularly among the poorer socio-economic groups, is a major goal of China’s healthcare reform.

The paper aims to explore how GHS was allocated across different socioeconomic groups, and how well the overall health system was performing in terms of the allocation of subsidy for different types of health services.

Methods

Data from China’s National Health Services Survey (NHSS) in 2013 were used. Benefit incidence analysis (BIA) was applied to examine if GHS was equally distributed across income quintile. Benefit incidence was presented as each quintile’s percentage share of total benefits, and the concentration index (CI) and Kakwani index (KI) were calculated. Health benefits from three types of healthcare services (primary health care, outpatient and inpatient services) were analyzed, separated into urban and rural populations. In addition, the distribution of benefits was compared to the distribution of healthcare need (measured by self-reported illness and chronic disease) across income quintiles.

Results

In urban populations, the CI value of GHS for primary care was negative. (− 0.14), implying an allocation tendency toward poor region; the CI values of outpatient and inpatient services were both positive (0.174 and 0.194), indicating allocation tendencies toward rich region. Similar allocation pattern was observed in rural population, with pro-poor tendency of primary care service (CI = − 0.082), and pro-rich tendencies of outpatient (CI = 0.153) and inpatient services (CI = 0.203). All the KI values of three health services in urban and rural populations were negative (− 0.4991,-0.1851 and − 0.1651; − 0.482, − 0.247and − 0.197), indicating that government health subsidy was progressive and contributed to the narrowing of economic gap between the poor and rich.

Conclusions

The inequitable distribution of GHS in China exited in different healthcare services; however, the GHS benefit is generally progressive. Future healthcare reforms in China should not only focus on expanding the coverage, but also on improving the equity of distribution of healthcare benefits.

The hidden costs: Identification of indirect costs associated with acute gastrointestinal illness in an Inuit community

BACKGROUND

Acute gastrointestinal illness (AGI) incidence and per-capita healthcare expenditures are higher in some Inuit communities as compared to elsewhere in Canada. Consequently, there is a demand for strategies that will reduce the individual-level costs of AGI; this will require a comprehensive understanding of the economic costs of AGI. However, given Inuit communities' unique cultural, economic, and geographic contexts, there is a knowledge gap regarding the context-specific indirect costs of AGI borne by Inuit community members. This study aimed to identify the major indirect costs of AGI, and explore factors associated with these indirect costs, in the Inuit community of Rigolet, Canada, in order to develop a case-based context-specific study framework that can be used to evaluate these costs.

METHODS

A mixed methods study design and community-based methods were used. Qualitative in-depth, group, and case interviews were analyzed using thematic analysis to identify and describe indirect costs of AGI specific to Rigolet. Data from two quantitative cross-sectional retrospective surveys were analyzed using univariable regression models to examine potential associations between predictor variables and the indirect costs.

RESULTS/SIGNIFICANCE

The most notable indirect costs of AGI that should be incorporated into cost-of-illness evaluations were the tangible costs related to missing paid employment and subsistence activities, as well as the intangible costs associated with missing community and cultural events. Seasonal cost variations should also be considered. This study was intended to inform cost-of-illness studies conducted in Rigolet and other similar research settings. These results contribute to a better understanding of the economic impacts of AGI on Rigolet residents, which could be used to help identify priority areas and resource allocation for public health policies and programs.

Catastrophic healthcare expenditure and poverty related to out-of-pocket payments for healthcare in Bangladesh-an estimation of financial risk protection of universal health coverage

The Sustainable Development Goals target to achieve Universal Health Coverage (UHC), including financial risk protection (FRP) among other dimensions. There are four indicators of FRP, namely incidence of catastrophic health expenditure (CHE), mean positive catastrophic overshoot, incidence of impoverishment and increase in the depth of poverty occur for high out-of-pocket (OOP) healthcare spending. OOP spending is the major payment strategy for healthcare in most low-and-middle-income countries, such as Bangladesh. Large and unpredictable health payments can expose households to substantial financial risk and, at their most extreme, can result in poverty. The aim of this study was to estimate the impact of OOP spending on CHE and poverty, i.e. status of FRP for UHC in Bangladesh. A nationally representative Household Income and Expenditure Survey 2010 was used to determine household consumption expenditure and health-related spending in the last 30 days. Mean CHE headcount and its concentration indices (CI) were calculated. The propensity of facing CHE for households was predicted by demographic and socioeconomic characteristics. The poverty headcount was estimated using 'total household consumption expenditure' and such expenditure without OOP payments for health in comparison with the poverty-line measured by cost of basic need. In absolute values, a pro-rich distribution of OOP payment for healthcare was found in urban and rural Bangladesh. At the 10%-threshold level, in total 14.2% of households faced CHE with 1.9% overshoot. 16.5% of the poorest and 9.2% of the richest households faced CHE. An overall pro-poor distribution was found for CHE (CI = -0.064) in both urban and rural households, while the former had higher CHE incidences. The poverty headcount increased by 3.5% (5.1 million individuals) due to OOP payments. Reliance on OOP payments for healthcare in Bangladesh should be reduced for poverty alleviation in urban and rural Bangladesh in order to secure FRP for UHC.

Situating mobile health: a qualitative study of mHealth expectations in the rural health district of Nouna, Burkina Faso

BACKGROUND

The implementation of mobile health (mHealth) projects in low- and middle-income countries raises high and well-documented expectations among development agencies, policymakers and researchers. By contrast, the expectations of direct and indirect mHealth users are not often examined. In preparation for a proposed intervention in the Nouna Health District, in rural Burkina Faso, this study investigates the expected benefits, challenges and limitations associated with mHealth, approaching these expectations as a form of situated knowledge, inseparable from local conditions, practices and experiences.

METHODS

The study was conducted within the Nouna Health District. We used a qualitative approach, and conducted individual semi-structured interviews and group interviews (n = 10). Participants included healthcare workers (n = 19), godmothers (n = 24), pregnant women (n = 19), women with children aged 12-24 months (n = 33), and women of childbearing age (n = 92). Thematic and content qualitative analyses were conducted.

RESULTS

Participants expect mHealth to help retrieve patients lost to follow-up, improve maternal care monitoring, and build stronger relationships between pregnant women and primary health centres. Expected benefits are not reducible to a technological realisation (sending messages), but rather point towards a wider network of support. mHealth implementation is expected to present considerable challenges, including technological barriers, organisational challenges, gender issues, confidentiality concerns and unplanned aftereffects. mHealth is also expected to come with intrinsic limitations, to be found as obstacles to maternal care access with which pregnant women are confronted and on which mHealth is not expected to have any significant impact.

CONCLUSIONS

mHealth expectations appear as situated knowledges, inseparable from local health-related experiences, practices and constraints. This problematises universalistic approaches to mHealth knowledge, while nevertheless hinting at concrete, expected benefits. Findings from this study will help guide the design and implementation of mHealth initiatives, thus optimising their chances for success.

Immediate and sustained effects of user fee exemption on healthcare utilization among children under five in Burkina Faso: A controlled interrupted time-series analysis

BACKGROUND

Little is known about the long-term effects of user fee exemption policies on health care use in developing countries. We examined the association between user fee exemption and health care use among children under five in Burkina Faso. We also examined how factors related to characteristics of health facilities and their environment moderate this association.

METHOD

We used a multilevel controlled interrupted time-series design to examine the strength of effect and long term effects of user fee exemption policy on the rate of health service utilization in children under five between January 2004 and December 2014.

RESULTS

The initiation of the intervention more than doubled the utilization rate with an immediate 132.596% increase in intervention facilities (IRR: 2.326; 95% CI: 1.980 to 2.672). The effect of the intervention was 32.766% higher in facilities with higher workforce density (IRR: 1.328; 95% CI (1.209-1.446)) and during the rainy season (IRR:1.2001; 95% CI: 1.0953-1.3149), but not significant in facilities with higher dispersed populations (IRR: 1.075; 95% CI: (0.942-1.207)). Although the intervention effect was substantially significant immediately following its inception, the pace of growth, while positive over a first phase, decelerated to stabilize itself three years and 7 months later before starting to decrease slowly towards the end of the study period.

CONCLUSION

This study provides additional evidence to support user fee exemption policies complemented by improvements in health care quality. Future work should include an assessment of the impact of user fee exemption on infant morbidity and mortality and better discuss factors that could explain the slowdown in this upward trend of utilization rates three and a half years after the intervention onset.

Assets and challenges facing caregivers when managing malaria in young children in rural Uganda

Background

Despite efforts to improve malaria management for children, a substantial gap remains between policy and practice in Uganda. The aim of this study was to create quantitative profiles of assets and challenges facing caregivers in Butaleja District when managing malaria in children aged 5 years and under. The objectives were: (1) to estimate caregivers’ assets and challenges during an acute episode; and, (2) to ascertain which caregiver attributes influenced receipt of an appropriate anti-malarial the most.

Methods

Data from a 2011 cross-sectional, household survey and ten psychometrically justified scales were used to estimate caregivers’ assets and challenges. The scales scores were simple counts across a series of items, for example, the number of times a caregiver answered a knowledge item correctly or the number of times a caregiver relied on a credible source for information. Since high scores on six of the scales reflected attributes that eased the burden of caregiving, these were labelled ‘caregiver assets’. Similarly, high scores on four of the measures signalled that a caregiver was having trouble managing the malaria episode, thereby reflecting deficits, and these were labelled ‘caregiver challenges’. ANOVAs were used to compare scale scores between caregivers of children who received an appropriate anti-malarial versus those who did not.

Results

On the six asset scales, caregivers averaged highest on knowledge (65 %), followed by correct episode management (48 %), use of trustworthy information sources (40 %), ability to initiate or redirect their child’s treatment (37 %), and lowest on possible encounters with health professionals to assist in treatment decisions (33 %). Similarly, the average caregiver reported problems with 74 % of the issues they might encounter in accessing advice, and 56 % of the problems in obtaining the best anti-malarial. Caregivers whose children received an appropriate anti-malarial demonstrated greater assets and fewer challenges than those whose child did not, with important regional differences existing. Overall, no one region performed particularly well across all ten scales.

Conclusions

Findings from this study suggest that the low use of artemisinin-based combination therapy (ACT) in Butaleja for children 5 years and under may result from caregivers’ high perceived barrier to accessing ACT and low perceived benefits from ACT.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1521-1) contains supplementary material, which is available to authorized users.

Willingness to pay for hypothetical malaria vaccines in rural Burkina Faso

Aims: This study aims to set priorities for anti-disease malaria vaccines by determining community preference in a hyperendemic area. Methods: A bidding game technique was used to elucidate willingness to pay in rural Burkina Faso and 2,326 adults were interviewed. Results: It is shown that there are significant differences between community preference for an anti-disease vaccine aimed at reducing pathology in pregnant women, and for a vaccine directed against childhood malaria. While the target population was willing to pay CFAfr 2101 for a vaccine against maternal malaria, its members were prepared to pay only CFAfr 1433 for a vaccine against childhood malaria. Conclusions: Whilst it is increasingly likely that anti-disease malaria vaccines will become available in the foreseeable future, lessons from the past suggest that a lack of acceptance and support from the intended recipients may lead to less than optimal compliance, and hence efficacy. For the planning of vaccine development and application strategies, it is therefore highly important to take community views into account. Here it is argued that such information could help researchers and funding agencies to set priorities for future vaccine research.

Treatment-seeking behaviour for childhood fever among caretakers of Chivuna and Magoye rural communities of Mazabuka District, Zambia: a longitudinal study

Background

Treatment-seeking for childhood fever among caretakers in most rural parts of African region is still a major challenge. The aim of this study was to determine the treatment seeking behaviour for fever in under-5 children of Magoye and Chivuna rural areas of Mazabuka district in Zambia.

Methods

Treatment-seeking behaviour was explored longitudinally among caretakers of 362 children aged 12–59 months with fever. The data was collected from caretakers using a structured interviewer-administered questionnaire at their homes. Chi-square test, one-sample test of proportions and logistic regression were the statistical methods used for data analysis.

Results

Of the 362 children with fever, 77 % of them had their treatment sought externally. In which 64 % had their treatment at health facility (HF), 18 % from community health workers (CHW), and 18 % from other sources. Early treatment (≤ 24 h) was sought for 42 % of the fever episodes. In dry season, a child had 1.53 times more likely to have early treatment compared to rainy season [OR 1.53; 95 % CI 1.30, 1.80; p < 0.001]. A child in Chivuna was less likely to have early treatment compared to one in Magoye [OR 0.62; 95 % CI 0.50, 0.76; p < 0.001]. Caretakers had a reduced chance of 27 % [OR 0.73; 95 % CI 0.56, 0.95; p = 0.022] of seeking early treatment if they took a child to other sources compared to a HF.

Conclusion

This study has revealed that seeking early and appropriate treatment was suboptimal in the study areas. Source of treatment, season and location were predictors of early treatment of fever among caretakers. Policies aimed at combating poor care-seeking behaviour should not omit to address these factors.

Malaria related care-seeking-behaviour and expenditures in urban settings: A household survey in Ouagadougou, Burkina Faso

In Sub-Sahara Africa, malaria inflicts a high healthcare expenditure to individuals. However, little is known about healthcare expenditure to individual affected by malaria and determinants of healthcare seeking behaviour in urban settings where private sector is thriving. This study investigated the level and correlates of expenditure among individuals with self-reported malaria episode in Ouagadougou, Burkina Faso. A cross-sectional household survey conducted in August-November 2011 in Ouagadougou covered 8,243 individuals (1,600 households). Using Generalized Estimating Equations, the analysis included 1082 individuals from 715 households, who reported an episode of malaria. Of individuals surveyed, 38.3% sought care from public, 27.4% from private providers, and, 34.2% self-medicated. The median cost for malaria treatment was USD10.1 (4,850.0XOF) with significant different between public, private and self-medication (p<0.001). In public primary care health facilities, the median cost was USD8.4 (4,050.0XOF) for uncomplicated malaria and USD15.2 (7,333.5XOF) for severe malaria. In private-for-profit facilities run by a medical doctor, the median cost was USD30.3 (14,600.0XOF) for uncomplicated malaria and USD 43.0 (20,725.0XOF) for severe malaria. Regardless of the source of care, patients with insurance incurred significantly higher expenditure compared to those without insurance (p<0.001) and medicine accounted for the largest share of the expenditure. The type of provider, having insurance, and the severity of the malaria predict the amount of money spent. The high financial cost of malaria treatment regardless of the providers poses threat to the goal of universal access to malaria interventions, the unique way to achieve elimination goals.

Independent Evaluation of the Rapid Scale-Up Program to Reduce Under-Five Mortality in Burkina Faso

We conducted a prospective evaluation of the "Rapid Scale-Up" (RSU) program in Burkina Faso, focusing on the integrated community case management (iCCM) component of the program. We used a quasi-experimental design in which nine RSU districts were compared with seven districts without the program. The evaluation included documentation of program implementation, assessments of implementation and quality of care, baseline and endline coverage surveys, and estimation of mortality changes using the Lives Saved Tool. Although the program trained large numbers of community health workers, there were implementation shortcomings related to training, supervision, and drug stockouts. The quality of care provided to sick children was poor, and utilization of community health workers was low. Changes in intervention coverage were comparable in RSU and comparison areas. Estimated under-five mortality declined by 6.2% (from 110 to 103 deaths per 1,000 live births) in the RSU area and 4.2% (from 114 to 109 per 1,000 live births) in the comparison area. The RSU did not result in coverage increases or mortality reductions in Burkina Faso, but we cannot draw conclusions about the effectiveness of the iCCM strategy, given implementation shortcomings. The evaluation results highlight the need for greater attention to implementation of iCCM programs.

Understanding Interpretations of and Responses to Childhood Fever in the Chikhwawa District of Malawi

Background

Universal access to, and community uptake of malaria prevention and treatment strategies are critical to achieving current targets for malaria reduction. Each step in the treatment-seeking pathway must be considered in order to establish where opportunities for successful engagement and treatment occur. We describe local classifications of childhood febrile illnesses, present an overview of treatment-seeking, beginning with recognition of illness, and suggest how interventions could be used to target the barriers experienced.

Methods

Qualitative data were collected between September 2010 and February 2011. A total of 12 Focus Group Discussions and 22 Critical Incident Interviews were conducted with primary caregivers who had reported a recent febrile episode for one of their children.

Findings and Conclusion

The phrase ‘kutentha thupi’, or ‘hot body’ was used to describe fever, the most frequently mentioned causes of which were malungo (translated as ‘malaria’), mauka, nyankhwa and (m)tsempho. Differentiating the cause was challenging because these illnesses were described as having many similar non-specific symptoms, despite considerable differences in the perceived mechanisms of illness. Malungo was widely understood to be caused by mosquitoes. Commonly described symptoms included: fever, weakness, vomiting, diarrhoea and coughing. These symptoms matched well with the biomedical definition of malaria, although they also overlapped with symptoms of other illnesses in both the biomedical model and local illness classifications. In addition, malungo was used interchangeably to describe malaria and fever in general. Caregivers engaged in a three-phased approach to treatment seeking. Phase 1—Assessment; Phase 2—Seeking care outside the home; Phase 3—Evaluation of treatment response. Within this paper, the three-phased approach is explored to identify potential interventions to target barriers to appropriate treatment. Community engagement and health promotion, the provision of antimalarials at community level and better training health workers in the causes and treatment of non-malarial febrile illnesses may improve access to appropriate treatment and outcomes.

Out-of-pocket nonmedical expenses associated with out-patient treatment of common childhood illnesses

BACKGROUND

Out-of-pocket expenses, medical and non-medical, have an impoverishing effect on the family.

OBJECTIVE

Determine non-medical out-of-pocket expenses incurred during out-patient attendance for primary care services.

METHODS

A descriptive survey was undertaken at a rural medical college using interviewer-administered questionnaire to parents of children <6 years over a period of 6 weeks. Seventy-six participants were interviewed for collecting demographic data and actual cost on travel and meals.

RESULTS

Median expenditure for travel was Indian rupees (INR) 20 with inter-quartile range (IQR) 14-48 and on food it was INR 110 with IQR 40-155. Median total expenditure on the visit was INR 122 with IQR 61-220. Among those who travelled >5 km, 36% attendance was for respiratory complaints, 27% with fever and as many as 86% for vaccination.

CONCLUSION

Families in rural India have substantial costs incurred in OPD attendance, most of which is for preventive health care such as immunization.

Provider payment methods and health worker motivation in community-based health insurance: a mixed-methods study

In a community-based health insurance (CBHI) introduced in 2004 in Nouna health district, Burkina Faso, poor perceived quality of care by CBHI enrollees has been a key factor in observed high drop-out rates. The poor quality perceptions have been previously attributed to health worker dissatisfaction with the provider payment method used by the scheme and the resulting financial risk of health centers. This study applied a mixed-methods approach to investigate how health workers working in facilities contracted by the CBHI view the methods of provider payment used by the CBHI. In order to analyze these relationships, we conducted 23 in-depth interviews and a quantitative survey with 98 health workers working in the CBHI intervention zone. The qualitative in-depth interviews identified that insufficient levels of capitation payments, the infrequent schedule of capitation payment, and lack of a payment mechanism for reimbursing service fees were perceived as significant sources of health worker dissatisfaction and loss of work-related motivation. Combining qualitative interview and quantitative survey data in a mixed-methods analysis, this study identified that the declining quality of care due to the CBHI provider payment method was a source of significant professional stress and role strain for health workers. Health workers felt that the following five changes due to the provider payment methods introduced by the CBHI impeded their ability to fulfill professional roles and responsibilities: (i) increased financial volatility of health facilities, (ii) dissatisfaction with eligible costs to be covered by capitation; (iii) increased pharmacy stock-outs; (iv) limited financial and material support from the CBHI; and (v) the lack of mechanisms to increase provider motivation to support the CBHI. To address these challenges and improve CBHI uptake and health outcomes in the targeted populations, the health care financing and delivery model in the study zone should be reformed. We discuss concrete options for reform based on the study findings.

Does health insurance improve health?: Evidence from a randomized community-based insurance rollout in rural Burkina Faso

From 2004 to 2006, a community-based health insurance (CBI) scheme was rolled out in Nouna District, Burkina Faso, with the objective of improving access to health services and population health. We explore the random timing of the insurance rollout generated by the stepped wedge cluster-randomized design to evaluate the welfare and health impact of the insurance program. Our results suggest that the insurance had limited effects on average out-of-pocket expenditures in the target areas, but substantially reduced the likelihood of catastrophic health expenditure. The introduction of the insurance scheme did not have any effect on health outcomes for children and young adults, but appears to have increased mortality among individuals aged 65 and older. The negative health effects of the program appear to be primarily driven by the adverse provider incentives generated by the scheme and the resulting decline in the quality of care received by patients.

Does enrollment status in community-based insurance lead to poorer quality of care? Evidence from Burkina Faso

INTRODUCTION

In 2004, a community-based health insurance (CBI) scheme was introduced in Nouna health district, Burkina Faso, with the objective of improving financial access to high quality health services. We investigate the role of CBI enrollment in the quality of care provided at primary-care facilities in Nouna district, and measure differences in objective and perceived quality of care and patient satisfaction between enrolled and non-enrolled populations who visit the facilities.

METHODS

We interviewed a systematic random sample of 398 patients after their visit to one of the thirteen primary-care facilities contracted with the scheme; 34% (n = 135) of the patients were currently enrolled in the CBI scheme. We assessed objective quality of care as consultation, diagnostic and counselling tasks performed by providers during outpatient visits, perceived quality of care as patient evaluations of the structures and processes of service delivery, and overall patient satisfaction. Two-sample t-tests were performed for group comparison and ordinal logistic regression (OLR) analysis was used to estimate the association between CBI enrollment and overall patient satisfaction.

RESULTS

Objective quality of care evaluations show that CBI enrollees received substantially less comprehensive care for outpatient services than non-enrollees. In contrast, CBI enrollment was positively associated with overall patient satisfaction (aOR = 1.51, p = 0.014), controlling for potential confounders such as patient socio-economic status, illness symptoms, history of illness and characteristics of care received.

CONCLUSIONS

CBI patients perceived better quality of care, while objectively receiving worse quality of care, compared to patients who were not enrolled in CBI. Systematic differences in quality of care expectations between CBI enrollees and non-enrollees may explain this finding. One factor influencing quality of care may be the type of provider payment used by the CBI scheme, which has been identified as a leading factor in reducing provider motivation to deliver high quality care to CBI enrollees in previous studies. Based on this study, it is unlikely that perceived quality of care and patient satisfaction explain the low CBI enrollment rates in this community.

Determinants of household direct and indirect costs: an insight for health-seeking behaviour in Burkina Faso

The objective of the study is to identify the determinants of household direct and indirect costs in the Nouna District, Burkina Faso. The data used were from a household survey conducted during 2000-2001. The multinominal logit models were applied to investigate the determinants of direct and indirect costs. The respondents who were sick in the rainy season and severity of illness significantly increased the probability of having high direct and indirect household costs. Acute illness occured in an adult was positively associated with magnitude of household indirect costs. Household economic status and utilization of western medical care played an important role in magnitude of direct cost. The information on determinants of household direct and indirect costs is necessary in order to get a complete picture of household costs for seeking health care and identification of vulnerable social groups and households.

Catastrophic health care spending and impoverishment in Kenya

BACKGROUND

Many health systems in Africa are funded primarily through out-of-pocket payments. Out-of-pocket payments prevent people from seeking care, can result to catastrophic health spending and lead to impoverishment. This paper estimates the burden of out-of-pocket payments in Kenya; the incidence and intensity of catastrophic health care expenditure and the effect of health spending on national poverty estimates.

METHODS

Data were drawn from a nationally representative health expenditure and utilization survey (n = 8414) conducted in 2007. The survey provided detailed information on out-of-pocket payments and consumption expenditure. Standard data analytical techniques were applied to estimate the incidence and intensity of catastrophic health expenditure. Various thresholds were applied to demonstrate the sensitivity of catastrophic measures.

RESULTS

Each year, Kenyan households spend over a tenth of their budget on health care payments. The burden of out-of-pocket payments is highest among the poor. The poorest households spent a third of their resources on health care payments each year compared to only 8% spent by the richest households. About 1.48 million Kenyans are pushed below the national poverty line due to health care payments.

CONCLUSIONS

Kenyans are becoming poorer due to health care payments. The need to protect individuals from health care related impoverishment calls for urgent reforms in the Kenyan health system. An important policy question remains what health system reforms are needed in Kenya to ensure that financial risk protection for all is achieved.

Treatment actions and treatment failure: case studies in the response to severe childhood febrile illness in Mali

Background

Appropriate home management of illness is vital to efforts to control malaria. The strategy of home management relies on caregivers to recognize malaria symptoms, assess severity and promptly seek appropriate care at a health facility if necessary. This paper examines the management of severe febrile illness (presumed malaria) among children under the age of five in rural Koulikoro Region, Mali.

Methods

This research examines in-depth case studies of twenty-five households in which a child recently experienced a severe febrile illness, as well as key informant interviews and focus group discussions with community members. These techniques were used to explore the sequence of treatment steps taken during a severe illness episode and the context in which decisions were made pertaining to pursing treatments and sources of care, while incorporating the perspective and input of the mother as well as the larger household.

Results

Eighty-one participants were recruited in 25 households meeting inclusion criteria. Children's illness episodes involved multiple treatment steps, with an average of 4.4 treatment steps per episode (range: 2–10). For 76% of children, treatment began in the home, but 80% were treated outside the home as a second recourse. Most families used both traditional and modern treatments, administered either inside the home by family members, or by traditional or modern healers. Participants’ stated preference was for modern care, despite high rates of reported treatment failure (52%, n=12), however, traditional treatments were also often deemed appropriate and effective. The most commonly cited barrier to seeking care at health facilities was cost, especially during the rainy season. Financial constraints often led families to use traditional treatments.

Conclusions

Households have few options available to them in moments of overlapping health and economic crises. Public health research and policy should focus on the reducing barriers that inhibit poor households from promptly seeking appropriate health care. Enhancing the quality of care provided at community health facilities and supporting mechanisms by which treatment failures are quickly identified and addressed can contribute to reducing subsequent treatment delays and avoid inappropriate recourse to traditional treatments.

Health and demographic surveillance systems: a step towards full civil registration and vital statistics system in sub-Sahara Africa?

BACKGROUND

In the developed world, information on vital events is routinely collected nationally to inform population and health policies. However, in many low-and middle-income countries, especially those in sub-Saharan Africa (SSA), there is a lack of effective and comprehensive national civil registration and vital statistics system. In the past decades, the number of Health and Demographic Surveillance Systems (HDSSs) has increased throughout SSA. An HDSS monitors births, deaths, causes of death, migration, and other health and socio-economic indicators within a defined population over time. Currently, the International Network for the Continuous Demographic Evaluation of Populations and Their Health (INDEPTH) brings together 38 member research centers which run 44 HDSS sites from 20 countries in Africa, Asia and Oceana. Thirty two of these HDSS sites are in SSA.

DISCUSSION

This paper argues that, in the absence of an adequate national CRVS, HDSSs should be more effectively utilised to generate relevant public health data, and also to create local capacity for longitudinal data collection and management systems in SSA. If HDSSs get strategically located to cover different geographical regions in a country, data from these sites could be used to provide a more complete national picture of the health of the population. They provide useful data that can be extrapolated for national estimates if their regional coverage is well planned. HDSSs are however resource-intensive. Efforts are being put towards getting them linked to local or national policy contexts and to reduce their dependence on external funding. Increasing their number in SSA to cover a critical proportion of the population, especially urban populations, must be carefully planned. Strategic planning is needed at national levels to geographically locate HDSS sites and to support these through national funding mechanisms.

SUMMARY

The paper does not suggest that HDSSs should be seen as a replacement for civil registration systems. Rather, they should serve as a short- to medium-term measure to provide data for health and population planning at regional levels with possible extrapolation to national levels. HDSSs can also provide useful lessons for countries that intend to set up nationally representative sample vital registration systems in the long term.

Who benefits from health services in South Africa?

South Africa is considering major health service restructuring to move towards a universal system. This calls for understanding the challenges in the existing health system. The paper, therefore, comprehensively evaluates an aspect of current health system performance - the benefit incidence of health services. It seeks to understand how the benefits from using health services in South Africa are currently distributed across socio-economic groups. Using a nationally representative household survey, results show that lower socio-economic groups benefit less than their richer counterparts from both public and private sector health services, and that the distribution of service benefits is not in line with their need for care.

Towards universal coverage: examining costs of illness, payment, and coping strategies to different population groups in southeast Nigeria

This study investigated the costs of illness to households in different socio-economic status (SES) groups and geographic places of abode in addition to the mechanisms that the different population groups used to pay for health services and cope with payments. A cross-sectional descriptive study of 3,200 households selected from six communities in two states was conducted using interviewer-administered pre-tested questionnaires. An SES index was used to divide the households into quartiles, and χ(2) analysis was used to determine the relationship of SES and geographic abode of households with cost of illness, payment mechanism, and coping strategies. The results show that malaria was the illness that most people had. The average cost of transportation for malaria was 86 Naira ($0.6 US), and the total cost of treatment was 2,819.9 Naira ($20 US); of this cost, drug costs alone contributed more than 90%. Out of pocket was the main method of payment. Treatment costs differed by geographic location and socio-economic status. Policy measures should establish targeted mechanisms to protect the general population, especially rural dwellers and poorer households, against the financial burden of direct healthcare payments.

Health insurance and health-seeking behavior: evidence from a randomized community-based insurance rollout in rural Burkina Faso

In 2004, a community-based health insurance (CBI) scheme was introduced in Nouna district, Burkina Faso, with the primary objective of improving access to facility-based health services. In order to overcome self-selection issues in the analysis of the behavioral effects of insurance, we combine four waves of the Nouna Health District Household Survey into a panel data set, and use the randomized timing of insurance rollout to estimate the causal effect of insurance coverage on health-seeking behavior. While we find a generally positive association between CBI affiliation and treatment seeking, we cannot reject the null that the introduction of health insurance does not have any effect on treatment seeking in general, and utilization of facility-based professional care, in particular. Low levels of health care provider satisfaction, poor perceived quality of care by enrollees, and ambiguity in the coverage level of the CBI benefit package appear to have contributed to these weak results. Our findings imply that the basic notion of insurance mechanically increasing facility-based professional care is not necessarily true empirically, and likely contingent on a large number of contextual factors affecting health-seeking behavior within households and communities.

Does the distribution of health care benefits in Kenya meet the principles of universal coverage?

BACKGROUND

The 58th World Health Assembly called for all health systems to move towards universal coverage where everyone has access to key promotive, preventive, curative and rehabilitative health interventions at an affordable cost. Universal coverage involves ensuring that health care benefits are distributed on the basis of need for care and not on ability to pay. The distribution of health care benefits is therefore an important policy question, which health systems should address. The aim of this study is to assess the distribution of health care benefits in the Kenyan health system, compare changes over two time periods and demonstrate the extent to which the distribution meets the principles of universal coverage.

METHODS

Two nationally representative cross-sectional households surveys conducted in 2003 and 2007 were the main sources of data. A comprehensive analysis of the entire health system is conducted including the public sector, private-not-for-profit and private-for-profit sectors. Standard benefit incidence analysis techniques were applied and adopted to allow application to private sector services.

RESULTS

The three sectors recorded similar levels of pro-rich distribution in 2003, but in 2007, the private-not-for-profit sector was pro-poor, public sector benefits showed an equal distribution, while the private-for-profit sector remained pro-rich. Larger pro-rich disparities were recorded for inpatient compared to outpatient benefits at the hospital level, but primary health care services were pro-poor. Benefits were distributed on the basis of ability to pay and not on need for care.

CONCLUSIONS

The principles of universal coverage require that all should benefit from health care according to need. The Kenyan health sector is clearly inequitable and benefits are not distributed on the basis of need. Deliberate efforts should be directed to restructuring the Kenyan health system to address access barriers and ensure that all Kenyans benefit from health care when they need it.

Does HIV services decentralization protect against the risk of catastrophic health expenditures?: some lessons from Cameroon

OBJECTIVE

Scaling up antiretroviral treatment (ART) through decentralization of HIV care is increasingly recommended as a strategy toward ensuring equitable access to treatment. However, there have been hitherto few attempts to empirically examine the performance of this policy, and particularly its role in protecting against the risk of catastrophic health expenditures (CHE). This article therefore seeks to assess whether HIV care decentralization has a protective effect against the risk of CHE associated with HIV infection. DATA SOURCE AND STUDY DESIGN: We use primary data from the cross-sectional EVAL-ANRS 12-116 survey, conducted in 2006-2007 among a random sample of 3,151 HIV-infected outpatients followed up in 27 hospitals in Cameroon. DATA COLLECTION AND METHODS: Data collected contain sociodemographic, economic, and clinical information on patients as well as health care supply-related characteristics. We assess the determinants of CHE among the ART-treated patients using a hierarchical logistic model (n = 2,412), designed to adequately investigate the separate effects of patients and supply-related characteristics.

PRINCIPAL FINDINGS

Expenditures for HIV care exceed 17 percent of household income for 50 percent of the study population. After adjusting for individual characteristics and technological level, decentralization of HIV services emerges as the main health system factor explaining interclass variance, with a protective effect on the risk of CHE.

CONCLUSION

The findings suggest that HIV care decentralization is likely to enhance equity in access to ART. Decentralization appears, however, to be a necessary but insufficient condition to fully remove the risk of CHE, unless other innovative reforms in health financing are introduced.

The straw that breaks the camel's back. Redirecting health-seeking behavior studies on malaria and vulnerability

In the wake of the Millennium Development Goals, the focus on vulnerability and access to care has increasingly gained ground in the malaria social science literature. However, little emphasis has been given to the cumulative processes of vulnerability. In this article, we draw on ethnographic data, in particular on case studies, gathered in southeastern Tanzania in the 1990s and reexamine them in the context of vulnerability. We analyze the underpinnings of the cumulative dimension of vulnerability at three levels: (1) structural, that is, elements that determine access to material and social resources; (2) agent driven, that is, the consequences of coping strategies that enhance vulnerability; and (3) conjunctural, that is, periods characterized by the confluence of adverse circumstances. We argue that the analysis of cumulative processes of vulnerability paints a more comprehensive picture of people's struggle for health. This opens up a more systemic and dynamic perspective on access to care for disadvantaged populations.

Compliance with referral for curative care in rural Burkina Faso

BACKGROUND

The goal of this study is to contribute to improving the functioning of the referral system in rural Burkina Faso. The main objective is to ascertain the compliance rate for referral and to identify the factors associated with successful referral.

METHODS

A record review of 12 months of curative consultations in eight randomly selected health centres was conducted to identify referral cases. To assess referral compliance, all patient documents at referral hospitals from the day of the referral up to 7 days later were checked to verify whether the referred case arrived or not. Descriptive statistics were then used to compute the compliance rate. Hierarchical modelling was performed to identify patient and provider factors associated with referral compliance.

RESULTS

The number of visits per person per year was 0.6 and the referral rate was 2.0%. The compliance rate was 41.5% (364/878). After adjustment, females (OR = 0.71; 95% CI = 0.52-0.98), patients referred during the rainy seasons (OR = 0.56; 95% CI = 0.40-0.78), non-emergency referrals (OR = 0.47; 95% CI = 0.34-0.65) and referrals without a referral slip (OR = 0.30; 95% CI = 0.21-0.43) were significantly less likely to comply. Children between 5 and 14 years old (OR = 0.61; 95% CI = 0.35-1.06) were at a higher risk of non-compliance, but the difference did not reach statistical significance. Moreover, none of provider characteristics was statistically significantly associated with non-compliance. CONCLUSIONS In a rural district of Burkina Faso, we found a relatively low compliance with referral after the official referral system was organized in 2006. Patient characteristics were significantly associated with a failure to comply. Interventions addressing female patients' concerns, increasing referral compliance in non-emergency situations, reducing inconvenience and opportunity costs due to seasonal/climate factors, and assuring the issue of a referral slip when a referral is prescribed may effectively improve referral compliance.

Health economics of dengue: a systematic literature review and expert panel's assessment

Dengue vaccines are currently in development and policymakers need appropriate economic studies to determine their potential financial and public health impact. We searched five databases (PubMed, EMBASE, LILAC, EconLit, and WHOLIS) to identify health economics studies of dengue. Forty-three manuscripts were identified that provided primary data: 32 report economic burden of dengue and nine are comparative economic analyses assessing various interventions. The remaining two were a willingness-to-pay study and a policymaker survey. An expert panel reviewed the existing dengue economic literature and recommended future research to fill information gaps. Although dengue is an important vector-borne disease, the economic literature is relatively sparse and results have often been conflicting because of use of inconsistent assumptions. Health economic research specific to dengue is urgently needed to ensure informed decision making on the various options for controlling and preventing this disease.

The Health and Demographic Surveillance System (HDSS) in Nouna, Burkina Faso, 1993-2007

The Nouna Health and Demographic Surveillance System (HDSS) is located in rural Burkina Faso and has existed since 1992. Currently, it has about 78,000 inhabitants. It is a member of the International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), a global network of members who conducts longitudinal health and demographic evaluation of populations in low- and middle-income countries. The health facilities consist of one hospital and 13 basic health centres (locally known as CSPS). The Nouna HDSS has been used as a sampling frame for numerous studies in the fields of clinical research, epidemiology, health economics, and health systems research. In this paper we review some of the main findings, and we describe the effects that almost 20 years of health research activities have shown in the population in general and in terms of the perception, economic implications, and other indicators. Longitudinal data analyses show that childhood, as well as overall mortality, has significantly decreased over the observation period 1993–2007. The under-five mortality rate dropped from about 40 per 1,000 person-years in the mid-1990s to below 30 per 1,000 in 2007. Further efforts are needed to meet goal four of the Millennium Development Goals, which is to reduce the under-five mortality rate by two-thirds between 1990 and 2015.

Bottlenecks for high coverage of intermittent preventive treatment in pregnancy: the case of adolescent pregnancies in rural Burkina Faso

BACKGROUND

While IPTp-SP is currently being scaled up in sub-Saharan Africa (SSA), the coverage with the required>or=2 doses of SP remains considerably short of the Roll Back Malaria (RBM) goal of 80%, not to mention of the recently advocated universal coverage.

METHODS

The study triangulates quantitative data from a health center randomized community-based trial on IPTp-SP effectiveness and the additional benefit of a promotional campaign with qualitative data from focused ethnography.

FINDINGS

In rural Burkina Faso, despite the significantly higher risk of malaria infection among adolescent primigravidae (PG) (OR 2.44 95%CI 1.81-3.28, p<0.001), making them primary target beneficiaries of IPTp-SP, adolescents adhered to the required three or more ANC visits significantly less (PG: 46.6%; SG 43.7%) than adults (PG: 61.9%; SG 54.9%) and had lower SP uptake during the malaria transmission season, further showing the difficulty of reaching this age group. Adolescents' structural constraints (such as their social position and household labor requirements) and needs (such as anonymity in the health encounter) leave them highly vulnerable during their pregnancies and, especially, during the high malaria transmission season.

CONCLUSION

Our study shows that adolescents need to be targeted specifically, prior to their first pregnancy and with measures adapted to their social context, addressing their structural constraints and needs and going beyond standard health promotion campaigns. Unless such specific measures are taken, adolescents' social vulnerability will present a serious bottleneck for the effectiveness of IPTi-SP.

How to do (or not to do) ... a benefit incidence analysis

Benefit incidence analysis (BIA) considers who (in terms of socio-economic groups) receive what benefit from using health services. While traditionally BIA has focused on only publicly funded health services, to assess whether or not public subsidies are 'pro-poor', the same methodological approach can be used to assess how well the overall health system is performing in terms of the distribution of service benefits. This is becoming increasingly important in the context of the growing emphasis on promoting universal health systems. To conduct a BIA, a household survey dataset that incorporates both information on health service utilization and some measure of socio-economic status is required. The other core data requirement is unit costs of different types of health service. When utilization rates are combined with unit costs for different health services, the distribution of benefits from using services, expressed in monetary terms, can be estimated and compared with the distribution of the need for health care. This paper aims to provide an introduction to the methods used in the 'traditional' public sector BIA, and how the same methods can be applied to undertake an assessment of the whole health system. We consider what data are required, potential sources of data, deficiencies in data frequently available in low- and middle-income countries, and how these data should be analysed.

Financing equitable access to antiretroviral treatment in South Africa

Background

While South Africa spends approximately 7.4% of GDP on healthcare, only 43% of these funds are spent in the public system, which is tasked with the provision of care to the majority of the population including a large proportion of those in need of antiretroviral treatment (ART). South Africa is currently debating the introduction of a National Health Insurance (NHI) system. Because such a universal health system could mean increased public healthcare funding and improved access to human resources, it could improve the sustainability of ART provision. This paper considers the minimum resources that would be required to achieve the proposed universal health system and contrasts these with the costs of scaled up access to ART between 2010 and 2020.

Methods

The costs of ART and universal coverage (UC) are assessed through multiplying unit costs, utilization and estimates of the population in need during each year of the planning cycle. Costs are from the provider’s perspective reflected in real 2007 prices.

Results

The annual costs of providing ART increase from US$1 billion in 2010 to US$3.6 billion in 2020. If increases in funding to public healthcare only keep pace with projected real GDP growth, then close to 30% of these resources would be required for ART by 2020. However, an increase in the public healthcare resource envelope from 3.2% to 5%-6% of GDP would be sufficient to finance both ART and other services under a universal system (if based on a largely public sector model) and the annual costs of ART would not exceed 15% of the universal health system budget.

Conclusions

Responding to the HIV-epidemic is one of the many challenges currently facing South Africa. Whether this response becomes a “resource for democracy” or whether it undermines social cohesiveness within poor communities and between rich and poor communities will be partially determined by the steps that are taken during the next ten years. While the introduction of a universal system will be complex, it could generate a health system responsive to the needs of all South Africans.

The Impact of Caregiving on the Health and Well-being of Kenyan Luo Grandparents

As the HIV/AIDS pandemic progresses in Africa, elders are increasingly responsible for the care of orphans. Several reports suggest that elderly Africans do not have the resources to provide care and are at risk of poor health, but few studies have systematically measured health of caregivers. The Kenyan Grandparents Study is a longitudinal study designed to compare elder Luo caregivers to noncaregiving peers. Several measures of health were collected, including body mass index (BMI), blood pressure, glucose, and hemoglobin. In addition, self-perceived health and mental health were measured using the MOS Short-Form 36 (SF-36). It was hypothesized that caregivers would have poorer health than noncaregivers and that the difference in health would widen over the three waves of the study. Caregiving did not affect physical health but did act to decrease mental health and perceived health over time.